As with many practitioners who practice a comprehensive system of medicine that includes dietary modification, lifestyle interventions and dose-dependent clinical nutrition and botanical medicine, treatment adherence is a common concern for me that can limit the effective management and treatment of chronic conditions, leading to poor outcomes and increased health care costs for my patients.
It’s estimated that the cost burden on the U.S. health care system due to non-adherence ranges between $100 to 290 billion annually.1,2 Furthermore, approximately 30 to 69 percent of hospital admissions are a result of medication non-adherence.3,4
Adherence is defined as the extent to which a patient’s behaviors follow an agreed-upon prescription or treatment plan.5-7 Although often used interchangeably with “compliance,” adherence encompasses a patient’s views and choices and gives them the opportunity to actively participate in the development of their treatment plan.
Despite adherence being a prevailing issue affecting the health care industry, there have been no comprehensive studies investigating treatment adherence in the context of integrative medicine. In response, Fullscript, a leading software platform, online supplement dispensary and patient adherence tool for integrative health care providers and their patients, conducted their own research by interviewing health care practitioners and carrying out a comprehensive review of existing literature in both conventional and integrative medicine. Continue reading to learn more about treatment adherence and some of the top solutions outlined by Fullscript’s integrative medical advisory team.
Factors That Influence Treatment Adherence
The World Health Organization’s (WHO) 2003 report on adherence outlined five interacting dimensions that influence adherence to treatment plans. These five dimensions, along with some of their factors, are summarized below.8
• Condition/disease factors, such as symptom severity, developmental course of the condition, and presence of comorbidities.
• Patient factors, such as forgetfulness, level of motivation, knowledge of the disease and therapy, and feelings towards the treatment or condition.
• Social and economic factors, such as age, race and gender, culture or social beliefs of the treatment or disease, literacy level, living location, income and level of social support
• Systemic and health care team factors, such as access to treatment, patient-practitioner relationship, and scope of care or coverage.
• Therapeutic factors, such as availability of medical support for side effects, frequency of treatment adjustments, presence of adverse effects, protocol complexity and therapy duration.
Although adherence is largely influenced by external contributing factors, treatment non-adherence is often considered a patient-centered problem. Traditional interventions remain focused on only addressing patient-related factors with little regard for the other four dimensions.9-12 The factors described by the WHO have mostly been studied within the realm of conventional medicine and medication adherence; however, many of the themes are applicable to integrative treatment components, including diet modification, physical activity and complementary and alternative medicines (CAM) such as supplements.13-21
Common Barriers to Treatment Adherence
Fullscript’s report on adherence illustrates the complexities within treatment adherence research and management. With the use of a survey and interviews, the Fullscript team identified some common themes such as cost, patient feelings and readiness to change as primary barriers to adherence.22
Of the various barriers preventing patients from adhering to their treatment plans, cost may be one of the most challenging barriers to address. In many cases, the cost of integrative medical care is not covered by private insurance plans, leaving patients with no choice but to pay out of pocket. Patients with severe, chronic or complex medical concerns may also seek care and solutions from numerous practitioners, further adding to their treatment costs.23
Readiness to Change
Patients can present with varying degrees of readiness to change, and some patients attend appointments at the direction of another medical practitioner or under pressure from a family member. If a patient is not committed to making modifications to their diet or lifestyle or adhering to supplement and/or medication protocols, positive patient outcomes can be challenging to achieve.24
Certain aspects of a treatment plan can overwhelm patients, particularly if they’re expected to make significant changes or take multiple supplements per day. Fullscript’s treatment adherence report explains that practitioners often report that their patients express feelings of being overwhelmed, especially in the beginning phases of their treatment plan. Some common barriers I see include lack of education, lack of time, unwillingness to really “partner” with me in the process, unrealistic expectations, lack of self-worth and lack of motivation to change.
Strategies For Improving Treatment Adherence
Using the industry insights gathered through interviews and a survey, the Fullscript Integrative Medical Advisory Team, which I am a part of, identified several strategies that practitioners can implement to improve patient treatment adherence and enhance patient outcomes.25
Assess Patient Readiness
Ask open-ended questions and use motivational interviewing or other evidence-based behavior strategies to understand your patient’s motivations, attitudes and beliefs regarding their treatment. These techniques can help communicate empathy and establish a shared partnership and investment in the patient’s health. Providing education to your patient about their condition, treatment plan, or any potential side effects of their treatment can also offer reassurance.26
Reduce Costs When Possible
Considering that cost is a major barrier to treatment adherence, it’s essential to introduce treatment plans with the patient’s financial restrictions in mind. Support value-based insurance designs, which is a strategy used to reduce costs for highly effective treatment instead of less effective treatments.27 Also, consider financial reward options, such as discounts or other incentives, to encourage treatment adherence.28
Use a Staged Approach
Fullscript’s report noted that 85.9 percent of surveyed practitioners employ a staged approach to improve the likelihood of patient adherence and to avoid overwhelming the patient. Set realistic goals with the patient and introduce treatments one at a time.
Simplifying regimens by reducing dose frequency, offering sustained-release formulations or multi-ingredient formulations, and suggesting products with compartmentalized packaging, can help improve adherence. In fact, treatment adherence has been shown to increase by 13 to 36 percent when patients are offered a daily dose compared to twice daily doses.29 Furthermore, adherence has been shown to increase by 5 percent when patients are offered combination pills compared to individual pills and by 3 percent when offered sustained-release formulations instead of regular-release.30,31
Fostering a strong practitioner-patient relationship can help establish trust in the practitioner’s expertise, thus improving treatment adherence and patient outcomes. A patient who trusts their practitioner is more likely to have confidence in their prescribed treatment plan. Establish trust with your patients by maintaining an open line of communication, offering complimentary introductory appointments, and utilizing an evidence-based approach when building treatment plans.32
You may find that different communication styles work better for some patients. Everyone is so different in how they learn and respond, but taking the time to provide education and learn about the person and what makes them tick is helpful. Some people like weekly five-minute check-ins, whereas some folks prefer text reminders about action items they need to take regarding our plan or program.
Many patients benefit from electronic reminders such as text messages or other automated cues to help them adhere to their treatment plan. Research demonstrates that the most successful technologies for improving adherence provide self-monitoring or feedback to patients.33 If your patient has difficulties remembering to take a supplement or medication daily and on time, recommend a mobile app or suggest that they set a reminder on their cell phone for the same time each day.
Electronic health records (EHRs) are valuable tools as they allow practitioners and patients to organize, collect, manage, and share medical information with ease. EHRs can also be used to provide education, feedback, medical appointment management, condition management and more.34
For those who like to track, there are numerous free and paid apps to help them do so. Smart devices can be helpful as well and virtual dispensing solutions like Fullscript and all of its functionalities can also help patients stay on track with ordering.
Virtual dispensing solutions offer many features to improve adherence. Fullscript’s virtual dispensary features refill reminders, which can ensure that patients have an ongoing supply of their supplements, and auto-shipping for patients following long-term plans who prefer not to place orders manually each month. You also have the option to add instructions or attachments to treatment plans via Fullscript’s online dispensary to provide additional information to patients regarding their treatment plans.
Adherence is essential for optimal patient outcomes; however, ensuring that your patients adhere to their treatment plans is a complicated and common concern among many integrative practitioners. Cost, readiness to change and patient feelings of overwhelm are among the most common barriers to treatment adherence. Several strategies have been shown to be effective for improving adherence, including assessing patient readiness, reducing costs, using a staged approach, communicating with your patients, and leveraging technology. Refer to Fullscript’s treatment adherence toolkit for more information.
Dr. Holly Lucille is a nationally recognized licensed naturopathic physician, lecturer, educator and author of Creating and Maintaining Balance: A Women’s Guide to Safe, Natural, Hormone Health. Her private practice, Healing From Within Healthcare, focuses on comprehensive naturopathic medicine and individualized care. Outside of her practice, Dr. Lucille holds a position on the American Association of Naturopathic Physicians board of directors and is on the faculty of the Global Medicine Education Foundation. She is the past president of the California Naturopathic doctors Association, where she spearheaded a lobbying effort to have naturopathic doctors licensed in the state of California. A graduate from the Southwest College of Naturopathic Medicine, Dr. Lucille’s commitment to naturopathic medicine has been recognized with the Daphne Blayden Award and, more recently, the SCNM Legacy Award.