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Consequences of Non-Compliance
By Nancy Kennedy

When people with chronic medical conditions fail to improve even though they are receiving appropriate medical treatment, the reason is often a complex problem that perplexes healthcare professionals: non-compliance, also called non-adherence. The term means the failure or inability of patients to follow the regimens prescribed by their physicians to help them manage their conditions, maintain their health and avoid complications. Non-compliance can take the form of failing to take prescribed medications, neglecting to keep appointments or refusing to follow dietary recommendations. It results in the development of avoidable and often severe complications which in turn lead to the emergency room, hospital admission and worsening health. It's a common and frustrating problem for physicians.

People with diabetes can live healthy lives when they understand their disease and make the modifications it requires. This means taking medications including insulin, losing weight and following an appropriate eating plan. It can be a tough adjustment, but the consequences of not managing this disease can be dreadful: skin problems, painful neuropathy, loss of limbs, kidney disease, loss of eyesight, heart disease and other problems. People with high blood pressure may be instructed to follow a low salt, low fat diet, take anti-hypertensive medication and lose weight. Uncontrolled high blood pressure can lead to stroke, heart attack, vision loss, heart failure and kidney disease.

There are numerous reasons why patients fail to follow their doctor's or dietician's recommendations. Sometimes, it's a lack of understanding: in the crisis of hearing a new diagnosis, many people are simply unable to take in and process the information being provided. Inadequate patient education can be the problem: it may be an overwhelming amount of information; or, it may be the opposite – not enough. Some patients receive printed handouts; others receive verbal instructions or are directed to web sites. Patient education is more likely to be successful when it is customized to meet individual patient needs, but that is not always possible.

Practical obstacles can interfere with a patient's ability to comply. Keeping appointments, for some, may involve making arrangements for rides, child care or eldercare; or having sufficient funds for gas, parking and co-payments. Lack of financial resources can be a major obstacle, forcing the patient to forego filling a prescription. Access is not a simple matter for many, who depend on public transportation or have mobility challenges.

Often, non-compliance is about the challenge of making lifestyle changes. Sara P., a 52 year old woman from Bridgeville, says that she and her husband go out several times a week for Chinese food. Sara's doctor has instructed her that her high blood pressure is not improving because she indulges in high salt foods, but Sara has been unwilling to change her habit. Even worse, Sara misunderstands her blood pressure medication, taking it only when she feels stressed, instead of daily.  As a result, her blood pressure continues to be a problem and her risk for stroke and heart attack grow greater.

Wayne Evron, M.D., a board certified endocrinologist on the Medical Services Staff at St. Clair Hospital, finds that taking a positive approach with his patients is most effective. He encourages his patients, many of whom are diabetics, to aim for improvement rather than perfection in their health habits. "I tell my patients to do their best to make moderate changes rather than drastic ones. If you need to lose weight, make it your goal to lose 10% of your weight. You're more likely to succeed when you set reasonable goals. When you try to be perfect, you set yourself up for failure."

Dr. Evron says that there are some patients who do not come in for maintenance visits, but only when they have a crisis. When this happens, he says, it is not helpful to berate the patient, but to educate them, bringing in the dietician and diabetes nurse educator to help out. He also points out that there may be depression involved: "Depression can be a major factor in non-compliance. It prevents people from taking care of themselves. In my experience, depression can be related to high blood sugar; when you improve the blood sugar, the depression improves and the patient does better."

Every patient is unique, Dr. Evron says, and he tries to tailor his teaching to the individual. "My basic message is this: live your life and find ways to incorporate healthier habits into your lifestyle. You can get to good control without going overboard. Any change is an improvement."

To contact Dr. Evron, call (412) 942-7295.

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