Tuesday, February 15, 2011

Health Reform's Open Frontier: Achieving , Monitoring,and Supporting Patient Compliance

There exists limitless opportunities in every industry. Where there is an open mind and a willing hand, there will always be a frontier.

Charles Kettering, 1876-1958

What I am about to propose is technologically doable. It is doctor-directed and patient-centered. But in this land that protects patient privacy and freedom to behave as one wishes, it may be difficult to carry out.

The last frontier in health reform is ensuring patient compliance. Until now most of the energy, money, and federal government policies have focused on physician compliance. This may be a misdirected effort. Poor patient outcomes may depend more on patient failure to comply with doctor advice and directions than on what doctors do.

What happens once patients leave the office may be more important than what happens in the office. In a survey conducted by Consumer Reports of 660 physicians, the top complaint of 37% of doctors about patients , was that patients did not comply with what they were told to do (Wall Street Journal Health Blog, “Survey: What Doctors Tell Patients (and Vice Versa,” February 8, 2011).

A Few Facts

Before going any further, a few obvious facts.

• 30% of Americans have hypertension.

• By far, the #1 cause of death is a combination of cardiovascular and chronic lung diseases, which kills one million Americans each year.

• 20% of Americans have diabetes, and 50% are overweight.

• Americans walk too little and consume too much salt.

• 30% of Americans never fill their prescriptions or do not adhere to the prescribed regimen of taking their medications.


Now, a few scattered anecdotes of what has been done to curb this epidemic of cardiopulmonary and other diseases, in part triggered by patient noncompliance and inappropriate behavior.

• Employers have launched a series of wellness programs.

• William Bestermann, MD, an internist at the Holston Clinic in Kingsport, Tennessee, has led a vascular center in which patients’ hemoglobin A1C, blood lipids, and blood pressures are scrupulously monitored, and patients are constantly advised on what to do to improve their cardiovascular status. Dr. Besterman’s operational concept is that hypertension, diabetes, kidney disease , dyslipidemias, and cardiovascular complications are all interrelated and should be approached as part of the same metabolic universe.

• Stanley Feld, MD, a retired Dallas endocrinologist, when in active practice, oversaw the monitoring of a large diabetic population. Dr. Feld had his patients sign a contract to abide by his rules or not to be his patients. In addition, he would gather them together to cheer them on and created T-shirts bearing the message “In Control.” Doctor Feld’s patients were hospitalized at 1/6 the rate of the diabetic population as a whole.

• Walter Kempner, MD, of Duke University Medical Center, who died in the 1990s, ran a series of “Rice Houses” in which patients were on strictly monitored “Rice Diets.” Doctor Kempner measured the salt in the urine to see if his patients were following his diet. These patients had advanced diabetes, health failure, hypertension, renal disease. In 1944, doctor Kempner published the first of a remarkable series of papers showing that many of the lifestyle diseases could be arrested or reversed by proper modification of diet and exercise.

• Doctors in 35 states are dispensing drugs from their offices. They profit from this dispensing, which delivers drugs at well below rates charged in pharmaceutical outlets, but their cogent argument is that when they hand their patients the drug before leaving the office and talk to them directly about effects and side effects, patient compliance is much higher than if the prescription is filled elsewhere.

• Randy Moore, MD, CEO of American Telecare in Eden Prairie, Minnesota, has placed audiovisual devices connected by ordinary phone lines at the bedside of chronically ill homebound patients. Through these devices, doctors and nurses can monitor weight, blood pressure, blood oxygen, listen to the heart and lungs, and observe the patients. Patients control the devices and have proven to be extraordinarily adept at learning and spotting complications. The result? Readmissions to the ER and the hospitals have dropped dramatically.

• Steven Anderson, an exercise physiologist in St. Paul, Minnesota, in conjunction with other exercise physiologists, has developed an easy-to-use, portable, inexpensive, low-risk cardiopulmonary testing system (Shape –HF), validated by the Mayo Clinic, that non-physicians can administer and that detects early and late heart and lung disease and that predicts risks of hospitalization and death.


I am proposing that doctors and patients adopt or consider a systematic, organized, and purposeful regimens or methods to help monitor and direct patient behavior and compliance.

These regimens or methods , would depend on the patients’ condition and problem, might include these elements.

• Dispensing drugs in the office, with face-to-face instructions from doctor-to-patient to increase patient compliance.

• A pedometer attached somewhere at the waist or lower extremities to check for physical activity (10,000 steps a day is the goal, but 6000 is more realistic).

• Telemonitoring devices to check for blood glucose, hemoglobin A1, lipid levels, blood pressure, and heart rhythms.

• Bedside audiovisual devices for the homebound and chronically ill.

• Periodic physiological evaluation for cardiac and lung function by a portable, small, low risk stress system to be administered in decentralized settings to check for coronary disease and/or pulmonary function and to have automated printouts pointing to the presence of heart or lung dysfunction with prognostic information.

All of these things could be done in decentralized settings under physician guidance with patient permission and patient initiation and control. In the end, physicians could support positive patient behavior and help control patient health destinies. Patient compliance with medical advice and instructions, aided and abetted by cost effective measurements, is the new, still largely unexplored frontier of health reform and entails disease prevention, symptom monitoring, and complication control.

Richard L. Reece, MD, blogs at Medinnovation and has a website under construction. www.doctorreece.com, with title of “The Doctor is In.” He is the author of three recent books, Obama, Doctors, and Health Reform (Iuniverse, 2009), Innovation Driven Health Care (Jones and Bartlett, 2007), and an E-book, Pros and Cons of Accountable Care Organizations (Practice Support Resources, 2011). He works with but does not speak for The Physicians Foundation, a 501C3 organization representing physicians in state medical societies. Opinions expressed in his blogs are his alone. He can be reached at rreece1500@aol.com, or 860-395-1501.

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