AlignMap

Adherence: The Silent CV Risk Factor,¹ presented by Dr. Keith C. Ferdinand,  Dr. Lars G. Osterberg,  and Dr. Roger S. Blumenthal, is a solid review of the basics of adherence (although special attention is directed, as the title indicates, to cardiovascular disease, almost all of the principles  are transparently applicable to compliance in general) but also offers insights in areas not typically covered by analogous reviews.

Rather than attempt to characterize these usually neglected points that are discussed in this piece, I will provide a few examples.

For instance, while the presenters trot out the familiar stats to indicate the extent of the problem,

… greater than $100 billion are wasted annually due to nonadherence; 125,000 unnecessary deaths are due to nonadherence; and of all medication related hospital admissions, 33% to 69% are due to poor medication adherence.

… they also include the much less commonly addressed point that practitioners rarely have an organized approach  to compliance:

We did a pre-survey and results demonstrated that nurse practitioners and physicians’ assistants are more likely than physicians to change treatment strategies to improve adherence. However, 74% of health care providers do not have an active adherence program.

Similarly, they do a nice job explalining the adherence versus compliance issue, defining concordance, and distringuishing betweeen adherence, compliance, and pesistence.

… researchers have recently defined adherence and compliance a bit differently, compliance meaning the day-to-day way patients take their medications from drug prescription as prescribed by the physician; persistence meaning the time they are on their medications, and it actually may discontinue before the actual prescription is ended. Adherence has been used to include the overarching term of compliance and persistence in medication-taking behavior. The British terminology actually uses a term called concordance, which implies more of a patient-centered approach in that the prescription is really a contract between the patient and the physician and that both are really responsible for the medication-taking. The National Council on Patient Information and Education has really now adopted the term adherence as the proper term because it really implies a more patient-centered approach.

They also make a interesting point about the specialist (cardiology is discussed but many other specialists would face the same conundrum) who has to be concerned about compliance in a patient who might only be seen by that practitioner once each year.

One of the challenges that we have in cardiology is that in the past, we used to be able to see certain patients more frequently, but now, almost always, Keith, patients need to get referrals from their primary care provider to see us. It is harder as a cardiologist to provide some of that reinforcement that I think the patient needs. And with the proliferation of managed care and everybody trying to cut costs, we have a struggle of trying to make sure we have gotten all the information we can from the visit to the referring physician and the patient. It is a lot harder for chronic diseases for the primary care physician to pay as much attention sometimes about lipid lowering medicine, blood pressure lowering medicine when the patient has come in for acute issue.

That is interesting: preauthorization may help keep costs down but it may actually lead to greater nonadherence.

I have always felt that when we see a specialist, it is always helpful to have some goals set not just from the medication point of view in terms of what the blood pressure and lipids would be, but also what they are doing from a lifestyle point of view. With the system we have now with the preauthorization, it is often a lot harder for us to see a nonacute patient back within a period of a few months. Many times, the best we can do is maybe see him back in a year.

And consider this economic insight:

One of the biggest issues that we are all struggling with and now, of course, we are dealing with the bailout of financial firms here, is the issue of money. Many of the medications that we prescribe to patients that are still on patent may be $2.00 or $3.00 a day, so the issue of needing to save money, and many times, physicians do not think of perhaps a less potent generic alternative. It would be nice to have a 50% LDL reduction in everybody, but if we can give a generic statin that may give us a 35% or 40% reduction and have people work on their lifestyle habits, that may work out just as well if they take the medicine and may work out better.

Over-reliance On Patient Education

The presentation does fall short in a few areas.  The discussion of a chart showing “Reasons For Not Taking Medication,” for example, should have included mention of how this data was collected (patient self-report I surmise) and, if it was by self-report, the possibility that the patient might not have provided accurate information.

My major concern, however, is the overwhelming faith demonstrated in patient education as a compliance enhancer.

… one of the things that I guess we are all trying to do is figure out ways for people to better understand why certain medications are prescribed and try to make these clinical trials that are the basis for the guidelines be more understandable. I have often thought that it would be helpful if the patient got a copy of the notes that we send to the referring physicians, but many times, that is not as easy for our office staff to do. But I think it just points to the fact that to improve adherence and compliance, we need to do a better job of making sure the patient understands why the medicine is prescribed and can relate to the clinical trial data, if there is any, related to blood pressure or cholesterol about why this is important.

While this may be a matter of emphasis, I believe that a teaching presentation such as this should acknowledge that some patients who fully understand the illness, the treatment, and the implications of compliance to their cases will nonetheless fail to adhere to the prescribed regimen unless other steps are taken.

Summary: Worthwhile Review Of Basics Plus Bonuses

That said, I return to my contention that this review is head and shoulders above the usual run of competent offerings and well worth reading, if only for the succinct, helpful summary of the Federal Study of Adherence to Medication in the Elderly (FAME).

In addition, one can earn  CME credits² for completing Adherence: The Silent CV Risk Factor.