Battling Nonadherence: What Actually Works?

James F. Sweeney

Disclosures

May 07, 2019

In This Article

Should You Drop the Nonadherent Patient?

Treating a nonadherent patient is frustrating for a physician and can feel pointless. In addition, nonadherent patients can hurt a practice's bottom line, as medicine shifts to outcome-based reimbursement.

Dropping patients who are consistently nonadherent is a big decision, and may involve liability issues.

Terminating a nonadherent patient should not be done casually or without making every effort to bring the patient into compliance, said Annemarie Provencher, a senior risk specialist at Coverys, a medical liability insurer.

"You almost have to be a detective," she said. "Why won't the patient engage? What can I do to help them engage?"

Doctors should make every reasonable effort to get the patient to adhere to the treatment and document it thoroughly to establish 'informed refusal' on the part of the patient.

Patients who have been dropped have successfully sued physicians, claiming abandonment and arguing that they were not adequately informed of the risks and negative effects of nonadherence or given adequate alternatives. The best defense for doctors is to make every reasonable effort to get the patient to adhere to the treatment and document it all thoroughly in order to establish "informed refusal" on the part of the patient, Provencher said.

Every physician's practice should have formal, well-developed, and consistent policies in place for termination of care. "Termination of the provider-patient relationship is a process, not an event," she said, adding that the practice should consult its malpractice insurer or an attorney before starting.

It begins when the doctor has determined the patient is stable and that there are no circumstances that would prevent termination. The doctor should explain in writing and in person the reasons for ending the relationship, the effective date of termination, a statement explaining the importance of the patient finding continuing care, a referral resource to find another physician in the community, and an offer to provide the medical records.

Noncompliance Versus Nonadherence

It's symptomatic of the problem that the medical community can't even agree on what to call it. For years, many physicians and other healthcare providers have used the terms "noncompliance" and "nonadherence" interchangeably to describe patients who don't follow treatment plans.

But there is a difference between the two terms. Understanding the distinction and labeling different behaviors correctly can help address the problems caused by the behavior.

Generally, "noncompliance" describes patients who deliberately refuse to follow a treatment plan. "Nonadherence" is the behavior in which a patient unintentionally fails to follow a plan.

Although the resulting behavior might be the same (e.g., unfilled prescriptions, missed appointments), the causes can be very different. A noncompliant patient could ignore a plan for several reasons, whereas a nonadherent patient might intend to follow physician orders, but be unable to do so.

Although both terms remain in common use, there is a trend in recent years to eliminate "noncompliance" in favor of "nonadherence." Proponents say that "noncompliance" smacks of physician authoritarianism and is a poor fit with the shared decision-making model. "Nonadherence," they argue, is broad enough to encompass all the relevant behaviors without judging the patient.

Similarly, "compliance" has come to mean passively following a physician's orders, whereas "adherence" denotes active participation.

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