The Noncompliance Epidemic

Can We Get Patients to Be More Compliant?

Neil Chesanow


January 16, 2014

In This Article

Giving Patients Access to Their Doctors' Notes

In addition to such large-scale efforts to improve medication compliance, some intriguing smaller experiments may have larger ramifications down the road.

One, the OpenNotes pilot study, included 3874 patients at Beth Israel Deaconess Medical Center in Boston, Geisinger Health System, and Harborview Medical Center in Seattle.[41,42] For a year, patients were able to use a special Internet portal to view the visit notes of their physicians exactly as they appeared in the doctors' EHR.

At the study's conclusion, 99% of the participants said that they wanted continued access to their physicians' notes.[41,42]

"With access to their doctors' notes, patients can read much more completely their doctors' thoughts on their diagnosis," says Geisinger's Thomas Graf. "On the brief summary form they receive after a visit to one of our clinics, it may just say 'Diabetes with kidney disease.' Whereas in the note, I would talk about the severity of the kidney disease and how worried or not worried I was about its progression. Maybe I would include a discussion I had with the patient's nephrologist about their diabetic disease that wouldn't be in that brief summary. Patients can now see it all there in the note. It increases the level of understanding."

But consider this: Nearly one half of all adults in the United States -- 90 million people -- have problems with health literacy, according to the Institute of Medicine.[43] Surely, in the OpenNotes study, at least some participants would normally have had comprehension difficulties even with patient education literature written just for them, which aims for a third grade reading level.

Yet nearly everyone in the study avidly read their doctor's notes, written not for them but for other healthcare professionals, painstakingly looking up the meaning of Dx, BID, and other abbreviations, poring over the definitions of clinical terms, puzzling out test results -- helped by references that Geisinger provides, Graf says -- all to get the unvarnished truth on the state of their health. A high level of patient engagement tends to promote better compliance.

Open physician notes "will become the standard of care," the study's authors confidently predict.[42] Of course, first you need a patient portal that gives you this capability and meets Health Insurance Portability & Accountability Act (HIPAA) privacy and security requirements. There aren't many portals like that yet.

Motivating Patients With Economic Incentives

It may strike you as odd -- and perhaps morally problematic -- for society to have to pay patients to do what's in their own best interest regarding their health.

Yet research shows that economic incentives can work wonders for compliance, motivating obese people to lose weight, smokers to quit smoking, patients with diabetes to take their statins, and patients on warfarin to stick to their regimens.

In several pilot projects conducted at the University of Pennsylvania in Philadelphia, for example, patients taking warfarin were entered into a lottery.[44,45,46]

Maintaining compliance to warfarin therapy is especially challenging. One in 4 patients with atrial fibrillation discontinue warfarin therapy within the first year of receiving their initial prescriptions, with potentially catastrophic results.[47]

Each day that patients remembered to take their warfarin, they had a 1-in-5 chance of winning $10, or a 1-in-100 chance of winning $100 in the lottery.[44,45,46] Up to $150 had previously been offered as the top award, but, counterintuitively, less money worked equally well, the researchers found.

"Rates of nonadherence to warfarin were significantly lower using daily lottery-based incentives," lead investigator Kevin Volpp, MD, PhD, an internist and behavioral economist who holds professorships at Penn's Perelman School of Medicine and the Wharton School, explained in a congressional staff briefing last spring.[48]

"It certainly does show an increase in adherence," adds Edmund Pezalla of Aetna, which funded the research. "People buy lottery tickets knowing that the odds are very small that they're going to win, but it gets you engaged, and that's really what it's all about. It's getting people to think about adherence and being engaged in the process, and less about the size of the reward."

In a variation on this theme, one software developer of a medication reminder smartphone app includes a charity donation as an incentive for users to stay on regimen.[49] Users can select a charity -- among them AIDS United, the American Diabetes Association, and Save the Children -- that will receive a 5-cent donation from the firm in their name for each day through May 17, 2014, that users indicate they have taken all their medications on time.

Will health insurers one day hold Mega-Millions-like lotteries in which tens or hundreds of thousands of members stand to win cash prizes if they will only take their medications as intended?

There's no sign of that yet, but employers seeking to reduce their healthcare costs have embraced economic incentives in a big way, Kevin Volpp says.

"The use of incentives for healthy behavior is increasingly becoming part of the benefit design in employer-sponsored plans, with approximately 85% of large employers using incentives for health behavior in some form in 2013," he noted in an email in response to a question from Medscape.

"Appropriate targeting of high-risk plan members or patients will be important," Volpp added, "as focusing on incentives in the highest-risk populations that are most in need of support will be one way to direct these resources where the impact is greatest."


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