Achieving Patient Adherence in the Wound Care Clinic

The term “compliance” is no longer appropriate to define patient behaviors toward care planning. How can wound care providers determine “adherence” and help patients improve self-care?

Adherence to one’s plan of care is a major healing variable that is rarely addressed in the literature. Our payer system is just beginning to address this by looking at cellular and tissue-based products and smoking, but the issue is far greater when it comes to wound care. This article will address the importance of patient compliance related to the patient’s understanding of implications of noncompliance as well as the provider’s understanding of the implications of noncompliance and the importance of taking the time to fully educate patients.

Compliance Vs. Adherence

Patient noncompliance to healthcare regime has been a topic of study for more than 40 years.¹ It is perplexing why medical advice, which is provided in response to query, can then be watered down or even outright ignored by the patient who sought it. As we move closer toward a quality-purchasing-based reimbursement system, patient noncompliance to a provider’s plan of care is likely to significantly impact provider reimbursement due to its obvious link to outcomes. It is therefore worthwhile to gain a better understanding of how to best manage this rather insidious roadblock to cost-effective care.

Noncompliance places a huge burden on the nation’s economy. Its direct and indirect costs have been estimated to be more than $100 billion per year in the United States alone.² One result of early research on this topic has been a better understanding of the term “compliance.” This term originated as part of a provider-centered paradigm and denotes a sense of provider control over the patient. But healthcare delivery should not be about provider control over the patient if the ultimate goal is to promote better patient control over his/her own well-being. Ensuing years have seen the healthcare community embrace the concepts of patient centeredness and activation.  Healthcare is now moving away from the term “compliance” and toward the term “adherence.” Adherence refers to the extent to which the patient’s behavior matches recommendations made by the prescriber.³ This term emphasizes that the patient is free to decide whether or not to adopt the provider’s recommendations and that failure to do so should not be a reason to focus blame. Adherence to a plan of medical care reflects a patient’s choice, which is at least in part based on the information supplied by the provider. Adherence improves upon the definition of compliance by emphasizing the need for the provider and the patient to reach an agreement.

Unfortunately, despite this change in paradigm, the World Health Organization reports the average patient nonadherence rate is 50% among those living with chronic illnesses,⁴ which can include the problem of a chronic wound. The majority of the research on this topic has focused on adherence to pharmacotherapy, but the consequences of not adhering to any aspect of a well-considered plan of care will result in worsening condition, increased comorbid disease, increased healthcare costs, and possibly death. Nonadherence can be a multifactorial problem relating to behaviors such as ignoring or modifying a recommended treatment plan or to an initial delay in seeking care. These behaviors may be motivated by financial constraints, convenience, or even fear. Despite the potentially complex nature of patient nonadherence, there is one universal first step required to address this challenge. This first step is the need for a collaboration between healthcare providers and their patients in order to achieve mutual understanding of and implications associated with an agreed upon plan of care.

Adherence/Compliance in Wound Care Planning

Patient adherence to a wound care plan can be particularly challenging because of the general lack of understanding of modern wound care theory. As of yet, there is no formally recognized “woundology.” This results in the unfortunate fact that education on chronic wound care theory is conspicuously absent from most general nursing and medical educational programs. For example, based on a < 50% survey response rate, which may indicate apathy on the part of the recipients, less than one-fourth of medical schools offer any significant training in wound care.⁵ Further, when this topic is offered, it is offered as an elective. This limited presence of wound care science among general educational programs is inadequate to support a clear understanding of "the explosion of basic science results in the field of wound care over the past 20 years.”⁶ The lack of both patient understanding and provider expertise can promote an increased risk for patient nonadherence due to unintentional acceptance of antiquated treatment theory and a potentially less than fully reasoned or effective approach to the wound treatment plan of care.  

The problem of wound care-related nonadherence has received minimal focus in the literature, perhaps based on the faulty assumption that it doesn’t really matter. However, wound care is a process that is far more complex than a non-specialist may consider it to be. Uncomplicated wound healing requires a multifaceted approach to assessment and treatment, including timely procurement and use of ordered supplies. High-level wound-related research shows wound healing potential is directly related to successful guidance of and adherence to factors involved in the wound healing process,^7,8 which makes it financially foolish to allow a non-specialist provider to guide wound care. Further, in the outpatient wound clinic setting, patients spend significant time away from the watchful eyes of a certified wound care professional.  Therefore, cost-effective, uncomplicated healing is heavily dependent upon patient adherence to ordered plans or processes of wound care. So the question is: How should wound care providers interact with their patients to optimize potential for adherence to a plan of care in the outpatient wound setting?

Patient-Focused Care

Offering comprehensive orientation to the patient is seen as a key factor to successful healthcare modernization.⁹ In other words, it is important to begin to shift healthcare delivery to focus more directly on the diverse needs of each patient. This approach to patient-centered care increases the patient’s willingness to share ideas with the provider and opens opportunities to collect important patient-specific information, which providers can use to guide the unique challenges to that particular patient’s wound care process. Further, a patient is more likely to adhere if there is a sense of cooperation with the provider as opposed to a more unilateral focus.¹⁰ The effort to promote patient-focused care should include an increased willingness to incorporate the use of high-quality wound specialty products. Such products can enhance the patient’s ability to practice self-care, which is especially significant for more compromised and perhaps older patients. Multistep complexity and product failure threaten patient adherence.¹¹ A well-designed specialty product may initially cost more than a generic product, but the cost can be recuperated through improved patient adherence, more effective use of products, and quicker healing rates. Restrictive formularies can limit access to the most appropriate treatment strategy and magnify patient barriers to adherence.¹² The practice of purchasing products based solely on “cost per item” is counterproductive and will ultimately add to overall expenditures.^{13, 14} Wound care facilities and providers who align their practices to a patient-driven healthcare theory will succeed by promoting both patient adherence and cost-effective care.

Expanded Provider Participation

Factors associated with poor adherence are lower educational level, poor socioeconomic status, cumbersome regimens (highlighting the importance of an array of product options), dislike of and perceived inconvenience of treatment, fear of side effects, anger about condition or its required treatment, forgetfulness or complacency, and ill attitudes toward health.¹⁵ Figure 1 shows how providers are positioned as connectors between the patient and external factors that may impact adherence. In an effective provider-patient relationship, providers will engage patients in shared decision-making regarding treatment needs and expected efficacy. As discussed, shared decision-making promotes adherence. Communication is central to the effectiveness of this relationship. Zolnierek et al¹⁶ reported in a recent meta-analysis that poor communication results in a 19% higher risk of nonadherence. A provider who is willing to take the time and put in the effort to communicate effectively with the patient is perceived by the patient to be supportive. The simple perception of provider support has been shown to increase achievement of a positive outcome by 100%.¹⁷ This is certainly important to a provider interested in maximizing quality-purchasing-based reimbursement. 

Patient Cost-Sharing

US healthcare cost is an immediate focus for both providers and patients. Strategies over the years have been employed to control the increasing cost of healthcare delivery. These strategies include protocols aimed at curbing patient overutilization by mandating higher out-of-pocket expenses for the patient. This has included higher copayments, coinsurance plans, more restrictive formulary listings, and a move from branded products to less-expensive generic brands through mandatory substitution. Interestingly, from the perspective of adherence to plan of care, a 30-year review of the literature on the topic revealed increasing patient cost-sharing was completely ineffective and associated with declines in treatment adherence, which, in turn, was associated with poorer health outcomes¹⁸ and increased cost of care. Again, this information supports the idea that efforts to limit quality in order to cut cost can actually end up costing more. 

Multifaceted Adherence Strategies

Roter et al¹⁹ undertook a review of 17 years of compliance-related literature to determine which type of intervention is most effective in promoting patient adherence. They divided the interventions into theoretical focus including cognitive, behavioral, and affective intervention categories. A cognitive intervention for promoting patient adherence involves education. For a wound care patient, this would include instruction about the plan of care, why a particular plan of care has been chosen over another, the patient’s role in proper and timely execution of this plan of care, and reporting when there is a problem procuring the ordered wound supplies. This type of intervention should include clear instruction on the risks associated with not adhering to ordered wound healing strategy as well as an overview of the signs and symptoms of complications to monitor and recommended processes for reporting any concerns to the wound clinic team. A cognitive intervention is enhanced by engaging the patient in the educational process. This can be accomplished by asking the patient to review the instructions and to ask questions or express concerns. This type of active learning has been found to improve adherence.²⁰ An active learning approach to patient education may be initially more time-consuming, but is able to more effectively enhance best results. Behavioral interventions seek to help the patient to alter or eliminate behaviors that work against the desired outcome. This type of intervention can include a discussion on methods of leg elevation to control swelling or on repositioning strategies, safe and proper ambulation, offloading, and nutritional support. The primary goal of an affective intervention is to help patients alter or accept their feelings related to having, treating, or requiring assistance to treat their current wounds. Patients may feel scared or less than capable of managing ordered care. They may also feel helpless or hopeless about their healing potential. The goal of an affective intervention is to neutralize such self-defeating attitudes and to allow a positive flow of energy and effort to be focused on the goal of healing. In summary, Roter and his colleagues discovered that no single strategy was more effective when compared with another. Interestingly, they also discovered that multifaceted interventions combining cognitive, behavioral, and affective components were more effective than use of any single-focus intervention on its own. 

Patient Participation

Participation is a way to encourage patients to engage in their healthcare, which will increase the likelihood of adherence.²¹ Oddly, it is reported that encouraging patient participation is perceived by some providers as a surrendering of their power and control. But, as discussed, the focus of healthcare delivery should not be on the needs of the provider. When encouraging patient participation, it is important to consider the manner in which this participation is prompted. If this is done as a supportive invitation, then patient participation will be enhanced. If participation is stated as a hurried afterthought, then meaningful exchange and participation is less likely. Challenges to patient participation are often related more to patient preference than to the patient’s ability to participate. As a whole, patients tend to prefer to take on a more passive role if they are uncertain about their providers’ acceptance of their participation. Patients will become more collaborative in efforts to participate if they are motivated by the provider to be so. Finally, there are different types of participation that a provider can encourage. These range from an obedient adherence to an interactive participation of self-care guided by the provider’s recommended plan of care. Increased levels of patient participation can become more time-consuming for the provider, but can also improve the appropriateness, safety, and outcome of care while time-reducing the number of complaints and risk of litigation.²² 

From The Patient’s Perspective

A visit to a healthcare provider to resolve a health issue should include a level of commitment, on the part of both the patient and the provider, to the understanding that the success of all efforts will require a working relationship between both individuals. The patient’s adherence to a provider’s plan of care is heavily dependent upon its relevance to solving the health problem. For this reason, the focus of the relationship between the patient and the provider must be generally focused on the needs of the patient. The patient must be willing to share personal information on all aspects related to the health issue and take on personal responsibility for supporting the healing process. The provider is responsible for gathering all the needed information about the patient’s illness in a supportive manner, so as to encourage participation of the patient who has presented in a vulnerable state. The provider is responsible for supplying appropriate education about the health issue and the recommended treatment options so that patients are able to understand their participating roles in treatment. The provider is also responsible for developing and maintaining expertise in the chosen area of practice, which will then improve likelihood of care plan relevance. This is particularly important in the field of wound care, which still lacks formal specialty recognition. The lack of both patient understanding and provider expertise can promote a significant risk for patient nonadherence due to unintentional acceptance of antiquated wound treatment theory and a potentially less-than-fully reasoned or effective approach to wound plan of care. Although wound care, as is the case for most healthcare specialties, does have a complete array of clinical practice guidelines that can guide best practice, even randomized controlled trials are limited by the variables studied. The likelihood of the success or failure of a particular treatment is not identical in all individuals because therapy is not the only determinant of outcome. Clinical reasoning is the pragmatic, tried-and-true process of expert clinical problem-solving. Clinical reasoning must be valued in conjunction with high-level practice evidence if the aim is to provide the best clinical care for all the individuals treated.²³ For this reason, wound care is best guided by providers who have actively sought and achieved the ability for expert clinical problem-solving of challenges related to the care of chronic wounds. This level of care cannot be provided without education and certification in this practice specialty. Henry Ford developed a great method for building cars. But the delivery of cost-effective wound care, which must include patient adherence to plan of care, requires far more than an efficiently run assembly lines. Cost-effective wound care requires communication, education, and understanding. 

Linda Hensley is on staff at Methodist North Comprehensive Wound Healing Center. Jennifer Hurlow may be reached at jenny.hurlow@gmail.com.

References

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