The Noncompliance Epidemic: Patients Are Not Taking Their Meds

In 2011, Consumer Reports published a survey of 660 primary care physicians, “What Doctors Wish Their Patients Knew.” The number-one complaint by far: Patients didn’t take the doctors’ advice or otherwise follow treatment recommendations.

Specifically, patients don’t follow through on their medication regimes: up to 75% of adults don’t take their medications as intended, a problem that is now among the most pressing in healthcare and described as “epidemic.”  When you consider that in the U.S. some 3.8 billion prescriptions are written every year, that involves a lot of people.

Surprisingly, the noncompliance problem even involves patients who are chronically ill and those that have suffered a life-threatening event – in both cases the compliance rate is only 50%.

The follow-through on antibiotics is interesting. Even though you have to take them for a very short time, 5 – 15 days, the compliance rate is still far from perfect. One study showed a compliance rate of 84% when you had to take 2 pills a day, but dropped markedly to 73% when you had to take 3 pills a day.

So what’s the problem?

Forgetfulness is the number-one barrier to compliance, experts believe, although a survey of 10,000 patients found that only 24% ascribed noncompliance to forgetfulness.  Up to 20% failed to take medications because of perceived side effects, 17% had cost issues, and 14% didn’t feel the need to take medication; they believed it would have little or no effect on their disease.

But researchers caution that the reasons may be more troublesome, emanating from the murky depths of human psychology, and which the patients (not to mention medical researchers) may not fully understand.

So for example even when doctors are patients, they tend to act just like everyone else. So if you ask an audience of physicians for a show of hands of who has ever taken an antibiotic, many hands are raised. And if you  then asks how many doctors took the full course of antibiotics even after their symptoms abated many  hands go down.

This points to a deeper concern that says higher compliance rates may not even be possible.  “We’re asking patients to adopt obsessive-compulsive behavior,” admits internist Edmund Pezalla, MD, MPH, National Medical Director of Pharmacy Policy & Strategy for the health insurer Aetna. “Taking medication every day is hard to do. We’re asking people to deal with the same boring situation over and over again. We’re not programmed to do that. Machines do that. Humans don’t do it very well.”

So what’s the answer?

With more than 40,000 peer-reviewed studies on the subject conducted over several decades, you’d think we’d at least be at Compliance 2.0 by now in the state of our knowledge. In reality, it’s more like Compliance 1.5. We are not on the verge of solving this immensely complex problem. The outlines of what is, at best, a partial solution are only just starting to emerge, say the authors of a special report on patient noncompliance.


Single-Patient Hospital Rooms: The New Standard

The new hospital standard

Most people think having a hospital room all to yourself is a luxury. When you’re sick and have to go to the hospital you’re just thankful to be there, so when they put you in a room with 3 other people you aren’t going to question it.

But medical researchers know something that we don’t: Canadian hospitals are hotbeds for infections. Canada’s Chief Public Health Officer just told us in his Report on the State of Public Health in Canada that over 200,000 patients get infected every year, more than 8,000 of whom die. And that the healthcare-associated MRSA infection rate increased by more than 1,000% from 1995 to 2009 (the latest year for which figures are available).

We also know that infection rates of MRSA and Clostridium difficile increase by about 10% with each exposure to a new hospital roommate. And changing from multi-bed to single rooms in the ICU reduces the rates of MRSA and Clostridium difficile by 47% and 43% respectively. In other words, hospital patients are your enemy!

This is why the Canadian Standards Association recently introduced a private room requirement as part of the Health Care Facilities Standard. It was developed with input from representatives of Health Canada and seven Canadian provinces, and specifies that “all inpatient bedrooms in Class A Health Care Facilities shall be singled bedded.” Moreover, this comports with similar standards now in place in  the US, the UK, and Scandanavia.

However good this new standard sounds, it leaves us with a very uncomfortable truth: The standard does not require existing health care facilities to renovate and convert multi-occupancy rooms to private rooms. This matters because most of the hospitals that currently exist in Canada are of an older variety: there are very few new hospitals.

Dr. Michael Gardam, director of infection prevention and control at the University Health Network in Toronto, says a move toward 100% private rooms in Canadian hospitals will “be a relatively slower process unless the government stands up and takes leadership.”

“There are places that have done this, that have had the vision and gone ahead and done it,” such as The Hospital for Sick Children in Toronto, which was built in the 1980s with 100% single rooms, he says.

Dr. Gardam adds that change will have to be driven by demand. “You’re looking to the health care community and to patients standing up and saying that they want 100% single rooms.”

There is another aspect to this debate that bears scrutiny: care of the elderly. A landmark Canadian study published last year told us that 1 in 12 adults in hospital across the country are infected or colonized with the pathogens MRSA (the major offender), C Diff, or VRE. In the back pages of the report was even a more crucial number: the average age of this patient population was over 70.

In other words, it is our seniors who are the most vulnerable and who therefore have the most to gain or lose by the new one patient per room standard.

So if there’s a scramble for single-patient rooms in our hospitals, it seems pretty clear who, in the words of Dr. Gardam, we should be “standing up [for]” and giving those rooms to.

Hospitals Are Built to Spread Infections

This is the problem

“Hospitals built in the 60s and 70s we now realize were built to spread infections,” says Dr. Michael Gardam, an infection control researcher at the Toronto General Hospital.

His statement was made in connection with the construction of the new billion dollar Humber River Hospital in Toronto, which is due to be completed in 2 years. The modern vision of patient care has changed based on hard lessons learned from the SARS outbreak in Toronto 10 years ago and from hospital outbreaks of drug resistant infections. From these hard-learned lessons a number of fundamental things about the design of the Humber River Hospital will be different. For example:

We’ll start with the big one – 80% of the rooms will be single-patient rooms thus minimizing patient-to-patient spread of disease. Dr. Gardam explains that multi-bed rooms and ICUs with bed after bed after bed separated only by a curtain are breeding grounds for disease and need to be done away with.

The ER and Outpatient Departments will be built on  opposite sides of the hospital. That way ER patients who are contagious can be admitted by a special entrance away from everyone else. And outpatients will also have a short walk from their entrance to the clinic so they’re not exposed to anyone else.

We have robots! R2D2-looking things will be used to deliver supplies throughout the hospital thus minimizing human hand contact with those supplies. Apparently the robots are able to call and use elevators on their own, and will email you when the supplies you’ve ordered have arrived.

Additional features in the hospital will be a constant flow of fresh air so that none has to be recycled; mainly hard surfaces because they’re easier to disinfect, and; the strict separation of clean linen and other supplies from soiled linen and used supplies.

Two Canadian reports issued just last year underscore the real and important problem of hospital infections. The first one told us that 1 in 12 adults in Canadian hospitals are colonized or infected with the bacterial pathogens MRSA (the major culprit), VRE or C Difficile. And the second report from Canada’s Chief Public Health Officer issued just 2 months ago and told us that (1) there has been more than a 1,000% increase in Healthcare-Associated MRSA between 2005 and 2009 (the latest date for available figures), (2) more than 200,000 patients get infections every year while receiving healthcare in Canada, and (3) more than 8,000 of these patients die as a result.

So what Dr. Gardam is saying is huge – that in essence we humans, by our very own design (literally), have built-in a guaranteed institutional failure when it comes to the control of hospital infections. In other words, all those people in Canada who get infections each year, and all those people who die each year – it doesn’t have to be that way.

Which raises one other question: If hospital design is a fundamental flaw that in essence breeds infectious disease, what are we doing about all the improperly designed hospitals we have now?

1,000% Increase in Healthcare Associated-MRSA in Canada

Dr. David Butler Jones

Canada’s Chief Public Health Officer, Dr. David Butler-Jones, in his Report on the State of Public Health in Canada, 2013concludes:

(1) The rate of healthcare-associated infections caused by MRSA (HA-MRSA) increased more than 1,000% from 1995 to 2009,

(2) More than 200,000 Canadians a year, while receiving healthcare, end up infected by the pathogens haunting the country’s healthcare system,

(3) At least 8,000 Canadians a year die from the infections, which are increasingly caused by bacteria that are resistant to antibiotics,

(4) These numbers are rising, and

(5) Up to 70 per cent of some types of infections could reasonably be prevented if infection prevention and control strategies are followed.

These stunning numbers give rise to a number of observations:

To begin with, they’re counter-intuitive. The 200,000 people who get infected and the 8,000 who die each year didn’t go to the hospital because they had an infection; rather, it was while at the hospital being treated for some other illness that they acquired the infection. Contracting an infection while in a healthcare setting challenges the basic idea that healthcare is meant to make people well. Hospitals, long-term care facilities, clinics and home care services are meant to help people get better, not make people sick.

Second, the numbers are at odds with comparable reports coming out of Britain and the United States. For example, the US Centers for Disease Control and Prevention reported this past September that their HA-MRSA rates have fallen 54% between 2005 and 2011. And over in Britain, a report out this week said the number and rate of MRSA infections was at its lowest of any quarter since the Health Protection Scotland surveillance program began in 2005, with just 29 cases recorded.

So what’s the matter with Canada?

Dr. Lynora Saxinger

Dr. Lynora Saxinger, who chairs the antimicrobial stewardship and resistance committee at the Association of Medical Microbiology and Infectious Disease Canada says, “There has been a real lack of what I call bold leadership,” which translates into a lack of coordination between the federal, provincial, and local governments.  Saxinger would like the Public Health Agency of Canada (PHAC) to step up and pull together a comprehensive program. She points out that it’s this very lack of a comprehensive program that has us having to go back 4 years to 2009 for the most recent data.

As to Butler-Jones’ point that much of this is preventable, Saxinger also points a finger at her colleagues telling us that physicians are over-prescribing antibiotics by as much as 30-60% which she concedes is “a lot.” And so you get “the risk of [antibiotic] resistance and the risk of side-effects without getting the benefit of treating something you have.”

And there’s one more thing: this recent and important report doesn’t seem to have been picked up and reported on by any of Canada’s major media outlets – I discovered it on the PHAC website while researching another issue.

Which leads us to this question: given the huge number of infections and the lack of reporting and public awareness, should we not be asking whether HA-MRSA constitutes a silent epidemic?

Has MRSA Ruined an NFL Career?

Tampa's Carl Nicks

As we reported last November in The Hercules Factor, Tampa Bay Buccaneer lineman Carl Nicks – all 350 pounds of him – had his season derailed because he contracted MRSA. It started with something we’ve all had – a blister on the foot that, in his case, somehow became infected. The infection worked its way down to the bone and surgery was needed. And as it turned out Nicks did not play one more down of football in the 2013-14 season.

Now reports have surfaced today saying Nicks’ career is in jeopardy because “in the past week Nicks is still dealing with pain in his foot in the aftermath of dealing with surgery and then a recurring bout with MRSA. As a result, there is some doubt about whether Nicks will be able to play next season or ever again. That may lead to the Buccaneers cutting the former high-priced free agent acquisition this off-season.”


It should be noted that Nicks wasn’t  the only Bucs player to be struck down by MRSA.. Kicker Lawrence Tynes also contracted it and didn’t play at all during the season, and though rookie cornerback Johnathan Banks was infected, he was fortunate to miss just one game.

The lessons learned here are that MRSA is a boomerang disease – it keeps coming back – and it likes to strike “mass gatherings:” schools, military barracks, long term acute care facilities, and hospitals – especially hospitals.

We concluded The Hercules Factor with a (much over-looked) study published last year by a research team at Toronto’s Sunnybrook Hospital. They found that 1 in 12 adults in Canadian hospitals were either infected or colonized by MRSA or 2 other organisms. And who were these 1 in 12? Their average age was just over 70: in other words, all of them were elderly.

And thus the question: if MRSA gets into professional  locker rooms and derails the careers of the strongest of us in the prime of their lives, what will it do if it gets loose in hospitals or care homes and infects a blister or a minor cut of a 70 year old?

Children at Risk: Study Shows a 10% Rise Every Year in Kids With MRSA

A USA TODAY investigation just published shows MRSA bacteria, once confined to hospitals, are emerging in communities to strike an increasing number of children, as well as schools, prisons, even NFL locker rooms.

The investigation cites a CDC-led report out this year, where  researchers found that MRSA is making its biggest gains among children. Not only did the study document a 10%-a-year rise in MRSA in kids ages 3 months to 17 tears from 2005-2010, it also found that the proportion of those cases involving community-associated MRSA jumped 55%.

For example, in the Detroit area alone 6 cases of school MRSA have been reported, the last one as recent as yesterday.

“With community strains getting more prevalent among children, that’s going in a direction we don’t want to see,” says Scott Fridkin, an infectious disease physician who oversees the CDC’s surveillance of antibiotic resistant illnesses.

The USA Today investigation observes that the struggle against antibiotic resistant bacteria is perhaps the nation’s most daunting public health threat. That no drug-defying bug has proved more persistent than MRSA, none has caused more frustration and none has spread more widely.

The daunting nature of the threat is in part because MRSA can move  fast once it takes hold. Reflecting on a outbreak of recent cases including that of a 9 year old boy, Dr. Muhammad Iqbal, an infection control physician at Saint Joseph-London Hospital in Kentucky said: “What really bothered me was the rapidity of their deterioration, a matter of hours …[or they show up] dead on arrival.”

The investigation concludes with a universal concern that is expressed whenever MRSA shows itself: Although the infections in the Kentucky community vanished as quickly as they arrived, nobody knows if the bacteria are gone for good or simply waiting for another opportunity to strike again.

The FDA proposes a ban on antimicrobial soaps

The US Food and Drug Administration announced today that it intends to ban certain ingredients in anti-bacterial soaps if manufacturers cannot prove these products are safe, and are more effective than plain soap and water. Thus, companies like Dial, Dove, and Lever, who make personal hygiene products such as bar soaps, liquid soaps, body washes, and dishwashing liquids labeled as “anti-bacterial” and “antimicrobial,” will likely have to reformulate their products.

“Antibacterial soaps and body washes are used widely and frequently by consumers in everyday home, work, school, and public settings, said Dr. Janet Woodcock, director of the FDA’s Center for Drug Evaluation and Research. In fact, “Millions of Americans use antibacterial hand soap and body wash products,” as there about 2,000 individual products contain the offending ingredients.

A key concern is that these products do the opposite of what they’re intended to do – they actually increase the risk of antibacterial resistance. That is because the soaps etc. manage to kill off the good bacteria we have and leave only the resistant bacteria: that’s why they’re “resistant” – they can’t be killed by these means. And so what you’re left with is what scientists call “job openings:” all that space that is now unoccupied by the death of the good bacteria gets filled up by the spread of the resistant bacteria via normal cell reproduction processes.

According to the US Centers for Disease Control and Prevention about one in three (33%) people carry the staph bacteria in their nose, and two in one hundred people carry MRSA.  The reason for the proposed ban then, is the concern that the antibacterial soap products have the potential to increase the 2 in 100 number.

Surprisingly, given what’s at stake, manufacturers will  be given about six months to respond to the planned regulation, which likely won’t be implemented for at least a year. In the meantime, the FDA recommends using plain soap and water to wash hands and to avoid using antibacterial soaps, which will remain on the market for now.

What’s Up Doc: Why are only half of you complying with hospital hand hygiene rules?

“The critical thing that all of us as healthcare providers can do is clean our hands between patient contact: and that is the number one, two, and three action to keep our patient safe,” said Dr. John Embil, Director of Infection Prevention and Control at Winnipeg’s Health Sciences Centre, in an interview (beginning at the 12:54 mark) at a recent conference on infection control at the HSC.

Patient safety is a live issue because hospital-associated infections (HAIs) are the most common serious complication of hospitalization in Canada, affecting 10% of all patients in acute-care hospitals and are the fourth leading cause of death. And crucially, the contaminated hands of healthcare workers are the most common vehicles of transmission in most settings. In other words, HAIs are preventable.

The solution is literally at our fingertips: just wash your hands. As simple as that seems, the data is telling us that not only is that not happening, it’s also telling us that doctors, of all people – the leaders and role models in the hospital environment – are the biggest offenders.

The hospitals themselves are reporting low hand washing compliance rates of about 65% for nurses and less than 50% for doctors. For example, the Vancouver Island Health Authority reported physician compliance rates as low as 18%.  Yet some people say even those numbers are too high because they are gathered at a time when staff are told they are being monitored. Thus, they argue, the true rate is anywhere between 10 and 30%, with anecdotal evidence suggesting – stunningly – that doctors never wash their hands, outside of surgery.

Physician non-compliance so concerns the medical community that it will be the focus of an upcoming Canadian study that was announced this past February: i.e. why aren’t physicians washing their hands and what can be done about it? In a literature review conduct by the researches in advance of their own investigations they have identified several reasons specific to doctors: namely, physicians reported not ‘remembering to perform hand hygiene;’ ‘high workload or feeling too rushed;’ educational gaps in infection control training among physicians; a perception among physicians that their compliance is much better than it actually is; the development of a more cavalier attitude towards infection control as clinical experience increases, with an associated drop in compliance rates; and the lack of positive role models among physicians who are part of a healthcare team.

Healthcare worker hand hygiene as defined by Dr. Embil above is a hospital Required Organizational Practice, what Accreditation Canada considers an evidence-based best practice that mitigates risk and contributes to improving the quality and safety of health services.

So what’s up doc? If you aren’t getting something  as simple as the hand washing thing right, should patients and their families be asking what else you might not be getting right?


Turkey farm

The BBC just reported an outbreak of MRSA in turkeys on a farm in England. It said that two thirds of the farm turkeys were infected and that hundreds of them had already been sold to the public.

The Department of Health says the risk to the public is low because the strain of MRSA found in turkeys, what they call livestock-associated MRSA (LA-MRSA), is different than the MRSA found in hospitals, and (so far) has “rarely” caused disease in humans.

However, two US studies recently published in the Journal of the American Medical Association and the Public Library of Science give us reason to question the low-risk-to-humans position taken by the DH.

The US researchers looked at whether factory farming methods were leading to an increased incidence of MRSA in farm workers in the one study, and to people in nearby communities, in the other study. In both cases they found a significant rise in MRSA rates. Moreover, in the farm worker study, they found significant amounts of LA-MRSA only on workers from factory farms and no LA-MRSA in the control group, workers on traditional farms.

In other words, MRSA and LA-MRSA travels from the animals and the farm to people living and working nearby. It should be pointed out that the animals in both of these studies were pigs, thus giving rise among scientists to calling  this strain of MRSA, Pig-MRSA.

Which leaves us with this question: if MRSA goes from pigs to humans, why wouldn’t it also go from turkeys to humans?

It’s a question that wasn’t put to the Department of Health.

The Bug Zone

I’m posting an excellent short video about the ease of transmission of bugs in hospitals. In fact, in the case shown in the film, the transmission of the pathogen was due, ironically, to cleaning the hospital room. The film vividly illustrates just how difficult it is to prevent transmission of germs.

It’s a fun video, a take-off of The Twilight Zone, and so in that spirit poses the question this way: Are differential patient outcomes due to “fate”? Or to something else? Watch the film and see!

The characters  are actual medical personnel from Winnipeg’s Health Sciences Centre. For example, the role of patient Ben Fortuna is played by Dr. John Embil, Director of the Infection Prevention and Control Unit at the HSC.

The film was shown as part of “Bug Day,” an annual conference on infection control put on by the HSC. It  received an enthusiastic response from the packed lecture theater I was in. It’s a great example of what dedicated people can accomplish when they present a pressing medical issue with humor and imagination.

Two thumbs way up!

To watch The Bug Zone video click here.

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