The Noncompliance Epidemic

Can We Get Patients to Be More Compliant?

Neil Chesanow


January 16, 2014

In This Article

Intervening With Patients Who Go Off-Regimen

Identifying patients who stop taking or fail to fill their prescriptions is useless without effective ways to get them back on track. The most advanced integrated delivery systems have practically turned this into a science.

Take the Geisinger Health System based in Danville, Pennsylvania. It serves more than 2.6 million patients in 44 counties in central and northeastern Pennsylvania, a population that is poorer, older, and sicker than the national average.[24,25]

Yet "admissions for our patients with multiple chronic diseases have been reduced by as much as 25%, and readmissions following discharges decreased by as much as 50% in community sites," Geisinger President and CEO Glen D. Steele Jr, MD, PhD, a surgeon, testified before Congress as healthcare reform was being debated prior to passage of the ACA.[25]

How do the clinicians at Geisinger do it? They use predictive modeling to identify patients who are noncompliant; bundled payments for acute care procedures; pay-for-performance incentives; enhanced support for primary doctors and their care teams; improved chronic disease management; and improved transitions of care between primary doctors, specialists, hospitals, and other care facilities.[25]

Consider the 25,000 patients with diabetes in Geisinger's care. Their prescription activity is monitored at Geisinger pharmacies, and if a patient goes off-regimen, fails to fill an electronically sent prescription, or misses a doctor's appointment, a care team, generally composed of nurse practitioners, promptly intervenes.

"It may start with a call from one of our care team members, who says, 'Gosh, Mrs. Jones, you're a month overdue to see your doctor for your diabetes,'" says family physician Thomas Graf, MD, Geisinger's Chief Medical Officer for Population Health. "'We'd like to get you scheduled for that. We also need to update your lab studies. And it looks like you might be out of some of your medications.'"

The patient's status on medications, exams, labs, imaging, shots, and vaccines is already known to the staff when the patient appears at the office or clinic. If labs are needed, for example, they are ordered. Work that doesn't require a physician -- diabetic foot exams, for instance -- are handled by nurses, who are eager for the opportunity to practice their clinical skills.

At Geisinger, patient education is primarily the responsibility of nurses, who are trained to deliver it. Research shows that the risk for noncompliance increases by 19% in patients whose physicians are poor communicators,[26] which may be a function of lack of time. When patient and doctor have a good relationship, however, the patient is more likely to be compliant.[27]

"A physician may do some education," Graf says, "but physicians aren't experts in education, and often that task can be performed as well by other individuals."

Patients who need additional help with compliance are referred to health coaches who specialize in disease-specific education for conditions like diabetes and chronic obstructive pulmonary disease. A separate care team may monitor the patient several times a month, week, or day via phone, texting, email, videoconferencing, or the use of wireless devices that remotely send team members data on the patient's vital signs.

As a result of such measures, since 2006, when Geisinger's care was "fragmented" and not focused on patients with chronic disease, the percentage of patients with diabetes whose hemoglobin A1c measurements were at goal rose from 2.4% to 12.9%.[28] Those whose LDL cholesterol levels were at goal rose from 50% to 54%. Those whose blood pressure was under control (< 130/180 mm Hg) rose from 39% to 54%.

Similar gains were achieved with other chronic diseases.[28] It can be done.

But most doctors and patients aren't part of integrated systems like this, with their extensive resources and mission to address noncompliance -- at least not yet.


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