Your patient has heart failure, and you
prescribe several medications. At the next visit, there is negligible
improvement, and you increase the doses. But are you sure that the
patient has been taking the pills as prescribed? In a chronic disorder,
the likelihood of noncompliance can exceed 50%. At first sight,
"failure to comply" seems to describe a conflict between the
doctor's rationalism and the patient's irrationalism; but matters are
not that simple, and some commentators no longer speak of compliance
but of adherence or even concordance. For best results, the treatment
may have to be negotiated. The American Heart Association has called
for a strategy in which numerous techniques that improve compliance are
applied at three levels: patient, provider, and organization
(Circulation. 1997;95:1085–1090).
In her address during the 70th Scientific Sessions, the president of
the AHA, Martha Hill, spoke of vast gaps between potential and reality
in cardiovascular medicine: between the results of
trials and those achieved in practice, between intention and action,
between information and behavior. These gaps, she declared, can be
narrowed by greater integration of social and behavioral sciences with
the biosciences: "Professional and patient education now requires
active learning techniques and consideration of cultural and
environmental factors. This is where interdisciplinary teams with the
appropriate mix of expertise and competencies can maximize patient
outcomes."
During the sessions, several presenters discussed the gaps, but
none described controlled trials of interventions to improve the uptake
of effective treatments. Noting that 60% of rehospitalizations in
congestive cardiac failure (CCF) are due to nonadherence to diet or
medications or to failure to heed signs of deterioration, Jane C.
Pederson (Stratis Health, Minneapolis, Minn) examined a random sample
of more than 4000 discharge charts of Medicare patients with CCF. Fewer
than half these patients had received usable instructions about their
medications, diet, or weight management. (Written instructions,
including the rationale for treatment, are one of the recommendations
of the AHA Expert Panel.) Alice H. Chen (University of California at
Los Angeles) suggested that young men may be an important target for
compliance intervention. She recorded a striking difference in
behavior between men younger than 40 and men aged 40 to 60 years with
advanced heart failure, the younger group being much less likely to
take medications as directed, follow the recommended diet, or keep
appointments; they also engaged more often in risky behavior such as
alcohol consumption, smoking, and drug abuse. At a simpler level,
Marieke D. Schoen (University of Illinois at Chicago) found that for
the uninsured, the cost of drugs can be a large influence on
compliance. For 110 indigent patients on Medicare, which does not cover
the costs of chronic medication, the price of prescribed drugs amounted
to one third of their income. When the patients were helped to obtain
their prescriptions free or at low cost, the noncompliance rate fell
from 52.6% to 13.5%.
Finally, Roy Ziegelstein (Johns Hopkins Bayview Medical Center,
Baltimore, Md) noted the epidemiological association between depression
and early death after myocardial infarction and asked whether
depression might affect compliance with treatment. When 222 patients
were assessed with the Beck Depression Inventory 3 days after
infarction, nearly one quarter met the criteria for depression. The 204
survivors were interviewed 4 months later to determine their adherence
to risk-modifying recommendations, and the depressed group proved to be
poorer compliers with advice on fat/cholesterol intake,
exercise, and stress reduction. Would antidepressant treatment make a
difference to compliance—and mortality?
© 1998 American Heart Association, Inc.
Cardiovascular News
Compliance, Adherence, Concordance
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