Risk Management

How to Improve Patient Compliance

By Paul Weber, JD

Argus, June, 1994

Caring for a patient means more than merely treating a patient’s disease. To reduce malpractice risk and assure the best possible result, the ophthalmologist must be certain that the patient understands and actively participates in the prescribed treatment plan. The patient’s cooperation is essential not only to achieve the benefits of the treatment but also because noncompliance could lead to an undeserved liability claim against the ophthalmologist.

Scope of the Problem

A number of medication studies highlight the scope of the problem of patient noncompliance. A study at the Veteran Affairs Medical Center in West Haven, CT, showed that 82% of patients complied with instructions five days after their visit to a physician. However, compliance dropped to 65% one month after the visit. This study illustrates the temporal nature of a patient’s ability to follow a treatment plan: As time passes, some patients forget, begin to feel better, suspect the medication is not helping, or become less motivated to adhere to the treatment plan.

Another medication study, conducted at Carnoustle Health Centre, Tayside, England, showed that a surprising number of patients are noncompliant from the beginning, never even starting their course of treatment. In this study, 15% of patients failed to pick up prescriptions they had ordered at a pharmacy.

Sometimes when medical malpractice claims arise, the role of noncompliance in causing the injury or poor result may not be fully appreciated by those who evaluate the claim. Thus, identifying noncompliant patients becomes extremely important for purposes of risk management.

Identifying the Noncompliant Patient

Physicians should try to determine if patients are complying with a prescribed treatment. One of the best methods is to ask a series of questions about the treatment regimen. For example, with a postop ophthalmic patient who was prescribed antibiotic ointment, ask, “What ointments are you using?” “How often do you use the ointment?” “How much ointment do you use?” “Can you demonstrate how you were taught to use the ointment?” These questions will compel the patient to reveal if he or she is using the medication properly.

Such open-ended questions are invariably better than the direct question, “Have you been applying the ointment?” This allows a noncompliant patient to cover up and assumes that the person has filled the prescription. This patient may be one who never even picked up the medication after it was ordered.

If a claim should arise where the patient failed to follow a treatment regimen, the plaintiff’s (patient’s) attorney will thoroughly investigate what the ophthalmologist did or did not do to instruct the patient in the treatment plan and will want to know what steps, if any, the ophthalmologist took to determine if the patient was compliant.

Intervening with Noncompliance

When an ophthalmologist discovers that a patient is noncompliant, the physician should identify the reasons so the problems impeding the patient can be remedied. If a postop ophthalmic patient is not using the prescribed ointment, this may be because the patient is having difficulty administering the medication or finds it irritates the eye. If the ophthalmologist questions the patient further, the physician might discover that the patient did not understand the purpose for using the antibiotic ointment, i.e., to prevent infection. A patient may discontinue using a medication if an immediate benefit is not realized.

Even if prior to surgery a patient is given oral or written instructions describing the benefits of a medication, compliance studies indicate that the ophthalmologist cannot rely on a patient remembering these instructions or having the diligence necessary to follow them.

Noncompliance may be financially related. Patients may be too embarrassed to admit they cannot afford a prescribed therapy. In these situations, the ophthalmologist could give the person a sample or try a less expensive, though equally effective, medication or therapy. Financial hardship presents a potential liability problem if the patient later states that he or she would have bought the medication or undergone the therapy if the physician had made clear the importance of the treatment. Carefully document any refusal of or delay in treatment that is caused by the patient. In some cases, the physician may want to have the patient sign a refusal of recommended medical or surgical treatment form.

Another reason for noncompliance is that the treatment may be inappropriate for the patient, who may feel the inconvenience or side effects of a medication outweigh its benefits. With glaucoma therapy, pilocarpine can cause such an accommodative spasm that the patient cannot function after using the drop. The patient may be able to help the ophthalmologist determine what therapy is best in a particular situation. Without allowing the patient’s health to be jeopardized, the ophthalmologist may want to discuss how to accommodate the patient’s preferences. Again, carefully document the reasons for any change in a selected course of treatment.

The time taken to talk to a patient to secure compliance with treatment is time well spent. Patients who understand and appreciate the importance of following their treatment plan are less likely to bring a claim against the physician for complications arising from their own noncompliance.