Curr Cardiol Rep (2014) 16:458 DOI 10.1007/s11886-013-0458-z
ISCHEMIC HEART DISEASE (D MUKHERJEE, SECTION EDITOR)
Medication Adherence and Heart Failure Eric M. Riles & Anuja V. Jain & A. Mark Fendrick
# Springer Science+Business Media New York 2014
Abstract Heart failure remains among the most prevalent and burdensome medical conditions in the United States. With increasing awareness regarding resource use and costs of care, there has been significant interest in the identification of factors that influence rates of hospitalization and readmission in individuals with heart failure. Medication adherence has been identified as one such modifiable factor. Many barriers to medication adherence have been identified and include factors related to the patient, those related to their medical condition, their medical regimen, the healthcare system and others that are social and socioeconomic in nature. Identification of these barriers has led to novel interventions for improving medication adherence with the goal of improving the care of individuals with heart failure. Keywords Heart failure . Therapy . Medication . Adherence
Introduction Heart failure remains among the most prevalent and burdensome medical conditions in the United States, presently
affecting five million individuals and expected to increase with an aging population [1, 2]. Nearly one in nine deaths and one million hospital admissions in this country are associated with heart failure annually [1]. The economic burden of caring for patients with heart failure is staggering. It is estimated that the total cost of caring for individuals with heart failure tops $40 billion per year [1, 3•]. Over the past several decades, important advancements in the medical therapy for heart failure have led to an increased life expectancy and decreased mortality for these patients. Despite these advancements, the last decade has seen little change in the rates of heart failure hospitalizations and readmission rates remains a concern. Nearly 25 % of individuals discharged with heart failure are readmitted within the first 30 days [1, 4]. With increasing awareness regarding the high costs of medical care, there has been substantial interest in identifying factors that influence the rates of readmission for patients with heart failure. Medication adherence has been identified as one potentially modifiable cause that contributes to increased rates of rehospitalization.
This article is part of the Topical Collection on Ischemic Heart Disease E. M. Riles (*) Cardiovascular Center, Boston Medical Center, 88 East Newton Street, Boston, MA 02118, USA e-mail: [email protected] A. V. Jain Department of Medicine, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115, USA e-mail: [email protected] A. M. Fendrick Department of Internal Medicine, University of Michigan, North Campus Research Complex. 2800 Plymouth Road, Ann Arbor, MI 48109, USA e-mail: [email protected]
Definition of Adherence & Magnitude of the Issue Over time, a number of terms have been developed to characterize the complex relationship between physician and patient that is implied in the term ‘adherence’. Medication adherence refers to the extent to which patient behavior is concordant with the physician recommendations to which he or she has agreed. This term emphasizes the patient’s agreement to actively participate in a given therapy. This differs from medication compliance, which refers to the extent to which a patient’s behavior matches the advice of the clinician without invoking the level of patient participation [5].
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Traditionally, medication adherence has been defined as a patient achieving at least 80 % of a prescribed regimen. However, this cutoff has been arbitrarily defined. Different disease states require different levels of adherence to therapy in order to achieve clinical effect. In individuals with heart failure, it has been proposed that survival is significantly improved at an adherence rate of at least 88 % [6]. The clinical consequence of non-adherence has been well described and is associated with increased rates of rehospitalization, emergency department visits, and worsened symptoms [7–9]. However, the extent to which individuals with heart failure are adherent to their medical regimens varies considerably in the literature with estimates ranging from 40 to 80 % [10–13].This variation has been attributed to a number of factors including varied study populations as well as bias from self-report. In the Medicare population, heart failure is the most common readmission diagnosis-related group [14]. Studies have shown between 20 % and 64 % of readmissions for heart failure are related to poor adherence with prescribed medications [15]. In addition, in a study that followed patients for 6 years, the number of hospitalizations reported in non- adherent patients was 2.5 times higher than that among adherent patients [9]. Roebuck and his colleagues found that adherence for patients with congestive heart failure was associated with nearly six fewer annual inpatient hospital days than those who were non-adherent [16••]. However, the studies related to medication adherence are often subject to self-report. Self-report of medication adherence has been shown to not be an independent predictor of survival in patients with heart failure [17]. Additionally, as noted in a review by Leventhal et al., other studies that use more objective measures of adherence using serum or urine drug concentrations (including digoxin, ace-inhibitors and loop diuretics) have shown inconsistencies in the relationship between medication adherence and readmission rates for individuals with heart failure [15]. Regardless, the consequence of non-adherence is relevant from a cost perspective. While the annual cost for managing individuals with heart failure remains high, it has been estimated that medication adherence reduces the average annual per-patient spending by nearly $8900 in individuals with heart failure [16••].
Curr Cardiol Rep (2014) 16:458
Patient- Related Factors The majority of the literature related to medication adherence in heart failure has focused on patient-related factors. Specifically, age and sex have been a major focus for a number of studies though the degree to which these variables predict medication non-adherence has been inconsistent. A recent systematic review by Oosterom found an equal number of studies showing age to be a determinant of medication adherence as those showing age to have no correlation with adherence [19•]. Of note, in those studies that showed a correlation between age and medication adherence, older age was associated with better rates of adherence [19•]. Patient knowledge has been another area of focus in determining patient-related barriers to medication adherence. A number of studies have demonstrated that patients with heart failure have poor comprehension of their medical regimens. In a study by Clark et al., patients demonstrated poor knowledge of the pharmacological management of heart failure, its progressive nature as a disease, and its link to death [20]. Wagdi et al. found that nearly 29 % of patients with heart failure had a lack of knowledge regarding their prescribed medications [21]. Finally, Cine et al. demonstrated that after discharge nearly 45 % of patients were unable to name their prescribed medications, 50 % did not know their prescribed doses, 64 % did not know how often to take the medications, and 82 % were taking medications that had not been prescribed to them [22]. By the virtue that therapies for heart failure are complex, it has been inferred that a certain level of patient knowledge is required in order to optimize patient medication adherence. However, a prospective study by Wu showed no correlation between patient knowledge and medication non-adherence [23]. This finding has been demonstrated in other studies as well [24]. Studies have shown varied correlations between patient level of education and the rate of medication adherence. Level of patient education has been associated with both increased and decreased rates of patient non-adherence [24–26]. While further studies are needed to better describe this relationship, two systematic reviews have suggested that the level of education does not significantly contribute to the level of patient non-adherence in heart failure [19•, 27]. In three out of five studies ethnic minorities were found to be less adherent, however in the other two studies, no relationship was found making this relationship inconsistent as well [23, 28–31].
Causes of Non-Adherence Condition- Related Factors The causes of medication non-adherence have been studied extensively. In short, barriers to adherence are complex and multi-dimensional. These barriers have traditionally been broken into specific dimensions including those related to the patient, the medical regimen, the health care team/system and those which are socioeconomic in nature [18].
Several studies have investigated whether the number of comorbidities in patients with heart failure was related to the degree of medication adherence. These have been met with conflicting results. An analysis from the large randomized CHARM trial showed that greater number of comorbidities
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was associated with worse medication adherence [32]. However, other studies have shown conflicting results [33]. Based on the availability of published data, there is not significant evidence to determine whether a relationship exists between the number of comorbid conditions and the extent of medication adherence in individuals with heart failure [19•]. Additionally, it has been shown that distressed emotions have been identified as significant barriers to adherence [34]. It is estimated that of individuals with heart failure, 10 % of outpatient and 50 % of hospitalized patients show evidence of depression [35, 36]. This is particularly important as the likelihood of non-adherence can be nearly three times higher in individuals who have signs of depression compared with those who do not [37].
medications. A critical component of the medical regimen also includes restriction of salt and fluid intake, avoidance of alcohol and tobacco, regular exercise, and monitoring daily weights. Riegel et al. found may individuals with heart failure to struggle with these lifestyle components of the treatment regimen [34]. The recent systematic review by Oosterom concluded that while different studies have analyzed different treatmentrelated barriers to medication adherence in heart failure patients, that overall, there is evidence that these factors do play a role in mediating patient adherence to their prescribed regimens [19•].
Regimen-Related Factors
Factors related to the health care system have also been studied as factors contributing to medication non-adherence in patients with heart failure. These include the patientphysician relationship, the reimbursement system, medication availability, training of providers in caring for patients with heart failure, and the amount of time available for patient interaction [18]. Strength of the patient-provider relationship has been shown to positively correlate with medication adherence in a number of chronic disease states [43]. In a series of in-depth interviews performed to identify factors influencing medication adherence in individuals with heart failure, it was similarly found that a positive patient-physician relationship was a favorable factor for improving rates of medication adherence [42]. Barriers to developing this relationship were identified by Horowitz et al. and included lack of education regarding both recognizing symptoms and symptom management, difficulty with contacting medical providers, and difficulty with receiving treatment through the health care system [44]. A recent systematic review by Oosterom investigated whether variation in the type of contact with healthcare institutions correlated with the rates of medication non-adherence in patients with heart failure. Types of healthcare institutions included inpatient and nursing facilities, outpatient centers and the number of contacts with healthcare professionals [19•]. This review concluded that institutionalization due to heart failure, was correlated with increased medication adherence whereas institutionalization for other causes was correlated with increased rates of non-adherence [19•]. On the other hand, contact with outpatient clinics showed no consistent correlation with medication adherence and contact with more healthcare professionals was not correlated with improved rates of medication adherence.
There are a number of treatment-related factors that have been identified as contributing to medication non-adherence in individuals with heart failure. These are varied and include complex medical regimens requiring alteration in lifestyle, the length of treatment regimens, experience with prior medical regimens, frequent changes in regimens and the variable lengths of time required before experiencing the positive effects of the medical regimens [18]. This large variety of factors involved has made it challenging to draw generalizations regarding the impact of regimen-related factors of nonadherence. However, a number of important observations have been documented in the literature. The number and frequency of pill regimens has been identified as a barrier to medication adherence in a number of studies. Studies have demonstrated simplification of medical regimens to once-daily dosing schedules to be an effective method for improving medication non-adherence in a number of chronic conditions including hypertension and type-2 diabetes mellitus [38, 39]. Similarly, reduction in the daily number of medication doses has been shown to be a simple and effective strategy for improving medication adherence in individuals with heart failure [40]. Additionally, the efficacy of fixed-dose combination pills has been of great interest and has been shown to similarly decrease the rates of medication non-adherence. A metaanalysis by Bangalore et al. found that fixed-dose combinations were effective in improving the rates of medication nonadherence [41]. Through a number of extensive patient interviews, Wu et al. showed difficulty with medical regimens to be a significant cause of non-adherence in individuals with heart failure. Common barriers included difficulty swallowing large pills, inconvenience of urinary frequency while on diuretics, and the number of medications taken each day [42]. For individuals with heart failure, adherence involves more than simply following the recommendation to take
Health Care Team/System- Related Factors
Social and Socioeconomic Factors Costs of medication have been shown to be barriers to adherence. In one study, as many as 42 % of patient did not fill their
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prescriptions when their medication costs exceeded the limits of the Medicaid prescription cap, 37 % changed the way medication was taken, and 11 % took another person’s medication [45]. In another study, Hsu et al. compared clinical and economic outcomes in close to 200,000 Medicare beneficiaries whose annual drug benefits were capped or unlimited. The researchers found that those patients whose benefits were capped took fewer of their prescribed medication and concurrently had poorer clinical outcomes and increased hospital and emergency department costs [46]. In another study, patients with a prescription benefit had greater medication adherence than those without a prescription benefit [47]. Similarly, when drug copayments increased, researchers found that patients’ medication adherence decreased, resulting in greater risks of hospitalization [48]. Finally, social support has been shown to correlate with medication adherence. Researchers found that patients who thought that they had adequate social support were more adherent to their medical regimen [23]. In a focus group, patients voiced that they needed practical and emotional support from others to assist them in taking their medications [49].
Novel Strategies for Promoting Adherence A number of novel strategies have been proposed with the intention of improving medication adherence among patients with heart failure. These have involved both inpatient and outpatient regimens. In part because of the success of such interventions, education targeted at medications remains a class I indication per the AHA/ACC management guidelines [3•]. Some studies have assessed the effect of initiating interventions prior to patient discharge. Nurse-led educational sessions prior to patient discharge have demonstrated significant reductions in first rehospitalization, total number of days hospitalized, total costs of care and knowledge at one year [50–52]. Additionally, the large OPTIMIZE-HF registry demonstrated mortality benefit in the initiation of beta-blockers prior to discharge in individuals with heart failure [53]. From an outpatient perspective, telemedicine systems have been studied for their effectiveness in the management of individuals with heart failure. These systems vary significantly and range from telephone-based reminders to home terminals outfitted with scales, oximeters, and blood pressure monitors. Interventions including home telecare videoconferencing and telephone-based communication have been shown to reduce hospital admissions and costs of care in individuals with heart failure [54, 55]. In a large randomized control trial involving the use of telephone intervention in individuals with chronic heart failure, it was found that medication adherence was improved at both in the initial trial follow-up period of 16 months, with an effect that lasted through three years of follow-up [56]. Medication adherence is more likely to decline when copayments increase for individuals. One approach to address
Curr Cardiol Rep (2014) 16:458
this concern, referred to as value-based insurance design (VBID) has been proposed [57]. VBID argues that copayments for high benefit services, such as medications essential for treatment of chronic diseases such as congestive heart failure, be kept low. Programs reducing patient copayments for chronic conditions have already been successfully introduced for individuals with diabetes, myocardial infarction, and asthma, leading to improvement in adherence with no increase in total expenditure [58]. Such targeted copayment relief will help shield patients from the deleterious clinical effects of patient cost sharing.
Conclusion Despite impressive advances in the management of heart failure over the past several decades, the prevalence of individuals affected by this condition remains high, and the economic burden significant. Medication adherence has been identified as a modifiable factor contributing to the high rates of admission and rehospitalization in individuals with heart failure. Barriers to medication adherence are complex and multidimensional. However, the identification and removal of these barriers has been shown to be effective in increasing medication adherence while reducing length of stay, rates of rehospitalization, and costs of care. Compliance with Ethics Guidelines Conflict of Interest Eric M. Riles, Anuja V. Jain, and A. Mark Fendrick declare that they have no conflict of interest. Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors.
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ISCHEMIC HEART DISEASE (D MUKHERJEE, SECTION EDITOR)
Medication Adherence and Heart Failure Eric M. Riles & Anuja V. Jain & A. Mark Fendrick
# Springer Science+Business Media New York 2014
Abstract Heart failure remains among the most prevalent and burdensome medical conditions in the United States. With increasing awareness regarding resource use and costs of care, there has been significant interest in the identification of factors that influence rates of hospitalization and readmission in individuals with heart failure. Medication adherence has been identified as one such modifiable factor. Many barriers to medication adherence have been identified and include factors related to the patient, those related to their medical condition, their medical regimen, the healthcare system and others that are social and socioeconomic in nature. Identification of these barriers has led to novel interventions for improving medication adherence with the goal of improving the care of individuals with heart failure. Keywords Heart failure . Therapy . Medication . Adherence
Introduction Heart failure remains among the most prevalent and burdensome medical conditions in the United States, presently
affecting five million individuals and expected to increase with an aging population [1, 2]. Nearly one in nine deaths and one million hospital admissions in this country are associated with heart failure annually [1]. The economic burden of caring for patients with heart failure is staggering. It is estimated that the total cost of caring for individuals with heart failure tops $40 billion per year [1, 3•]. Over the past several decades, important advancements in the medical therapy for heart failure have led to an increased life expectancy and decreased mortality for these patients. Despite these advancements, the last decade has seen little change in the rates of heart failure hospitalizations and readmission rates remains a concern. Nearly 25 % of individuals discharged with heart failure are readmitted within the first 30 days [1, 4]. With increasing awareness regarding the high costs of medical care, there has been substantial interest in identifying factors that influence the rates of readmission for patients with heart failure. Medication adherence has been identified as one potentially modifiable cause that contributes to increased rates of rehospitalization.
This article is part of the Topical Collection on Ischemic Heart Disease E. M. Riles (*) Cardiovascular Center, Boston Medical Center, 88 East Newton Street, Boston, MA 02118, USA e-mail: [email protected] A. V. Jain Department of Medicine, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115, USA e-mail: [email protected] A. M. Fendrick Department of Internal Medicine, University of Michigan, North Campus Research Complex. 2800 Plymouth Road, Ann Arbor, MI 48109, USA e-mail: [email protected]
Definition of Adherence & Magnitude of the Issue Over time, a number of terms have been developed to characterize the complex relationship between physician and patient that is implied in the term ‘adherence’. Medication adherence refers to the extent to which patient behavior is concordant with the physician recommendations to which he or she has agreed. This term emphasizes the patient’s agreement to actively participate in a given therapy. This differs from medication compliance, which refers to the extent to which a patient’s behavior matches the advice of the clinician without invoking the level of patient participation [5].
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Traditionally, medication adherence has been defined as a patient achieving at least 80 % of a prescribed regimen. However, this cutoff has been arbitrarily defined. Different disease states require different levels of adherence to therapy in order to achieve clinical effect. In individuals with heart failure, it has been proposed that survival is significantly improved at an adherence rate of at least 88 % [6]. The clinical consequence of non-adherence has been well described and is associated with increased rates of rehospitalization, emergency department visits, and worsened symptoms [7–9]. However, the extent to which individuals with heart failure are adherent to their medical regimens varies considerably in the literature with estimates ranging from 40 to 80 % [10–13].This variation has been attributed to a number of factors including varied study populations as well as bias from self-report. In the Medicare population, heart failure is the most common readmission diagnosis-related group [14]. Studies have shown between 20 % and 64 % of readmissions for heart failure are related to poor adherence with prescribed medications [15]. In addition, in a study that followed patients for 6 years, the number of hospitalizations reported in non- adherent patients was 2.5 times higher than that among adherent patients [9]. Roebuck and his colleagues found that adherence for patients with congestive heart failure was associated with nearly six fewer annual inpatient hospital days than those who were non-adherent [16••]. However, the studies related to medication adherence are often subject to self-report. Self-report of medication adherence has been shown to not be an independent predictor of survival in patients with heart failure [17]. Additionally, as noted in a review by Leventhal et al., other studies that use more objective measures of adherence using serum or urine drug concentrations (including digoxin, ace-inhibitors and loop diuretics) have shown inconsistencies in the relationship between medication adherence and readmission rates for individuals with heart failure [15]. Regardless, the consequence of non-adherence is relevant from a cost perspective. While the annual cost for managing individuals with heart failure remains high, it has been estimated that medication adherence reduces the average annual per-patient spending by nearly $8900 in individuals with heart failure [16••].
Curr Cardiol Rep (2014) 16:458
Patient- Related Factors The majority of the literature related to medication adherence in heart failure has focused on patient-related factors. Specifically, age and sex have been a major focus for a number of studies though the degree to which these variables predict medication non-adherence has been inconsistent. A recent systematic review by Oosterom found an equal number of studies showing age to be a determinant of medication adherence as those showing age to have no correlation with adherence [19•]. Of note, in those studies that showed a correlation between age and medication adherence, older age was associated with better rates of adherence [19•]. Patient knowledge has been another area of focus in determining patient-related barriers to medication adherence. A number of studies have demonstrated that patients with heart failure have poor comprehension of their medical regimens. In a study by Clark et al., patients demonstrated poor knowledge of the pharmacological management of heart failure, its progressive nature as a disease, and its link to death [20]. Wagdi et al. found that nearly 29 % of patients with heart failure had a lack of knowledge regarding their prescribed medications [21]. Finally, Cine et al. demonstrated that after discharge nearly 45 % of patients were unable to name their prescribed medications, 50 % did not know their prescribed doses, 64 % did not know how often to take the medications, and 82 % were taking medications that had not been prescribed to them [22]. By the virtue that therapies for heart failure are complex, it has been inferred that a certain level of patient knowledge is required in order to optimize patient medication adherence. However, a prospective study by Wu showed no correlation between patient knowledge and medication non-adherence [23]. This finding has been demonstrated in other studies as well [24]. Studies have shown varied correlations between patient level of education and the rate of medication adherence. Level of patient education has been associated with both increased and decreased rates of patient non-adherence [24–26]. While further studies are needed to better describe this relationship, two systematic reviews have suggested that the level of education does not significantly contribute to the level of patient non-adherence in heart failure [19•, 27]. In three out of five studies ethnic minorities were found to be less adherent, however in the other two studies, no relationship was found making this relationship inconsistent as well [23, 28–31].
Causes of Non-Adherence Condition- Related Factors The causes of medication non-adherence have been studied extensively. In short, barriers to adherence are complex and multi-dimensional. These barriers have traditionally been broken into specific dimensions including those related to the patient, the medical regimen, the health care team/system and those which are socioeconomic in nature [18].
Several studies have investigated whether the number of comorbidities in patients with heart failure was related to the degree of medication adherence. These have been met with conflicting results. An analysis from the large randomized CHARM trial showed that greater number of comorbidities
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was associated with worse medication adherence [32]. However, other studies have shown conflicting results [33]. Based on the availability of published data, there is not significant evidence to determine whether a relationship exists between the number of comorbid conditions and the extent of medication adherence in individuals with heart failure [19•]. Additionally, it has been shown that distressed emotions have been identified as significant barriers to adherence [34]. It is estimated that of individuals with heart failure, 10 % of outpatient and 50 % of hospitalized patients show evidence of depression [35, 36]. This is particularly important as the likelihood of non-adherence can be nearly three times higher in individuals who have signs of depression compared with those who do not [37].
medications. A critical component of the medical regimen also includes restriction of salt and fluid intake, avoidance of alcohol and tobacco, regular exercise, and monitoring daily weights. Riegel et al. found may individuals with heart failure to struggle with these lifestyle components of the treatment regimen [34]. The recent systematic review by Oosterom concluded that while different studies have analyzed different treatmentrelated barriers to medication adherence in heart failure patients, that overall, there is evidence that these factors do play a role in mediating patient adherence to their prescribed regimens [19•].
Regimen-Related Factors
Factors related to the health care system have also been studied as factors contributing to medication non-adherence in patients with heart failure. These include the patientphysician relationship, the reimbursement system, medication availability, training of providers in caring for patients with heart failure, and the amount of time available for patient interaction [18]. Strength of the patient-provider relationship has been shown to positively correlate with medication adherence in a number of chronic disease states [43]. In a series of in-depth interviews performed to identify factors influencing medication adherence in individuals with heart failure, it was similarly found that a positive patient-physician relationship was a favorable factor for improving rates of medication adherence [42]. Barriers to developing this relationship were identified by Horowitz et al. and included lack of education regarding both recognizing symptoms and symptom management, difficulty with contacting medical providers, and difficulty with receiving treatment through the health care system [44]. A recent systematic review by Oosterom investigated whether variation in the type of contact with healthcare institutions correlated with the rates of medication non-adherence in patients with heart failure. Types of healthcare institutions included inpatient and nursing facilities, outpatient centers and the number of contacts with healthcare professionals [19•]. This review concluded that institutionalization due to heart failure, was correlated with increased medication adherence whereas institutionalization for other causes was correlated with increased rates of non-adherence [19•]. On the other hand, contact with outpatient clinics showed no consistent correlation with medication adherence and contact with more healthcare professionals was not correlated with improved rates of medication adherence.
There are a number of treatment-related factors that have been identified as contributing to medication non-adherence in individuals with heart failure. These are varied and include complex medical regimens requiring alteration in lifestyle, the length of treatment regimens, experience with prior medical regimens, frequent changes in regimens and the variable lengths of time required before experiencing the positive effects of the medical regimens [18]. This large variety of factors involved has made it challenging to draw generalizations regarding the impact of regimen-related factors of nonadherence. However, a number of important observations have been documented in the literature. The number and frequency of pill regimens has been identified as a barrier to medication adherence in a number of studies. Studies have demonstrated simplification of medical regimens to once-daily dosing schedules to be an effective method for improving medication non-adherence in a number of chronic conditions including hypertension and type-2 diabetes mellitus [38, 39]. Similarly, reduction in the daily number of medication doses has been shown to be a simple and effective strategy for improving medication adherence in individuals with heart failure [40]. Additionally, the efficacy of fixed-dose combination pills has been of great interest and has been shown to similarly decrease the rates of medication non-adherence. A metaanalysis by Bangalore et al. found that fixed-dose combinations were effective in improving the rates of medication nonadherence [41]. Through a number of extensive patient interviews, Wu et al. showed difficulty with medical regimens to be a significant cause of non-adherence in individuals with heart failure. Common barriers included difficulty swallowing large pills, inconvenience of urinary frequency while on diuretics, and the number of medications taken each day [42]. For individuals with heart failure, adherence involves more than simply following the recommendation to take
Health Care Team/System- Related Factors
Social and Socioeconomic Factors Costs of medication have been shown to be barriers to adherence. In one study, as many as 42 % of patient did not fill their
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prescriptions when their medication costs exceeded the limits of the Medicaid prescription cap, 37 % changed the way medication was taken, and 11 % took another person’s medication [45]. In another study, Hsu et al. compared clinical and economic outcomes in close to 200,000 Medicare beneficiaries whose annual drug benefits were capped or unlimited. The researchers found that those patients whose benefits were capped took fewer of their prescribed medication and concurrently had poorer clinical outcomes and increased hospital and emergency department costs [46]. In another study, patients with a prescription benefit had greater medication adherence than those without a prescription benefit [47]. Similarly, when drug copayments increased, researchers found that patients’ medication adherence decreased, resulting in greater risks of hospitalization [48]. Finally, social support has been shown to correlate with medication adherence. Researchers found that patients who thought that they had adequate social support were more adherent to their medical regimen [23]. In a focus group, patients voiced that they needed practical and emotional support from others to assist them in taking their medications [49].
Novel Strategies for Promoting Adherence A number of novel strategies have been proposed with the intention of improving medication adherence among patients with heart failure. These have involved both inpatient and outpatient regimens. In part because of the success of such interventions, education targeted at medications remains a class I indication per the AHA/ACC management guidelines [3•]. Some studies have assessed the effect of initiating interventions prior to patient discharge. Nurse-led educational sessions prior to patient discharge have demonstrated significant reductions in first rehospitalization, total number of days hospitalized, total costs of care and knowledge at one year [50–52]. Additionally, the large OPTIMIZE-HF registry demonstrated mortality benefit in the initiation of beta-blockers prior to discharge in individuals with heart failure [53]. From an outpatient perspective, telemedicine systems have been studied for their effectiveness in the management of individuals with heart failure. These systems vary significantly and range from telephone-based reminders to home terminals outfitted with scales, oximeters, and blood pressure monitors. Interventions including home telecare videoconferencing and telephone-based communication have been shown to reduce hospital admissions and costs of care in individuals with heart failure [54, 55]. In a large randomized control trial involving the use of telephone intervention in individuals with chronic heart failure, it was found that medication adherence was improved at both in the initial trial follow-up period of 16 months, with an effect that lasted through three years of follow-up [56]. Medication adherence is more likely to decline when copayments increase for individuals. One approach to address
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this concern, referred to as value-based insurance design (VBID) has been proposed [57]. VBID argues that copayments for high benefit services, such as medications essential for treatment of chronic diseases such as congestive heart failure, be kept low. Programs reducing patient copayments for chronic conditions have already been successfully introduced for individuals with diabetes, myocardial infarction, and asthma, leading to improvement in adherence with no increase in total expenditure [58]. Such targeted copayment relief will help shield patients from the deleterious clinical effects of patient cost sharing.
Conclusion Despite impressive advances in the management of heart failure over the past several decades, the prevalence of individuals affected by this condition remains high, and the economic burden significant. Medication adherence has been identified as a modifiable factor contributing to the high rates of admission and rehospitalization in individuals with heart failure. Barriers to medication adherence are complex and multidimensional. However, the identification and removal of these barriers has been shown to be effective in increasing medication adherence while reducing length of stay, rates of rehospitalization, and costs of care. Compliance with Ethics Guidelines Conflict of Interest Eric M. Riles, Anuja V. Jain, and A. Mark Fendrick declare that they have no conflict of interest. Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors.
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