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The Costs of Noncompliance
October 1, 2010   
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Przemys³aw Kardas, M.D., head of the 1st Family Medicine Department at the Medical University of £ód¼, talks to Piotr Bartosz.

You are the scientific coordinator of a European Union project called Ascertaining Barriers for Compliance (ABC), which aims to prevent patient noncompliance in Europe. You also came up with the idea for the project. Why is it so important that patients should do what their doctors tell them?

Many patients do not take their medicine as prescribed. They refuse or delay treatment, change the dosage on their own, skip some procedures and complete their treatments too early; some even abandon long-term treatment. The ABC project was launched in response to an appeal from the European Commission as part of the EU’s 7th Framework Program.

The ABC project began in 2009 and will run until 2012. It is being carried out by an international research consortium led by the Medical University of £ód¼. The consortium partners are experts in research on noncompliance, or why patients refuse to comply with medical advice. The partners are the Bangor University in Wales, the Keele University in England, the Aberdeen University in Scotland, Katholieke Unversiteit Leuven in Belgium, and the Pharmionc Systems company in Switzerland, which specializes in precise surveys of patient compliance. The research covers 16 European countries. Apart from Poland, Belgium, Britain and Switzerland, which are directly involved in the project, surveys will be carried out in Austria, the Czech Republic, Denmark, Finland, France, Greece, Germany, Hungary, Italy, the Netherlands, Portugal and Spain. We want to work out European health policy guidelines to prevent patient noncompliance.

What are the main aims of the ABC project?

The primary objective is to develop a set of recommendations for health policy makers, including ministries, central EU institutions and the World Health Organization. These institutions are interested in pursuing activities aimed at ensuring medical treatment is more effective, so that better quality of health can be attained for the same money. The results of our research can also help insurance institutions.

Financed with public funds, the results of our research will be available to anyone interested free of charge. Apart from recommendations for the public administration and private institutions, we are planning to come up with recommendations for institutions training physicians, nurses and pharmacists. These people, community nurses in particular, should be the ones to make sure that patients benefit from their treatments to the greatest possible extent.

We also want to suggest some ideas to the pharmaceutical industry, which, quite naturally, is interested in our field of research. Patients who take less medication than prescribed by their doctors mean lower profits for the pharmaceutical industry. While the immediate goal of the ABC project is to help patients, the recommendations will also benefit the pharmaceutical industry.

Will public awareness campaigns targeted at patients be combined with similar campaigns among healthcare professionals?

The misuse of pharmaceuticals can lead to tragic consequences. For this reason, physicians find it illogical to think that patients could voluntarily give up the benefits offered by modern treatment methods. Many doctors refuse to accept the fact that, despite their high expertise and all the effort they put in treating people, some of their patients fail to comply with their advice and refuse to cooperate.

Apart from looking for the most efficient preventive measures, the ABC project seeks to raise awareness of the problem among the medical community in Europe. We want to come up with know-how and a set of teaching aids to be used in training physicians, nurses and other healthcare professionals.

How can doctors be sure that patients do not follow their instructions?

Physicians frequently deal with patients who seem not to respond to their treatment regimens despite being administered the necessary drugs. Consecutive checkups show that, for example, the patient’s blood pressure remains unstable, the heart rate has not slowed down as expected and the blood sugar concentration is not what it should be. In situations like these, doctors usually do one of two things and either administer higher doses of a given drug or prescribe more drugs and treatments. Intensified treatment seems only natural under such circumstances, but the next checkup shows that the patient still has hypertension, the heart is racing and the blood sugar level is far from satisfactory. So, should the dosage be raised again and the list of drugs expanded? Playing cat and mouse like that can go on until the doctor stops to think or the patient finally admits that they simply are not taking the prescribed medication. Research shows that up to 50 percent of patients make radical departures from what their doctors tell them to do. This happens in the case of both chronic conditions and acute diseases like infections.

Isn’t this simply because pharmaceuticals are too expensive? Or that patients get their “medical education” from online forums?

A patient who browses the internet for information is a marvelous patient, as he or she is clearly determined to get treatment. Such a patient is a potential partner to work with the doctor and so the doctor-patient relationship will be better than in the case of patients who seek no information because they do not want to undergo any treatment in the first place. Whether the doctor is happy with what the patient finds online is a different story because a lot of information available on the internet is unreliable.

Cases where patients failed to comply with their doctors’ recommendations were described in ancient times by Hippocrates, the father of medicine. Nothing has changed in this area since then, except for the fact that modern treatment methods are really effective and so the damage that noncompliance does to patients, their families and all of society is immense.

What are the consequences of patients failing to comply with medical advice?

Depending on the kind of treatment, such a behavior may prolong a disease like bronchitis or lead to permanent complications—such as a heart valve disorder after inadequately treated angina or a stroke caused by an inefficient treatment of hypertension. For some patients, hospitalization may be necessary—for example, in the case of inadequate treatment of diabetes. Patient noncompliance may also lead to an unplanned pregnancy when birth control pills are taken irregularly, or even become the cause of death when a patient stops taking drugs for heart failure. It is easy to figure out that these and other consequences translate into greater demand for healthcare benefits and thus direct and indirect costs resulting from a temporary or permanent inability to work, worse quality of life and so on.

The indirect costs of patient noncompliance are hard to estimate, but some time ago they totaled around $100 billion annually in the United States alone. The cost of health services and treatment related to patient noncompliance in Poland is estimated at zl.6 billion a year, which is more or less the equivalent of what the National Health Fund spends annually on basic healthcare. This is food for thought, especially as a lot seems to indicate that patient noncompliance is a major obstacle preventing a better health status of societies. This applies to both developed countries, where lifestyle diseases are the main concern, and developing countries, which are struggling with infectious diseases requiring strict adherence to treatment plans—such as HIV/AIDS, tuberculosis and malaria. This problem is at the center of a recent report by the World Health Organization. The European Commission is also aware of the problem; it has included patient noncompliance among issues covered by the EU’s 7th Framework Program for Research and Technological Development.

How is the ABC project coming along?

The project is expanding fast, allowing us to work with the world’s foremost experts in this field. Polish research institutions, including those dealing with medicine, are in for a veritable revolution. Public money is running out and grant applications will become the basic means of survival. We have a lot of successes under our belt, as the Medical University of £ód¼ has taken part in over 20 research projects co-financed by the EU. Looking forward to more successes, we train young staff members at our university on how to secure European funds for research.

The first results of the research conducted as part of the ABC project were presented at the 13th European Symposium on Patient Adherence, Compliance, and Persistence in Bangor, Wales.

So far, tens of thousands of surveys have been made, helping identify over 200 factors that influence patient compliance. These include the patient’s awareness, the form in which medical advice is provided, the price of pharmaceuticals, the fact whether or not drugs are administered in a way that the patient feels comfortable with, easy-to-use packaging, infrequent dosage, absence of side effects, and the ease of combining taking drugs with other activities. The way in which the doctor and other individuals supervise the patient plays a part as well. The absence of standardized terminology in this area makes it extremely difficult to compare different methods objectively and, consequently, draw conclusions as to which methods are cost-efficient and worth applying on a larger scale in Europe.

What is the budget of the project?

In the EU terminology, the ABC project is defined as a “small” project, with the upper funding limit at 3 million euros. But the total budget of the project is higher, because not all the costs are paid for by the EU. However, this is an exceptionally profitable deal for a nonprofit, public institution like our university and most other universities in Poland, because for every zl.1 we spend, we get zl.1.30 back from the EU. That way, the EU not only finances the entire project, but also makes sure our university makes a profit out of it.
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