Alarming Number Of Patients Don't Follow Their Physicians' Orders

By Connie Lauerman

Chicago Tribune

CHICAGO - These days doctors have an unprecedented arsenal of drugs and other treatments to offer their patients.

If only the patients would follow their orders.

A growing body of medical literature shows that, in some cases, up to 50 percent of patients don't take the medications that their doctors prescribe.

That means that some people don't even fill their prescriptions. Others take their pills for a while then leave the rest languishing on medicine-cabinet shelves.

Such behavior is not uncommon among people at risk for strokes and heart disease, people with diabetes and even a few who have received organ transplants.

"Noncompliance is a major health problem, a hidden epidemic," said Nancy Houston Miller, a nurse and associate director of Stanford University's cardiac rehabilitation program. "And it has the potential to get worse."

Dr. Aaron Michelfelder, a family physician at the Loyola Center for Health in Maywood, called it "a huge problem, larger than anyone imagines."

According to the American Heart Association, studies have found that noncompliance results in 20 million lost workdays and $1.5 billion lost earnings per year as well as $37 billion spent on hospitalizations that could have been avoided.

It's Also Deadly

A study by the University of California found that, regardless of age, heart-failure patients who had problems complying with doctor's orders were more likely to die sooner than those patients who cooperated fully in their treatments.

Beyond medication, most chronic diseases require lifestyle changes - namely diet and exercise.

"Look at the high rates of obesity in the country, with at least a third of the population being considered obese and 50 percent being considered overweight," said Stanford's Miller. "We have made almost no strides from behavioral standpoint."

Why is complying with treatment such a problem for so many people?

Albert Bellg, a cardiac psychologist in the Rush Heart Institute, is usually "the primary interventionist" in that clinic when patients have trouble taking their medicine.

He said one way of thinking about why people defy logic and risk their well-being is to examine their beliefs about illness and medicine.

"Someone who comes into our clinic with high cholesterol and no family history of heart disease may tend to pooh-pooh the risk of developing serious problems.

"Obviously someone who thinks they're very susceptible to a problem would be more motivated to engage in treatment.

"Then you look at the severity of the problem. Someone may feel susceptible to a problem but not feel that it's a big deal. Perhaps it's more like a medical problem that many people in their family have but nobody had a huge problem with it."

Similarly, he said, patients come in with psychological baggage about medication that may make them less likely to take it.

"A lot of people are being asked to stay on medication for the rest of their lives. Many patients don't like the idea that they're dependent on it. It's (viewed as) a sign of weakness or loss of control. There's an illusion that they ought to be able to take care of themselves."

Loyola's Michelfelder said that, in his experience, compliance is the most difficult for chronically ill patients.

"I think you probably get to a point where you're just sick and tired of dealing with it. And I think denial is strong for a long time. In primary care, diabetes is the prototypical chronic disease but it can certainly apply to high blood pressure and asthma.

"We'll see diabetics out of control for 5 or 10 years, then it's like something snaps inside when something happens. Their friend has a heart attack, their grandmother has a leg amputated and the next day they're in my office saying, `You know, doctor, I need to take control to keep this from happening to me.' And then things change. It's amazing."

"Education is very important, and the patient has to be accountable," said Linda Eugene, a diabetes educator and registered dietitian at the University of Chicago Medical Center. "Before we label somebody as `noncompliant,' we have to make sure that they've had all the proper tools to take care of their diabetes. If they are given the information over and over and they still don't make the necessary changes, then the label of `noncompliant' would be justified."

It may seem incredible that a person who received the lifesaving gift of an organ transplant would sabotage it by not taking the medication that maintains it, but Dr. Michelle Josephson, a transplant nephrologist at the University of Chicago, said that there can be a compliance problem among kidney transplant patients, although it's often difficult to prove.

"The connotation of `noncompliant is `bad patient,' " said Josephson, "but the issue is broader than that.

"Sometimes medications make people sick and they just can't stomach them. There could be a misunderstanding Once a pharmacy sent one of my patients half the medication he was supposed to be on. He didn't want to bother me, so instead of calling me he just halved his medication. Nothing happened to him but you can't keep doing that."

On the other hand, if a transplant fails and there's a suspicion that it was caused by noncompliance, Josephson said there's "concern" about approving that patient for a second transplant.

Said Stanford's Miller, who chaired an expert panel on compliance convened in 1996 by the American Heart Association:

"The patient has been blamed for everything when in actuality it's a three-tiered problem involving patients, health-care providers and health-care organizations. We need to intervene in all three areas and develop strategies for patients."

Copyright © 2000 The Seattle Times Company.

This article posted December 11, 2000.