Scarce health care resources require CMs to focus efforts on compliance
Scarce health care resources require CMs to focus efforts on compliance
Experts share possible solutions to classic problem
As the purse strings controlling the allocation of health care dollars draw ever tighter, case managers have a greater responsibility to improve their patients' compliance with treatment plans. Faced with the ethical dilemma of fairly allocating scarce health care resources, national experts gathered recently at the First International Symposium on Transplant Recipient Compliance in Arlington, VA. The symposium was sponsored by the division of continuing medical education of the University of Alabama School of Medicine in Birmingham. If you aren't familiar with the prevalence of noncompliance among American patients, here are a few facts:
· Patients with chronic conditions with few or no symptoms are most likely to be noncompliant.
· Noncompliant transplant patients were readmitted to the hospital 5.9 times, compared with 2.5 times for compliant patients.
· Several studies show 15% to 18% of kidney transplant patients are noncom pliant, and 91% of noncompliant patients lose their grafts or die from medical complications.
· About 50% of prescriptions written in the United Sates are taken improperly. (For selected resources on compliance, see p. 95.)
"I heard a physician admit once that it took him 20 days to finish a 14-day supply of antibiotics," says Gigi Spicer, RN, BSN, nursing director of the kidney transplant program at Henrico Doctor's Hospital in Richmond, VA.
"We're asking our patients to take drug regimens that could baffle an RN. And we're sending them home from the hospital so quickly that don't have time to think and process the information necessary to comply with complex regimens," Spicer explains.
Even with more hospital time for education and counseling, not all patients are willing or able to comply with treatment plans, notes Christopher Combs, PhD, a clinical psychologist with Temple University Hospital in Philadelphia. "Education is important, but it's not the most important factor, or you could just talk to folks and they would be compliant."
Predicting compliance
The predictors of noncompliance listed by our experts are familiar to most case managers. They include the following:
· required length of prescribed treatment;
· complexity of treatment;
· cost of treatment;
· severity of symptoms;
· beliefs about severity of disease;
· failure to fully understand regimen;
· past behavior;
· inadequate social support;
· history of substance abuse;
· personality disorders.
"Many predictors of noncompliance can be addressed and overcome given enough time," says Combs. "For example, it's possible for case managers to create a social network using community resources."
Yet other barriers to noncompliance may not be addressed easily, he admits. "Personality disorders are by definition so pervasive and persistent that they take years to treat, not the short time often dictated by the health care system," he says. "Some patients may lack the ability to think in a linear fashion about cause and effect. They don't recognize the consequences of failure to comply with treatment plans."
Transplant regulations require that all transplant candidates receive a psychological evaluation, but they don't mandate the format of the evaluation, Combs says. However, the interviews generally follow a script, and there are some common factors that even a cursory evaluation can reveal about a patient's ability or willingness to comply with treatment plans. "Case managers can help patients prepare for interviews by reassuring them that they are not being singled out and that cooperating with the interviewer will make a favorable impression," he says. Here are some factors Combs looks for during patient interviews:
· Defensiveness. "It's common for patients to begin in a defensive posture," he says. "However, I expect patients to ease into a comfort zone and become more verbal as the interview progresses."
· Logic. "Patients should be able to tell me a logical, coherent story. They should demonstrate their recognition between cause and effect."
· Courtesy. "Patients should be reasonably polite and forthcoming. They should try to answer all questions honestly and in full," he says. "If a patient appears paranoid, he or she may not be able to successfully handle the demands of a transplant. Instead of a transplant, improving their health and reducing their stress, it might actually increase their stress."
Reducing anxiety
Case managers can play an important role in helping patients understand treatment plans. "Patients who are frightened hear only about 20% of what they are told. Having a case manager review all the necessary information helps facilitate the entire process and improve chances for patient compliance," Combs says.
Furthermore, the need for case management intervention doesn't end immediately following an acute episode. Patients with chronic disease often slip into noncompliance as their initial fear of illness, disability, or death fades. (For more on stages of behavior, see p. 96.) "As time passes, patients become less afraid that something acute is going to happen. In addition, over time patients have less frequent contact with providers and case managers," he says. Two possible solutions to this problem are more frequent follow-up from case managers and participation in peer support groups.
In addition to the pre-transplant psychological evaluation, payers sometimes rely on provider perceptions of patient compliance to make decisions regarding placement on transplant waiting lists or authorization of other expensive procedures, says Donna K. Hathaway, PhD, RN, FAAN, a professor and director of clinical transplant research with the College of Nursing and the College of Medicine at the University of Tennessee in Memphis.
"As I sat in monthly patient meetings with the dialysis staff, questions arose about whether or not patients were compliant with their dialysis regimen," Hathaway says. "We noticed that provider perceptions about a patient's compliance with the dialysis regimen were influencing decisions about whether the patient would be compliant following a transplant."
Missing the mark
Hathaway and her colleagues identified a group of 28 kidney transplant patients who had undergone transplantation and had a functioning graft for at least six months. They sent a Likert scale questionnaire to the patient's dialysis staff and asked for their perceptions of the patient's compliance.
In addition, the patient's post-transplant nurse practitioners were asked to fill out the same questionnaire.
"What struck us immediately was the high degree of perceived compliance reported by both groups," Hathaway says. "It seemed to contradict the information shared at monthly meetings."
Providers were asked to rate their perceptions of patient compliance and knowledge in the following areas:
· medication regimens;
· dietary restrictions;
· appointments;
· effects of disease on activities of daily living;
· medication cause and effect;
· diet and its effects.
The high incidence of noncompliance reported during staff meetings and the low incidence of noncompliance reported on the questionnaires may be explained by the fact that when asked to focus on specific areas of compliance, staff recognized that patients are not noncompliant across the board.
"They may see more clearly that patients are only noncompliant in one area that is not vital to successful outcomes or can easily be addressed," Hathaway says.
"If a patient is slightly noncompliant with instructions to start a regular exercise routine, that may not be as great a concern as failure to comply with taking anti-hypertensive medi cations," she says.
The University of Tennessee study also found little or no correlation between provider perceptions of noncompliance and patients who experienced episodes of graft rejection. "Perhaps provider perceptions are not always on target. And perhaps a degree of noncompliance is not a great predictor of poor outcome," Hathaway explains.
"Case managers are in a position to hear the label of 'noncompliance' attached to a patient. But, before you immediately expect the worst, you should raise your antenna and start asking specific questions about who deems the patient noncompliant and what they base their perceptions on."
In addition, case managers should evaluate the "window of compliance behavior," she says. "I think that there are different levels of tolerance for noncompliant behavior based on each individual's health status.
"For example, if you have someone who is at high risk for graft loss due to immunological problems beyond their control, it's much more important for that patient to comply strictly with treatment regimens than it is for a patient who has just received a first transplant from a related, living donor who was well-matched."
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