Patient Adherence: Understanding Why We’re All Bad at It

I did a small unofficial survey of PTs in private practice. It only had two questions:

• What percentage of clients do you estimate complete their home exercise program (HEP) sufficiently to make optimal progress in the treatment of a typical musculoskeletal condition?
• Assuming no barriers from insurance, what percentage of clients do you estimate to complete a course of treatment sufficient to make optimal progress in the treatment of a typical musculoskeletal condition?

The questions were wordy, the sample size was small, and the answers varied more than you might think—but the median answer to both was about 50%.

Perhaps your experience is different, but my strong impression is that:

• PTs can be quite gloomy about the fact that people don’t fulfill their HEP ‘obligations’, nor make all their visits, and 
• PTs usually do this lamenting in private—and when they think only other PTs are listening.

This is understandable, as most of them are trying to represent their profession well while resisting the urge to claim loudly and publicly that some days they’re not sure why some people come to PT at all. But what PTs need to understand is this: adherence to treatment plans is bad because your clients are perfectly normal people. Adherence is bad almost everywhere in health care.

In the rare cases where adherence is high, their one commonality is that they address something life-threatening. For example, chemotherapy can have horrible, debilitating side effects but adherence rates to medication are more like 80%. However, if we take one step away from the life-or-death consequences of cancer, and look at something that’s only ‘very serious’—like conditions you’d treat with anti-psychotic or heart failure medication—adherence rates fall again.

To better understand this, let’s take a look at how we are currently defining adherence.

What is adherence?

As a topic of academic study, adherence in health care is defined as something like “the successful execution of a mutually-agreed plan of care.” (Note that we left ‘compliance’ out of the definition because it seems that people rather resent being told to ‘comply’ to things they didn’t necessarily agree to.) It sounds like a broad definition because it is. If behavior interacts with long-term medical treatment, someone has studied adherence to it.

Per the World Health Organization (WHO), this includes:

“Seeking medical attention, filling prescriptions, taking medication appropriately, obtaining immunizations, attending follow-up appointments, and executing behavioral modifications that address personal hygiene, self-management of asthma or diabetes, smoking, contraception, risky sexual behaviors, unhealthy diet, and insufficient levels of physical activity…”

Adherence is such an important factor in health care that the WHO commissioned an entire report on it, which calls adherence to a treatment plan “the single most important modifiable factor that compromises treatment outcome.” However, in developed countries, adherence to long-term therapies in the general population is around 50%. Which is exactly the same percentage I found from my aforementioned PT survey. 

In other words, we don’t have a ‘my patients are lazy, bad, or problematic’ problem—we have a ‘literally everyone in every field of health care is bad at adherence’ problem. Subpar adherence is a human problem, not a PT problem.

Why are we bad at adherence as a species?

The answer is multifactorial. Most reviews of the adherence literature list more than a dozen factors—and a recent paper even splits this into 31 areas over 6 factors. (See the chart below for context.)

Figure 1; from Kvarnström et al. 2021; the spelling mistakes aren’t mine.

Some of the medical items we can immediately discard (i.e., polypharmacy effects, medicine shortage, and medication complexity), and we can adapt the above into six important points which will probably sound familiar:

1. I forgot.
2. I don’t have time.
3. I don’t know why I need to do it.
4. Exercise hurts.
5. I’m not in pain right now.
6. I don’t trust doctors.

The same solutions to these issues are inevitably offered, and you can find them in many academic papers, including much of the literature on PT: more structure, flexibility within that structure, consultation, accountability, education, persistence. However, if it was truly that simple, everyone would be doing it.

Why is addressing patient adherence so difficult?

Directly addressing the problem of adherence creates more work for your patients and for you. Not only does it take more time (which is uncompensated as it’s unbillable), but it may be difficult to schedule and maintain as every new initial evaluation is coming with an unpredictable amount of extra work.

It’s also extra emotional work. The research on emotional work in health care is actually quite unclear. We know that at any given time there is an inverse relationship between burnout and empathy—but is this because:

• More empathic people are more likely to resist burnout; or
• Burnout reduces empathy; or 
• Some other combination of factors? 

All we truly know is that it is more work, by definition, to personalize programs, invest in and educate patients, and maintain a therapeutic alliance over time.

Both of the above should be considered in an environment where:

• PT burnout is quite common, and 
• PT billables are falling.

As an illustration, I took the top 10 CPT codes that PTs bill, and indexed their Medicare reimbursements against 2020 values for the last two years in Colorado. They are trending down (you can see the Relative Value Unit dilution at work here), and very definitely down relative to inflation. Unfortunately, the gap that you see between the bottom of those red bars and the ‘inflation’ value (9.5% over two years) is substantial.

This is a business environment which makes “extra work” a fairly unpalatable idea. You might argue that treating patients more effectively and for longer periods will provide a financial reward, but that too is unpredictable. What if higher expectations for participation in treatment drive them away? Then an increased adherence focus would result in more uncompensated clinical work, more administrative work, and worse patient outcomes.

So, to recap:

• Adherence problems are a feature of all health care (and don’t exist solely in PT.
• We are quite well aware of how to improve adherence.
• However, it is more uncompensated work in a difficult professional and fiscal environment!

In part two, we’ll discuss what we can do about it.

To hear more from James, join us at Ascend—the ultimate rehab therapy business summit—where he will be speaking about the remote therapeutic monitoring technology behind Cipher Skin, and its benefits in PT practice. Check out our full agenda here.