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Dermatology practices face a perfect storm when it comes to promoting patient adherence. Many conditions for which patients seek out dermatologists have symptoms that come and go, do not instantly respond to therapy, and may require regular application of one or more potentially unpleasant medications. Add in the average physician’s jam-packed daily schedule, and it’s no surprise that managing patient adherence is a top concern for dermatologists.
The first step on the road to improving patient cooperation is to stop taking each incidence of noncompliance personally, says Lawrence Blanchard, MD, managing partner of Dermatology Associates of Virginia, in Richmond. "You can assume that virtually 100 percent of your patients are to some extent noncompliant," Blanchard says, but "in dermatology compliance is extremely important for the success of treatment."
Blanchard says he’s not a natural pessimist, just realistic. He points to a 2004 study by Steven R. Feldman, MD, who asked a small group of psoriasis patients to keep diaries as they followed a prescribed regimen of pills and creams. Feldman secretly placed small computer chips in the caps of the medications to detect when they were actually opened. He found that three-quarters of the patients were out of compliance with the routine after four days even though half of the participants continued to claim adherence in their diaries.
Says Blanchard, "Just assume there's a lot of noncompliance and work from there." He advocates an approach sometimes called CRAS — combine, remind, and support.
Simplify, simplify, simplify is the motto that works for many patients. When possible, Blanchard suggests switching patients to medications that need application only once or twice a day instead of every four to six hours. When two topicals are required, look for creams or ointments that can be applied on the same schedule. Alternatively, a combined medication may be available.
The medication itself could also be a barrier. For example, some topical corticosteroids are available in an ointment but also as a creamy emollient that some patients find more comfortable. "Sometimes the greasyfeeling ointment is the one that works the best, but they just aren't going to do it," Blanchard says. "There are times when it's better to take half a loaf instead of none."
Issuing frequent reminders is a close cousin to good old-fashioned nagging. But repetition can improve adherence. It may be worth the time it takes for a nurse or medical assistant to make a personal call to a patient a few days after he receives a new prescription. "It sounds silly to spend time on that phone call, but if that's a patient you really want to have stick to a regimen, then that initial contact could save you a lot of time, trouble, phone calls, and extra office visits later on," says Rosemarie Nelson, MS, Syracuse, N.Y.-based practice management expert and principal with the Medical Group Management Association's Health Care Consulting Group.
You'll need a lot more than a phone number to keep up with many of today's busy patients, she says. Nelson suggests using low-cost automated appointment reminder and patient contact services that can be easily programmed to send telephone, e-mail, or even wireless text messages to dozens of patients at a time. "For some age groups, like teenagers, [text messaging] may be the only way you can get to them," she says.
Patients should be asked to sign consent forms before they are sent any electronic messages, Nelson advises. The reminders should be kept vague enough to protect privacy but also display a message clear enough to promote adherence, such as, "We hope your treatment is going well. Don't forget to call us if you have questions." The messages could be used to quickly remind patients using topical retinoids or antibiotics that increase sun sensitivity to use sun block before summer holiday weekends.
Patients aren't the only ones who might need reminders. Nelson says patient adherence can be improved when practices beef up their internal communications to remind staff of each patient's special needs at each office visit. And you don't need an EMR, although it helps, she says.
"Put the latest dictated orders at the bottom of the note or in a special part of the chart template so there's always one place staff can look when preparing for that patient's next visit," she suggests. "Then, the medical assistant or the nurse will know to ask, 'How's that treatment going?' as part of the rooming process."
Placing special flags on potentially nonadherent patients' records in the practice management system or on a spreadsheet can work, too. Nelson warns against keeping track of patients via a paper notebook — it's more difficult to share among several staff and tends to become the property of the person assigned to maintain it.
Visual reminders can help grab the patient's attention. Blanchard suggests that pill dispensers often used by elderly patients who take many medications can help parents spot teenagers who skip daily antibiotics for acne.
Whether you follow Blanchard's suggested CRAS approach or make up your own, consider also attacking the adherence problem from the patient's perspective. Determine if a patient's compliance issues are based on emotions, education, or logistics — psychology professor Helen Meldrum, PhD, calls them the EEL factors.
Meldrum, coauthor of the book Provider-Patient Partnerships, has studied the breakdowns in physician-patient communications. These include compliance, which she prefers to call adherence. "Scaring the patient is a common technique I see doctors using for adherence because they figure it's quick and effective, but it usually just inspires rebellion, especially in educated patients. They will push back on what they consider a low-level threat," says Meldrum, associate professor of psychology and communication at Massachusetts College of Pharmacy and Health Science in Boston.
An emotional issue may be why one patient uses too much of a prescribed ointment — she may fear aging and hope the medicine will make her look younger. An educational barrier could prevent a patient from understanding written instructions or an educational brochure. Logistical barriers may cause a patient to skip afternoon applications of a prescribed cream because he has only one tube of the medication and always forgets to bring it to work.
Meldrum suggests listening carefully to the tone of voice in which a patient expresses a concern. Dermatologists and staff should reply with an equal level of concern. "The biggest thing you can do is listen to patients, ask probing questions to find out if their issues are emotional, educational, or logistical, and find a way to address that underlying issue," she says.
Digging into the issues that can block a patient's adherence to medication or treatment protocols may add a minute or two to the office visit. And time is already in short supply for a dermatologist who sees 40, 50, or more patients each day. But with the help of simple technology and a few probing questions, dermatology practices can turn around patient adherence issues.
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