eTable. Potential Reasons for Adherence Miscommunication
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Hines R, Stone NJ. Patients and Physicians Beliefs and Practices Regarding Adherence to Cardiovascular Medication. JAMA Cardiol. 2016;1(4):470–473. doi:10.1001/jamacardio.2016.0634
What is the frequency of cardiologists’ discussions with patients regarding their adherence to cardiovascular medications?
In this survey study, 67% of patients reported rarely or never discussing their adherence to medication with their cardiologists. Only 1 cardiologist of the 13% of patients with the least adherence correctly identified a patient as having poor adherence.
To address the failure of cardiologists in our study to identify poor adherence, we recommend that they ask highly specific questions about adherence, such as “How many heart drugs have you missed in the last 30 days?” at every patient visit.
Nonadherence to medication is a salient cause of poor outcomes of health care and a primary driver of growing health care costs. Little is known about physician communication with patients regarding their adherence to cardioprotective medication.
To identify patients’ and physicians’ beliefs and practices regarding discussions of adherence to cardioprotective medication.
Design, Setting, and Participants
Paired patient and physician questionnaires were developed based on the 8-item Morisky Medication Adherence Scale and administered to 2 academic and 2 community-based cardiology practices in the Chicago, Illinois, metropolitan and suburban areas from June 2 to July 22, 2015. Twenty-one cardiologists and 66 of their outpatients 18 years and older participated.
Main Outcomes and Measures
Patient and physician beliefs about discussions of adherence to medication, the frequency of such discussions, and physician recognition of patients who are nonadherent to medication.
A total of 21 physicians (5 [24%] women) and 66 patients (23 [35%] women; mean age, 71.6 years) participated in the study. Forty (61%) patients reported rarely or never discussing their adherence to medication with their physicians. Of these patients, 8 (13%) had poor adherence and 36 (55%) had moderate adherence. Only 1 of the physicians of the patients with the poorest adherence correctly identified a patient as being poorly adherent. Fourteen physicians (67%) disagreed with the statement, “I am aware of how often my patient misses a dose of medication.” By contrast, all of the physicians agreed that it is important for them to discuss adherence to medication with their patients.
Conclusions and Relevance
Physicians acknowledge the importance of discussing adherence to medication with their patients, yet for many reasons these discussions are uncommon. More important, our study found a notable failure by cardiologists to correctly recognize which of their patients were nonadherent. The novel design of our research identified an important yet neglected aspect of clinical practice. We recommend that physicians include a highly specific question about adherence to medication at every patient visit.
Cardiovascular disease is a leading killer worldwide. Pharmacotherapy for atherosclerotic cardiovascular disease has dramatically improved cardiac outcomes, reducing rates of myocardial infarction, stroke, and mortality.1 However, cardioprotective medications fail to achieve their therapeutic potential when nonadherence or rates of discontinuation of use are high.2,3As the number of individuals with atherosclerotic cardiovascular disease rises globally, nonadherence will prove a salient cause of adverse health outcomes and a primary driver of growing health care costs.
Several studies have identified varied reasons for nonadherence to medication, ranging from prohibitive medication costs and a fear of adverse effects to misunderstandings of the benefits of medication.4,5 In 2015, Rosenbaum6 cited the lack of immediate, conspicuous benefits of a medication for chronic disease, such as a statin for reducing blood cholesterol concentrations and the formation of a “sick identity” among patients taking a medication, as 2 principal causes of nonadherence to its prescribed use.
A burgeoning field of multifaceted interventions designed to reduce nonadherence to medication has emerged in recent years. Although researchers have developed several interventions and programs, to our knowledge, no single intervention strategy has proven effective across all patients and health systems. To improve adherence, patient-physician communication regarding adherence to cardioprotective medications must be explored. We sought to identify patients’ and physicians’ beliefs and practices regarding discussions of adherence to cardioprotective medication.
To identify patients’ and physicians’ beliefs and practices about discussions on adherence to cardioprotective medication, we conducted a survey-based study of 2 academic and 2 community-based cardiology practices in the Chicago, Illinois, metropolitan and suburban areas from June 2 to July 22, 2015. Physicians were contacted via telephone and told that the general goal of the study was “to understand an important aspect of patient-physician communication,” but were not told the specific aims of the study. The same interviewer for the study attended a morning or afternoon session of each participating physician’s practice and invited consecutive patients to complete a short, orally administered survey following the patient’s visit. The study included all patients 18 years or older who were taking a cardioprotective medication and excluded patients who did not speak English. A script was used to obtain oral informed consent from patients and physicians participating in the study. The Institutional Review Board at Northwestern University, Feinberg School of Medicine, approved the study protocol, and strict measures were taken to protect participant confidentiality.
We developed patient and physician questionnaires based on the 8-item Morisky Medication Adherence Scale (MMAS-8).7 In addition to recording basic demographic and medical information, the patient questionnaire included questions about how often the patient fails to take a dose of medication, how often the patient discusses adherence with the patient’s physician, and the primary reasons for nonadherence. The physician questionnaire included questions about the physician’s impression of each patient’s adherence, the frequency with which the physician discusses adherence with that patient, and the physician’s understanding of why adherence may be a challenge.
We defined our primary outcome variable as patients’ reporting having discussed adherence with their physician. We defined our secondary outcome variable as physicians’ recognition of patients with poor adherence to medication.
The characteristics of the 21 physicians and 66 patients who participated in the study are found in Table 1 and Table 2. Forty patients (61%) reported rarely or never discussing their medication adherence with their physician. Of those 40 patients, 18 (45%) said that they sometimes or usually forgot to take their medication and 4 (10%) reported having missed 1 or more doses of medication in the past 2 weeks. On the basis of MMAS-8 scores, 8 of the 66 patients in the study (12%) had poor adherence and 36 (55%) had moderate adherence. Of the 8 patients with the poorest adherence, only 1 (13%) was correctly identified by the patient’s physician as poorly adherent.
Fourteen of the 21 physicians (67%) disagreed or strongly disagreed with the statement, “I am aware of how often my patient misses a dose of medication.” All 21 physicians (100%) agreed with the statement, “It is important for me to discuss medication adherence with my patient.” Eight of the 21 physicians (38%) reported that there were times that they wanted to discuss adherence with a patient without having done so. Of these 8 physicians, 5 (63%) cited time as the greatest barrier to such discussions and 3 (38%) reported believing that their patient had more important problems to be addressed.
We used a novel design that allowed us to determine whether physicians discuss adherence to regimens of cardioprotective medication with their patients routinely, and more important, whether they were able to recognize, during their visit, which of their patients were nonadherent.8 We found that physicians acknowledge the importance of discussing adherence to medication with their patients, but that in practice these discussions are infrequent (eTable in the Supplement). Furthermore, we found that the physicians in our study were frequently unable to recognize which of their patients were nonadherent.
Our findings are in accord with several reports regarding poor adherence to cardiovascular medication, and our study, albeit brief, has important implications for patients and physicians. The lack of recognition of poor adherence could result both in suboptimal treatment and the potential for the use of additional medications to improve a patient’s risk-factor profile. We were impressed to learn that the situation we uncovered could be addressed with a single, direct question such as, “How many of your heart drugs have you missed in the past 30 days?” Although the degree of acuity of a patient’s problem and the limitations of time are always present in patient-physician encounters, the physician’s inclusion of a detailed question about adherence to medication would add only a few seconds to a patient’s visit, and it has the potential to provide clinically useful information.
We acknowledge that a single detailed question about a patient’s adherence to a medication regimen cannot address all of the issues related to such adherence. However, it provides a useful way to begin recognizing unsuspected poor adherence. It may be especially valuable in cases in which a patient with previously good adherence misses taking medications for reasons such as changed insurance coverage or travel. A patient’s missing of medication for heart failure, elevated blood pressure, or an elevated blood cholesterol concentration in the past 30 days before a visit may in great part explain abnormalities observed during the visit, and which may be bypassed if other issues require immediate attention. Moreover, a detailed question about adherence to medication may prevent the addition of medications to a patient’s treatment regimen when all that is needed is better adherence to the patient’s existing regimen.
Our brief study had several limitations. First, we examined a group of cardiologists and their patients in only a single metropolitan and suburban area of the United States. Second, the size of our sample was small. Further work is needed to assess the generalizability of our results. Third, our findings are based on self-reports. Recall bias and socially desirable response bias are 2 concerns in respondents’ replies to questions about their behavior. Fourth, a more detailed evaluation of comorbidity, especially depression, a wider range of patient ethnicity and socioeconomic status, and interviews with physicians other than cardiologists would make our results more generally applicable to the medical community. A larger study for determining the utility of a more specific question about adherence to medication, and which takes into account issues other than those included in our study, would be both useful and informative. Last, our study design did not examine the content of patient-physician discussions about adherence to medication or examine how often physicians consider patients’ adherence without directly discussing these concerns.
Through a novel approach that involves interviewing both patients and physicians in an outpatient setting, our study corroborates prior data indicating poor patient adherence to cardiovascular medication. An important finding in the study is that cardiologists appear to be less aware than they know about which of their patients are nonadherent. A single direct question posed by physicians to patients, such as, “How many of your heart drugs have you missed in the last 30 days?” could help resolve the apparent lack of awareness by some physicians about some patients’ poor adherence to medication, with important implications for improved cardiovascular care.
Correction: This article was corrected on October 5, 2016, to add a reference.
Accepted for Publication: March 8, 2016.
Corresponding Author: Neil J. Stone, MD, Division of Cardiology, Northwestern University, Feinberg School of Medicine, 676 N St Clair; Ste 600, Chicago, IL 60611 (firstname.lastname@example.org).
Published Online: May 11, 2016. doi:10.1001/jamacardio.2016.0634
Author Contributions: Both authors had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Both authors.
Acquisition, analysis, or interpretation of data: Both authors.
Drafting of the manuscript: Both authors.
Critical revision of the manuscript for important intellectual content: Both authors.
Statistical analysis: Both authors.
Administrative, technical, or material support: Both authors.
Study supervision: Stone.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Additional Contributions: G. Caleb Alexander, MD, MS, Johns Hopkins School of Public Health, Center for Drug Safety and Effectiveness, Baltimore, Maryland, provided thoughtful comments about the method of our study. We especially thank the clinical cardiologists who allowed us to interview their patients and themselves. No one received compensation for their participation.