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?
- Copyright © 1998 by American Heart Association