Compliance – The Bane of the Clinician
Date: 07-09-2023
This is the first of a regular blog I will be posting for Therapy in Motion, TN, P.C. Funny how the very first topic is that which seasoned and new clinicians of every branch of healthcare struggle with, often to epic proportions. Simply put “compliance” is the behavior of following the recommendations given to them by their provider. No big deal right? WRONG. Failure to comply with instructions is in my experience the number one reason for treatment and intervention to fail. This is of course empirical from my solitary perspective, but the research evidence confirms my experience.
In the domain of pharmacology, “nonadherence can account for up to 50% of treatment failures, around 125,000 deaths, and up to 25% of hospitalizations each year in the United States. Typically, adherence rates of 80% or more are needed for optimal therapeutic efficacy. However, it is estimated that adherence to chronic medications is around 50%(1).”The lack of compliance in this case is merely taking a pill. Now when the behavior involves 30 minutes or more of a change in physical activity (ideally) every day, imagine the dismal numbers. Well, we don’t have to. This has been researched. The results are bleak.
“Patients adhere poorly to their prescribed home program, with varying estimations from research. Non-adherence to a home exercise program has been shown to be as high as 50-65% for general musculo-skeletal conditions. In the low back pain patient population, non-adherence to home exercise has been shown to be as high as 50-70%.”
Neurological patients unfortunately have up to a 90% non-compliance rate. This is due to a host of factors from memory issues to family and caregivers being overwhelmed(6). I knew that in developing the Envision Technology System this (compliance) was a very challenging barrier to recovery. I worked over many years to find a way to solve the problem.
During development a host of different methods were tried and even though the overall rate activity improved, it was not enough for the changes in neuroplasticity that were essential. Research had the general answer to what was needed, and this was proven clinically. Yet only a small fraction of patients were able to meet the activity and behavioral goals to effect the desired changes. I followed the recommendations found in research, consulted other professionals( all who found this near the top of list of challenges in working with patients). Some methods were so disastrous it likely caused a decrease in compliance. I tried a program that emailed and texted a patient multiple times per day. It advised walking or performing some specific exercise or activity. What happened was that the patient and even the caregivers were annoyed. They quickly became desensitized to the prompts and even rebellious, almost determined not to comply with their home program. As a result, I had to abandon this approach. This issue was on the front burner in a manner of speaking during the development of the Envision System Technology. Guided treatment was a great technical leap forward, but we needed a way to motivate the patient to work.
The answer came simply enough from the fitness technology currently used combined with a few other elements, It was so simple, I felt a bit of embarrassment. The engineer on the project suggested “why try to re-invent the wheel? Lets start with a calendar and a “dot” that shows activity.” I know personally that this works for me. But for a stroke patient?
After thinking about it, we put together as a part of the technology the following elements to facilitate the holy grail of healthcare…”compliance”.
1. A calendar of the month
2. A blue dot indicating performance of prescribed activity
3. A report either monthly or at any interval which objectively tracked the patient’s compliance rate. This was in simple terms merely a percentage 0 – 100%. The patient and caregivers have ongoing access to this compliance rate and can check on it whenever they wish.
4. They know 30 minutes of actual activity (or more) daily is needed to create desired changes. So blue dots alone are not indicative of anything other than frequency. In other words, they could “cheat”. The total time they are engaged in performance is tracked and that is part of the compliance report.
5. The report is a simple pictorial – objective narrative given to the patient and family. The report consists of the image of the month(s) retrospectively with the blue dots accounting for the time spent exercising. The color of the month will either be Red(insufficient level of exercise/activity to effect a change), Yellow( minimal level of activity to effect a change, but that change will be very slow) and Green( good to ideal level of activity and the best possibility of the desired changes are in place).
This of course was a process, and still is. Empirically though it motivates! My 5 – 10% compliance rate improved to the 60 – 70% range. I know that this does not mean anything in the real or research world. This would have to be studied in a controlled and rigorous fashion.
My 30 years of practice though gives me some perspective. I will share. I believe the elements that contributed to these changes are as follows:
1. The patient and family has access to their compliance level and know it is being tracked and is vital. They are invested.
2. They know exactly what is expected of them. The tiers of compliance and performance expectations.
3. Their program is listed daily and after performance of each activity, it is checked off, this gives a sense of accomplishment to the patient and caregivers.
4. The report is objective. Whether they are in the Red, Yellow, or Green is entirely up to them. The report is objective and factual. No emotion is involved. If they want a yellow or green compliance rate, they increase their frequency and duration of activity. I believe this offers a sense of empowerment to a population that feels powerless.
Most importantly I have taken myself emotionally out of the mix. While I will always try to motivate the patient during sessions or interaction, I let the patient’s performance dictate the result. It does not judge, harass, lecture or shame. It just gives the patient and family factual information. What they do with it is their choice.
References:
1. DiMatteo MR, Giordani PJ, Lepper HS, et al. Patient adherence and medical treatment outcomes: a meta-analysis. Med Care. 2002;40(9):794-811.
2. Wright BJ, Galtieri NJ, Fell M. Non-adherence to prescribed home rehabilitation exercises for musculoskeletal injuries: the role of the patient- practitioner relationship. J Rehabil Med, 2014, 46: 153–158
3 Karnad P, McLean S. Physiotherapists’ perceptions of patient adherence to home exercises in chronic musculoskeletal rehabilitation. International Journal of Physiotherapy. 2011 Jun;1(2):14-29
4. Beinart NA, Goodchild CE, Weinman JA, Ayis S, Godfrey EL. Individual and intervention-related factors associated with adherence to home exercise in chronic low back pain: a systematic review. The Spine Journal, 2013, 13:1940–195
5. Bassett SF. The assessment of patient adherence to physiotherapy rehabilitation. NZ J Physiother, 2003, 31: 60–66
6. Annals of Physical and Rehabilitation Medicine.Volume 53, Issue 4, May 2010, Pages 250-265
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