Last September, Tom Jackson’s battered 73-year-old heart was beating so feebly, after a half-dozen heart attacks and quintuple bypass surgery, that “we all thought I was going to pack it in,” he recalls.
Now the retired textbook editor from Walpole, Mass., is back to his beloved watercolor painting, daily 1-mile constitutionals, shopping expeditions with his wife Dorothy and play sessions with his grandchildren.
Jackson calls it a miracle and gives the credit to Dr. Lynne Warner Stevenson, his new cardiologist. But Stevenson says the difference is due mainly to what doctors call “compliance.” Everyone else calls it following the doctor’s orders.
“We didn’t give him a bunch of new medicines,” says the Boston heart specialist. “Patients always underestimate how much their own compliance matters–how much they’ve made the difference.”
It should be obvious: Your pills can’t help you unless you take them. Ditto for diet, exercise, stopping smoking and the other things doctors tell us to do for our own good.
Authorities say half of all patients–of any age–fail to stay on the drugs prescribed for them. Of the 50 percent who stick with them, half don’t take the right dose.
Elders are especially at risk. Not that they’re any less likely to do what they’re told, caregivers say, but they have more drugs to keep track of and they face more obstacles–of cost, fading memory, failing eyesight, poor dexterity. Moreover, when elders lapse, the consequences can be dire.
Non-compliance is one of health care’s biggest secrets. “It’s a subject no one wants to address,” says Sherrie Kaplan of New England Medical Center, who studies how doctors and patients interact. “It undermines much of what we do in medicine,” adds Dr. Brian Haynes of McMaster University in Ontario, an expert on the subject.
Dr. Jerry Avorn of Brigham and Women’s Hospital in Boston calls non-compliance “one of the nation’s bigger public health issues.” The United States spends more than a trillion dollars a year on health care but wastes uncounted billions of that–more than $100 billion annually, says one study–on drugs not taken, on avoidable emergency room visits and hospitalizations of people who got into trouble because they didn’t follow doctors’ orders, and on nursing home care of individuals who could have continued to live independently.
Researchers estimate that non-compliance causes one in every 10 hospital admissions. Among heart disease sufferers alone, more than 300,000 hospital admissions and 125,000 deaths every year are traced to failing to follow the prescribed therapy.
The problem is growing, Haynes thinks, because “the number of effective treatments is increasing, but we aren’t addressing the compliance problem at all.” Managed care plans, with their financial incentives to head off costly illnesses, should help. “But sometimes health plans think that if people are following treatment more closely, they’ll use more drugs and cost more,” Haynes says.
Non-compliance is rooted in deeply held attitudes among both doctors and patients and is made worse by the trend in medicine toward more rushed encounters between the two.
The first step in improving compliance is for doctors to recognize that patients need to be involved, not just commanded. “You can’t really tell people what to do,” says Dr. Shelly Greenfield of New England Medical Center. “You should become the patient’s agent, not his master.”
This involves several stages. “First, patients need to understand how and why to use the medication,” notes Richard Herrier of the University of Arizona College of Pharmacy. Herrier and others say patients often leave a doctor’s office clutching prescriptions without understanding why they’re supposed to take them.
That helps explain why 1 in 10 prescriptions is never even filled, and the doctor may never know.
A key factor for many elders is cost. Medicare does not cover drugs, and private insurance plans that do are becoming increasingly costly.
Once doctors have explained a regimen and addressed the cost issue, they need to motivate patients to follow through.
Good follow-through requires doctors to be flexible and realistic. For example, Greenfield tried to persuade 74-year-old Odessa Bowden of Milton, Mass., who suffers from diabetes, to divide her daily insulin into several shots instead of her accustomed morning injection, to achieve better control of her blood sugar.
Bowden resisted. “I’m a pro at taking my medicine,” she says, “but I know if I get busy I’d forget to take it if I had to do it at noon and again at 5. Thank goodness, Dr. Greenfield agreed we could do it once a day.”
Whatever it takes, those who care for elders say the effort to maximize compliance is well worth it. “As a geriatrician, I really love it when there are problems related to medications, because we can fix them,” says Dr. Muriel Gillick of Hebrew Rehabilitation Center for Aged in Boston. “It makes us feel we have done something important.”
