Page 913 - Cardiac Nursing

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CHAPTER
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A A A A Adherence to Cardiovascular
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T T T Treatment Regimens
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Lora E. Burke / Kyeongra Yang /
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Adherence or compliance has been studied extensively in recent when prescribed by practitioners can be influenced by the pa-
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de decadess. 1–4 Thee termss adherencee andd compliance have been used ti tient’ss adherennce to the treatment regimen, 1 10 which is less than
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interchangeably in the literature; however, more recently the use ideal in both clinical trial and clinical practice settings. The sur-
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of adherence has superseded compliance. Compliance is viewed vival benefits of several drugs have been demonstrated in large-
by many as having a negative connotation that implies an author- scale clinical trials. However, it has been shown repeatedly that
itarian relationship between the provider and the patient with the 50% of individuals prescribed statins will discontinue the therapy
provider issuing instructions that the patient is expected to follow. within 6 months 10 or stop taking the drug for an extended pe-
Adherence is similar but is seen as recognizing the rights of the pa- riod. 11 A quantitative review of 50 years of research in patient ad-
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tient to chose and thus removes the concept of blame. Concor- herence revealed that the average nonadherence rate is 24.8%; the
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dance, a term used mainly in the United Kingdom, has been more highest adherence rates are among patients with HIV disease,
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broadly defined and today ranges from prescribing and communi- arthritis, gastrointestinal disorders, and cancer, the lowest are
cating to supporting the patient in medication taking, and includes among patients with pulmonary disease, diabetes, and sleep dis-
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consideration for the preferences and beliefs of the patient. Today, orders. 12 Approximately 31% of hypertensive participants in a
it seems to be more widely recognized that the patient is only one Veterans Affairs study reported unintentional nonadherence
part of the equation when adherence is considered. Numerous mainly due to carelessness or forgetfulness and 9% reported in-
factors may play a part in adherence, which involves the health tentional nonadherence. 13 The rates of nonadherence to treat-
care professional, the system or organization in which care is de- ment recommendations are found to be 20% to 40% for acute ill-
livered, and the patient, for example, the provider’s suboptimal ness, 30% to 60% for chronic illness, and 80% for prevention. 14
use of evidence-based treatment guidelines or the health organi- The most common preventable cause of rehospitalization in the
zation’s practices that present barriers to the patient’s attempts to heart failure population is nonadherence to the regimen. 15 In the
being adherent. 7 United States, 33% to 69% of medication-related hospital admis-
Other terms that sometimes are considered synonymous or re- sions are the result of poor medication adherence, resulting in an
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lated include self-management and disease management. 5,7 Heart annual cost of $100 billion. These statistics illustrate how med-
failure disease management focuses on educating patients about ication nonadherence is a major health problem; however, it is not
adherence, monitoring symptoms that may warn of decompensa- limited to the United States.
tion, factors that may precipitate an exacerbation, and being seen Nonadherence is a ubiquitous problem that spans across con-
in close follow-up by nurses specialized in heart failure care. tinents and treatment regimens. Indeed, the magnitude of this
Broader than adherence or compliance, self-management includes problem was underscored by the World Health Organization
general strategies and behaviors that contribute to disease manage- (WHO) convening a panel of experts to examine its prevalence
ment, improved health, and prevention or reduction of complica- and develop an evidence-based report on treatment strategies. The
tions rather than mainly focusing on following specific regimen panel reported that adherence to long-term therapies in developed
components. 8,9 countries is approximately 50% and is much lower in developing
This chapter reviews adherence and the significance of nonad- countries. Poluzzi et al. 16 reported 69% adherence during the sec-
herence in the management of the cardiac patient. Methods used ond year and 60% during the third year of antihypertensive therapy
to assess adherence across the behaviors of medication taking, di- among Italian adults. A study among Asian Pacific Americans
etary self-management, following an exercise program, and smok- (Japanese, Filipino, Chinese, Korean, and part-Hawaiian; N
ing cessation are reviewed. Factors that influence adherence and 28,395) showed that Japanese living in Hawaii were 21% more
strategies to enhance adherence are discussed and guidelines for likely to adhere to antihypertensive medications than white popula-
implementing educational and behavioral strategies are provided. tion while individuals of Korean, Hawaiian, and Filipino descent
were less likely to adhere than white population, after controlling
for patient’s education and physician characteristics such as spe-
SIGNIFICANCE OF cialty, gender, and race. 17 Among all ethnic groups in this sample,
NONADHERENCE overall adherence rates were less than 60%.
Several risk factors associated with CVD are related to lifestyle;
A number of pharmacologic therapies are used in the prevention, however, adherence to public health recommendations for dietary
as well as the acute and chronic management of cardiovascular dis- and physical activity habits is also lacking. Generally, Americans
ease (CVD). However, the extent to which these therapies can be exceed the dietary fat limit by 2% to 5%, depending on ethnic
demonstrated to be efficacious in clinical trials and later effective group and exceed the 2,400 mg of sodium per day guideline by
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