Patients lag in adhering to heart therapy
■ Introducing antihypertensive and lipid-lowering medications at the same time improved patients' generally poor compliance, according to a new study.
By Susan J. Landers — Posted June 13, 2005
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Washington -- A more difficult problem than diagnosing people at risk for cardiovascular disease might be getting them to take their medicine to address it.
It's a huge problem, several physicians acknowledged. "I think that nonadherence to medical therapy is one of the greatest challenges we face in cardiology," said Lori Mosca, MD, PhD, MHP, director of preventive cardiology at New York Presbyterian Hospital.
Christie Ballantyne, MD, director for cardiovascular disease prevention at Baylor College of Medicine in Houston, won't ever forget his conversation with one patient, a lawyer, in the coronary care unit.
When the patient, who had just had a heart attack, was asked why he wasn't taking the statins prescribed three months earlier, he responded, "Doc, did you ever read all the side effects?"
Cardiovascular disease accounts for at least 930,000 deaths a year, and physicians have the tools to help reduce that toll.
Lipid-lowering statins and the range of antihypertensive drugs available have been proven to reduce cardiovascular risk. But they do no good if patients don't take them.
Now comes a new study that confirms physicians' fears.
Within six months of receiving prescriptions for a lipid-lowering medication and an antihypertensive drug, only one in every three people is still likely to be taking both medications. The study appeared in the May 23 issue of the Archives of Internal Medicine.
Researchers found that compliance with treatment already had begun to decline sharply within three months and continued to decline for a year, after which adherence generally stabilized.
The study also found that older people and women were less likely to stick with their prescribed medications, as were patients who were already taking several drugs.
The study, funded by Pfizer, was a retrospective cohort study of 8,400 enrollees in a managed care plan who had begun treatment with a lipid-lowering drug and an antihypertensive within a 90-day period.
Timing is everything
One finding that surprised lead author Richard H. Chapman, PhD, director of health economics at ValueMedics Research, a small consulting firm in Falls Church, Va., was the important role that timing of prescriptions played in adherence.
"The longer the gap between the start of each of these [drugs] the less likely patients were to be compliant," he said. "That went counter to what a lot of doctors think, which is to deal with problems one at a time. But this shows getting both drugs at the same time makes a difference to the patient."
Difficulty in sorting out possible side effects is the reason physicians would rather not prescribe two new medications simultaneously, said J. Sanford Schwartz, MD, a study author and professor of medicine, health management and economics at the University of Pennsylvania in Philadelphia. But since the side effects of these particular drugs are different, perhaps consideration should be given to prescribing them together if it improves adherence levels.
"Nonadherence really is a waste," he noted. "We've done the work, identified the problem to be treated and then, either because of errors by the patient or the doctor, we aren't achieving the potential we could achieve."
While compliance with treatment would seem to be the patients' fault, physicians are shouldering some of the blame. "I don't think most physicians appreciate how many patients aren't being treated at all and how many aren't reaching goals set by national guidelines," Dr. Schwartz said.
Patient education could go a long way toward resolving the issue, said several physicians. "It takes a lot of counseling from doctors and nurses and time with patients," said Robert Bonow, MD, chief of cardiology at Northwestern Memorial Hospital in Chicago and past president of the American Heart Assn. "Key is to spend time with patients and if they aren't taking their medications to figure out why and go into individual circumstances."
Dr. Mosca considers adherence to therapy as important as a patient's vital signs and systematically checks weight, blood pressure, cholesterol levels, lifestyle changes, and whether patients adhere to medication more or less than 80% of the time.
But why don't patients adhere to a medication regimen? "There are as many reasons as there are people," she said.
Often, as with Dr. Ballantyne's patient, a fear of side effects overwhelms the patient's belief in the drug's benefit, especially when the symptoms of a disease are as silent as high cholesterol and hypertension.
"Most of the time they fear side effects that are relatively uncommon. So a reassuring conversation on the absolute risk of side effects versus the absolute benefit of compliance with therapy often results in compliance," Dr. Mosca said.
Providing timely feedback is another way to encourage patients to stick to a treatment regime, Dr. Ballantyne said. One study showed that if a doctor reported lab test results to patients within the first few months of starting a treatment, they were more likely to keep at it, he said.
Physicians also must note the cost for patients. "Patients may have to chose between paying for drugs or heating their home," Dr. Bonow said.
And it's worth considering trimming the number of medications a patient must take if possible. "For me, one of the most striking findings was the number of prescription medications that patients were taking before they started on the antihypertensives and lipid-lowering drugs. That seemed to make a big difference as to whether they were adhering to treatment or not," he said.
The researchers found that patients taking no other medications were twice as likely to be adherent as were patients taking six or more other medications.