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Peter J. Papadakos MD, FCCM, FCCP, FAARC, FNIV
Director Critical Care Medicine, University of Rochester

The global pandemic has had a major impact on ICU utilization.  We have all experienced major shortfalls in being able to admit critically ill patients to properly staffed critical care units. This crisis has also been an opportunity for neurocritical care professionals to look inward and address how we can decrease the incidence of hospital and ICU admissions.  One of the major addressable factors leading to hospital admission and ICU care is patient non-compliance.  As an active ICU clinician, I can tell you I am confronted with patients for whom non-adherence plays an active role each week in my practice.  We all have patients in our units who did not take their antihypertensive, antiarrhythmic, anti-seizure, and diabetes medications, and who have not used their CPAP machines to care for their sleep apnea.

Patient compliance with a proper medication regimen is essential for the success of their medical therapy, especially in the treatment of chronic long-term illnesses.  Estimates of non-compliance among some patient groups range from 26%-59% worldwide. Elderly patients are at the highest risk and make up the bulk of our critically ill admissions.  Their impact on our ICUs is substantial, as they often have a prolonged length of stay and require placement in rehabilitation or long-term care facilities.  Specific factors associated with higher rates of non-compliance in this at-risk population include living alone, using two or more medications, not receiving assistance with taking medications, and using two or more pharmacies. ¹

This issue raises very real questions we need to address, as patient non-compliance can have major downstream implications. How many stroke admissions could have been prevented had patients taken their antihypertensive, antiarrhythmic, and anticoagulant medications as directed? How many patients with epilepsy would have avoided a visit to our emergency rooms and ICUs if they had taken their medications properly? These are only a few examples of classic Neuro ICU admissions triggered by non-adherence.

How do we address this issue as neurocritical care professionals?  I believe that as a diverse group of practitioners, nurses, social workers, and pharmacists, we are in an ideal position to impact both our patients and our health systems. We have a pivotal role to play in decreasing ICU admissions and improving the lives of our patients, and we can do so by addressing patient non-compliance. We need to actively engage our patients and the health infrastructure to tackle this core issue.

Our first goal should be to prioritize patient education and be active with targeted talks to our elderly and senior patients, as well as their family and caregivers. This group has an especially great fear of stroke and cardiovascular disease, and an important first step in combating this fear is to provide education on the increased risks associated with not taking their medications. Senior, veteran, and church groups represent another target for us to reach out to, as building partnerships with these groups can help provide ground-level community speakers on this important topic. Such talks can then be coupled with blood pressure and other health screening clinics in the community to increase patient engagement and understanding of their individual health details.

Pharmacists and social workers can also play major roles in increasing patient compliance through their unique skillsets.  As part of comprehensive multi-disciplinary efforts, universal electronic medical records should be reviewed to determine how many pharmacies are being used by patients and whether they are receiving support services like visiting nurses.  Medications can also be reviewed to identify opportunities to streamline medication regimens and centralize prescribing and dispensing to one pharmacy at the lowest cost. Meanwhile, social workers should arrange for needed support services and develop channels for patients to obtain their medications affordably. Case managers and nurses can further ensure that patients are reminded of outpatient follow-up appointments so their health can stay on track in the long run.

There are many health care inequities that the pandemic has identified and we as a society need to actively address them so all patients can have equal access to the best care possible. Because we are engaged in the delivery of an especially costly form of care, we must do more to shift costs equitably. This should begin with improving patient compliance and improving systems of outpatient care, and we can get the ball rolling in the ICU. 

What Can I Do

1. Educate patients on medication adherence in a social environment: senior centers, veteran halls, church groups, etc.
2. Ensure systems are in place to aid in medication adherence: health educators, visiting health services, etc.
3. Solicit in-depth input from pharmacy: review medication lists, centralize medication delivery at one pharmacy at the lowest cost, etc.
4. Provide ongoing reinforcement to patients identified as at risk for non-compliance: via phone, email, internet, etc.
5. Ensure systems are in place to provide equity in health care delivery in your individual communities.

References

1. Nanada C, Fanale JE, Kronholm P. The Role of Medication Noncompliance and  Adverse Drug Reactions in Hospitalizations of the Elderly. Arch Intern Med. 1990;150:841-845