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BMJ Quality & Safety Online First, published on 25 October 2017 as 10.1136/bmjqs-2017-006968
Simplifying care: when is the
treatment burden too much for
patients living in poverty?
Joseph Nwadiuko,1 Laura D Sander1,2
Department of Medicine, Johns
Hopkins School of Medicine,
Baltimore, Maryland, USA
Department of Medicine, Johns
Hopkins Community Physicians,
Baltimore, Maryland, USA
Correspondence to
Dr Joseph Nwadiuko,
Department of Medicine, Johns
Hopkins School of Medicine,
5200 Eastern Avenue, Baltimore,
MD 21205, USA;
j​ nwadiu1@​jhu.e​ du
Received 30 May 2017
Revised 26 September 2017
Accepted 15 October 2017
To cite: Nwadiuko J,
Sander LD. BMJ Qual Saf
Published Online First: [please
include Day Month Year].
It is usually a grand affair when ‘Ms
Noelle’ makes it to clinic. The 52-year-old
mother with a history of hepatitis C
cirrhosis, hypertension, uterine fibroids
and migraines has been in our care for
over a year. Even so, each visit still brings
a new crisis. Today, we found out that Ms
Noelle, the caretaker of a daughter with
bipolar disorder and nine grandchildren,
had just been evicted from her home. She
had been without any income for months,
and her applications for temporary cash
assistance and disability were denied. Ms
Noelle maintained a remarkable ability
to keep her family protected and fed
despite all this, but we have watched as
she became the ultimate victim: she struggled to remember her medications, their
doses and indications, and her cirrhosis
was frequently on the verge of decompensation during appointments she was
barely able to keep. She was overwhelmed
by even the simplest of tasks, such as
completing forms or picking up meds
from the in-house pharmacy, despite how
much she knew she needed to follow
We make innumerable health choices
daily. Behavioural economics can help us
understand these choices, as well as the
logical errors to which all patients are
vulnerable. For example, patients may
downgrade the importance of future
health status in relation to current gratification.1 Individuals are also risk averse
in decision-making, valuing losses disproportionally relative to gains, which makes
them susceptible to make vastly different
treatment decisions dependent on how a
choice is presented.1 Further, decisions
made in certain emotional states may not
translate to behaviour change when in
different emotional states (eg, committing to a diet while in a calm state, then
succumbing to dessert when stressed).2
These relatively small choices and errors
may have substantial effects on health
behaviours and health outcomes.
Patients who have multiple chronic
conditions and live in poverty, such as
Ms Noelle, are constantly negotiating
a number of trade-offs created by a
lack of economic resources. As a result,
they are disproportionately affected
by cognitive errors. The ‘mental bookkeeping’ required to survive under these
conditions might actually lead them to
develop heightened accounting skills
compared with higher income counterparts.3 However, under chronic scarcity, the energy put towards survival
overwhelms natural mental capacity (a
phenomenon described as ‘attentional
capture’), reducing fluid intelligence,
the mental capacity required for other
tasks.3 The ‘cognitive tax’ brought by
the stress of navigating chronic scarcity
has been measured to be equivalent to a
drop of 13 IQ points—enough to push
individuals from ‘average’ intelligence
to ‘borderline-deficient’—thus increasing
susceptibility to commit cognitive errors
in activities that fall out of the sphere of
pressing concerns.4
Poverty-related attentional capture,
while shown to be reversible, has been
cited as an contributing factor behind
so-called ‘paradoxes’ such as low uptake
of social services and dependency on
high-interest loans.3 Attentional capture
affects how low-income individuals
engage with complex health interventions and health systems, as managing the
myriad demands that must be fulfilled to
survive in low resource settings—financial
and non-financial in nature—can limit
retrospective and prospective memory
necessary for patients to engage in healthcare. This has implications for adherence,
as forgetfulness is one of the most cited
Nwadiuko J, Sander LD. BMJ Qual Saf 2017;0:1–4. doi:10.1136/bmjqs-2017-006968
Copyright Article author (or their employer) 2017. Produced by BMJ Publishing Group Ltd under licence.
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causes of non-adherence.5 For example, in a study of
callers to a United Way assistance hotline, researchers
demonstrated that individuals with increased levels of
stress related to unmet basic needs such as housing,
food or safety, displayed diminished recall of provided
referrals for cancer prevention services, leading to
reduced levels of follow-up.6
Higher levels of therapeutic burden have been shown
to relate to lapses in engagement in patients of all
socioeconomic strata.5 7 A recent perspective demonstrated that a theoretical patient with non-insulin-dependent diabetes, hyperlipidaemia and hypertension
has to complete at least 12 health-related actions daily
and 4563 annually to adhere to standard recommendations of health maintenance.8 Compound these tasks
with the unique costs that low-income patients might
bear to reach medical care—such as financing transportation, missing work and funding child care—and
it follows that chronic disease self-management and
care coordination might become a disproportionate
burden for those experiencing chronic financial stress.
We should strive towards ‘minimally disruptive medicine,’ tailoring treatment regimens and delivering care
that minimises burden on patients.7 Opportunities to
alleviate undue cognitive burden exist at the provider,
practice, health system and community levels.
At the provider level, recognition of poverty-related stressors should guide clinician–patient discussions. Identifying and aligning priorities to reflect
patients’ most potent life stressors in initial encounters is important to building a therapeutic relationship, even if those stressors are non-medical. In an
analysis of medical system ‘home runs,’ Milstein and
Gilbertson identify success as dependent on reciprocation, claiming that programmes that improved
outcomes tended to engage patients in their own
care by convincing them that their overall well-being,
not just health outcomes, was the provider’s chief
concern.9 Using motivational interviewing to build
self-efficacy in sustaining behavioural change should
also be taken into account, particularly as self-efficacy
has been shown to be eroded by multidimensional
poverty.10 Clinical teams should partner with patients
to achieve small ‘wins’ in financial and health challenges, thereby increasing patients’ confidence and
eventually improving adherence.11
For providers, simplifying healthcare also involves
reducing complex regimens when possible, synchronising refill dates across medications, and prescribing
in 90-day cycles to reduce the risk of non-adherence.12 Fixed-dose combination medications, despite
their dosing limitations, might be a useful option, and
prudent deprescribing where possible is a must.13
Appointment adherence is a potential area of intervention at the practice level. In 2010, Americans made
1.03 billion visits and spent 2.4 billion hours seeking
outpatient care for themselves or loved ones, 31% of
which was spent travelling to appointments and only
17% was spent face-to-face with physicians, with the
rest spent waiting to ‘check-in’, ‘check-out’ or see a
provider.14 Racial minorities and unemployed patients
spend even more time travelling and waiting for care
with no increase in face-to-face time with providers.15
A combination of practitioner maldistribution and
shortages in underserved areas as well as practice-level
workflows contribute to this time disparity.16 17
Care must be organised efficiently from the patient’s
point of view; otherwise, the myriad of competing
priorities that underserved populations face will deter
access to appropriate outpatient care. One potential
solution is to provide flexible scheduling for patients.
Open-access scheduling and extended hours may
provide greater latitude to low-income patients who
might be otherwise forced to make trade-offs on their
healthcare for child care or their work. Data demonstrate that open-access scheduling may decrease
no-show rates, and extended hours paradoxically
decrease healthcare expenditures.18 19
How traumatised patients experience clinical care
is also an important practice-level consideration.
Chronic socioeconomic stress, often coupled with
childhood traumas and ongoing social and family
instability, increases the risk of chronic medical and
psychiatric diseases.20 Health clinics may trigger a
strong emotional and behavioural reaction due to
perceived lack of control and emotional and physical
exposure inherent to medical settings, creating a situation in which adults with a high disease burden paradoxically avoid healthcare.21 Trauma-informed care
principles should be incorporated across a practice
to create a caring environment for patients. Engaging
patients in a physically, psychologically and emotionally safe space will help them manage stressors in and
out of the clinic.21
Beyond providers and individual practices, delivery
innovations may limit the number of cognitive steps
needed to use and access healthcare systems. Mobile
technology has great potential to engage patients in
care, to support chronic disease self-management and
to promote behaviour change, such as with medication adherence or smoking cessation.22 While there is
limited evidence for use in low-income populations,
there are ongoing studies in this area.23 To expand
access outside the clinic, home visits by paraprofessional programmes have demonstrated improvement
in adult asthmatic control and in child health in
low-income settings.24 25
Direct financial assistance in the form of conditional
cash transfers has also led to improved health system
engagement in low-income and middle-income countries. A systematic review on the topic demonstrated
increases in individuals returning for voluntary HIV
counselling and number of children taken to health
facilities, although data on immunisation uptake and
health outcomes are mixed.26 Also, a conditional
cash transfer programme in New York City decreased
Nwadiuko J, Sander LD. BMJ Qual Saf 2017;0:1–4. doi:10.1136/bmjqs-2017-006968
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poverty and improved adult and child health status.27
Further research on how this tool may engage US
patients, target health behaviours and affect health
outcomes is needed.
Finally, it is most important to emphasise that cognitive costs brought about by the stress of navigating
chronic scarcity have been shown to be reversible
when financial constraints are ameliorated,3 which
points to the need for community-level interventions
that liberate mental ‘bandwidth’ for patients to focus
on long-term health goals. The study of United Way
callers demonstrated higher odds of follow-up in individuals who had all their material needs addressed
after the original screening.28 Various nationwide
models of integrated care have focused on partnerships with community organisations to link them with
patients with material needs. One such programme,
Health Leads, has demonstrated gains in low-density
lipoprotein and blood pressure control among clients
with satisfied social needs.29 The Center for Medicare and Medicaid Innovation’s Accountable Health
Communities model is another example of community
While many of these ideas have been piloted or
proven in other contexts, some might require experimentation to demonstrate effectiveness in low-income populations. Furthermore, the proposals might
need to be adapted to contexts in low-income and
middle-income countries where resources may be
limited, although the need to acknowledge scarcity-induced distress might be even more pressing. If we are
to make progress at improving health outcomes for
our most vulnerable patients, we must reimagine and
reshape clinical interactions, as well as the structure
and function of our health system and communities.
Only then may we simplify the treatment burden many
of our patients face.
Ms Noelle remains challenging to engage, although
her son now helps connect her to care. In conjunction with a behavioural specialist, we created a treatment plan to prioritise her medical, behavioural and
social needs. She committed to a hepatology appointment once her income stabilises. We move towards
goals incrementally and celebrate all achievements,
including coming to clinic appointments. And most
of all, we strive to provide compassionate care that
preserves Ms Noelle’s dignity and empowers her to
progress forward.
Acknowledgements We acknowledge our colleagues at Johns
Hopkins Community Physicians and Priority Partners Managed
Care Organization, who support the care of underserved
patients in our practice.
Contributors Both authors contributed equally to this
Competing interests None declared.
Provenance and peer review Not commissioned; externally
peer reviewed.
Nwadiuko J, Sander LD. BMJ Qual Saf 2017;0:1–4. doi:10.1136/bmjqs-2017-006968
© Article author(s) (or their employer(s) unless otherwise
stated in the text of the article) 2017. All rights reserved.
No commercial use is permitted unless otherwise expressly
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Nwadiuko J, Sander LD. BMJ Qual Saf 2017;0:1–4. doi:10.1136/bmjqs-2017-006968
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Simplifying care: when is the treatment
burden too much for patients living in
Joseph Nwadiuko and Laura D Sander
BMJ Qual Saf published online October 25, 2017
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