Improving Medication Adherence in Chronic Cardiovascular Disease

Improving Medication Adherence in Chronic Cardiovascular Disease
Nancy M. Albert
Crit Care Nurse 2008, 28:54-64.
© 2008 American Association of Critical-Care Nurses
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Clinical Article
Improving Medication
Adherence in Chronic
Cardiovascular Disease
Nancy M. Albert, RN, PhD, CCNS, CCRN, NE-BC
D
PRIME POINTS
• Heart failure patients
and MI survivors often
have complex medical
regimens and poor
adherence to medication.
• Nurses can improve
quality of care by assessing potential barriers to
adherence and implementing strategies to
increase adherence.
• APNs can implement
treatment at discharge
and prescribe oncedaily agents that result
in easier regimens,
improved adherence,
and better outcomes.
espite recent
advances in therapeutic management
of patients with
heart failure and
those who have had a myocardial
infarction, prognosis remains poor
once a patient has been hospitalized. On the basis of a 44-year
follow-up of the Framingham Heart
Study of the National Heart, Lung,
and Blood Institute, the mortality
rate is almost 80% at 8 years after
diagnosis of heart failure.1 Among
approximately 18 000 Medicare
recipients who were hospitalized
with heart failure, 44% were readmitted within 6 months.2 Outcomes after myocardial infarction
are no more optimistic: 11% to 32%
of patients with new or recurrent
CEContinuing Education
This article has been designated for CE credit. A
closed-book, multiple-choice examination follows
this article, which tests your knowledge of the following objectives:
1. Recognize the barriers to adherence of medication regimens for chronic cardiovascular
patients
2. Describe strategies that nurses can implement to increase patient medication regimen compliance
3. Understand the correlation between medication regimen compliance and patient safety
myocardial infarction die within 1
year, 14% to 32% of patients experience reinfarction within 5 years, and
1% to 6% experience sudden death.1
Patients at high risk after myocardial
infarction, such as those with left
ventricular systolic dysfunction,
have an even poorer prognosis, with
a 4- to 5-fold higher risk of inpatient
mortality compared with patients
without systolic dysfunction.3-5
Data from recent large-scale
registries6-8 have indicated that lifesaving therapies are underused in
cardiovascular patients. Compounding the difficulties of suboptimal
care is the problem of poor adherence to medications, which is often
overlooked. Although researchers
may have unique definitions of the
term “therapy adherence,” high percentages of cardiovascular patients
are nonadherent in several areas,
including taking medications (31%58%), attending follow-up appointments (16%-84%), and following
diet recommendations (13%-76%).9
In one study10 of 1291 patients after
myocardial infarction and/or with
heart failure, the self-reported medication nonadherence rate was 66%.
In a retrospective cohort of 7247
patients with heart failure, on the
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basis of prescription claims files,
only 10% were adherent to therapy
after 1 year.11
The reasons for poor prognosis in
patients with heart failure and in
those who have left ventricular systolic
dysfunction after myocardial infarction are multifactorial. In a prospective study12 of 280 patients with
advanced heart failure, researchers
applied 4 prognostic models to determine predictors of mortality. Data
on a total of 27 variables were collected, and patients were followed
up for 4 years to determine survival
and the sensitivity and specificity of
each model for predicting mortality.
The results indicated that current
models had limited predictive power
and that many component characteristics of each model did not have
independent prognostic significance.
Interestingly, the most powerful factors predictive of mortality were
increasing age, ischemic cause of
cardiomyopathy, history of cardiomyopathy (vs new onset), ankle edema,
decreased peak oxygen consumption,
and no prescription for a β-blocker.12
Because β-blocker therapy was the
only class of medication predictive
of survival, it is imperative that
nurses play a critical role in ordering medications and promoting
medication adherence to improve
clinical outcomes.
In this article, I describe the
problem of medication adherence in
patients with heart failure and those
with left ventricular systolic dysfunction after myocardial infarction and
discuss ways that nurse-based management can increase medication
adherence. Critical care, intermediatetelemetry, and general care nurses
have multiple opportunities to
improve the adherence essential to
optimizing health-related clinical
outcomes.
Medication Nonadherence
Heart failure and myocardial
infarction require long-term use of
medications to reduce morbidity
and mortality. Clinical management
often involves multiple drugs to
reduce mortality (eg, an angiotensinconverting enzyme [ACE] inhibitor,
a β-blocker, and an aldosterone
inhibitor plus or minus aspirin, a
statin, and warfarin as indicated)
and others to ameliorate signs and
symptoms (eg, digoxin, diuretics,
and nitrates). Nonadherence to prescribed medications can result in
many problems, including poor
blood pressure control, pathologic
changes and signs and symptoms
associated with worsening cardiac
function, hospitalization, and mortality13-21 (Table 1).
Despite advances in treating
patients with heart failure and after
myocardial infarction, treatment
regimens are only beneficial if patients
adhere to their prescribed therapy.
Author
Nancy M. Albert is the director of Nursing Research and Innovation, Nursing Institute,
and a clinical nurse specialist at George M. and Linda H. Kaufman Center for Heart
Failure, Cleveland Clinic Foundation, Cleveland, Ohio.
Corresponding author: Nancy M. Albert, RN, PhD, Director, Nursing Research and Innovation, Nursing Institute,
9500 Euclid Ave, Mail Code P32, Cleveland, OH 44195 (e-mail: [email protected]).
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Adherence rates, however, are suboptimal. In a multicenter analysis22
of more than 17 000 patients who
were prescribed β-blockers after a
myocardial infarction and had health
insurance and prescription drug
coverage, only 45% were adherent
(defined as prescription claims covering ≥75% of days) to β-blockers by
1 year after discharge; the biggest
decrease in adherence occurred
between 30 and 90 days. Adherence
to statin therapy among patients after
myocardial infarction was also poor;
the 2-year adherence rate was 40%.23
Information from the Duke
Databank for Cardiovascular Disease
for the years 1995 to 2002 was used
to assess the annual prevalence and
consistency of self-reported use of
aspirin, β-blockers, lipid-lowering
agents, and combinations of the 3
drugs in patients with coronary
artery disease and of ACE inhibitors
in patients with and without heart
failure.24 At the end of the study, rates
of self-reported medication use by
patients with coronary artery disease were highest for aspirin (83%);
next were lipid-lowering agents (63%),
β-blockers (61%), aspirin and a
β-blocker (54%); the lowest was for
use of all 3 (39%). Rates of consistent
(ie, reported on ≥2 consecutive followup surveys and then through death,
withdrawal from the study, or end
of the study) medication use followed a similar pattern: aspirin (71%),
β-blocker (46%), lipid-lowering agent
(44%), aspirin and β-blocker (36%),
and 21% for all 3 medications. Use
of an ACE inhibitor among patients
with heart failure was 51%; consistent
use was only 39%. Overall, consistent
use was associated with lower adjusted
mortality, although survival remained
suboptimal.24
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Table 1 Potential outcomes of nonadherence to evidence-based medications commonly used to treat patients with clinical
heart failure and patients with left ventricular systolic dysfunction after myocardial infarction
Drug class
Examples
Angiotensin-converting
enzyme inhibitor13
Captopril
Enalapril
Lisinopril
Ramipril
Fosinopril
Quinapril
Trandolapril
Angiotensin receptor blocker14
Losartan
Candesartan
Valsartan
Aldosterone antagonist15,16
β-Blocker17,18
Digoxin19, a
Loop diuretic20
Thiazide/thiazide-like diuretic20
Statins21
a
Eplerenone
Spironolactone
Carvedilol
Carvedilol CR
Bisoprolol
Metoprolol succinate
Digoxin
Furosemide
Bumetanide
Torsemide
Hydrochlorothiazide
Metolazone
Atorvastatin
Pravastatin
Simvastatin
Rosuvastatin
Potential outcomes of nonadherence
Activation of renin-angiotensin-aldosterone system
↑ Systolic blood pressure
↑ Myocardial oxygen demand
↑ Preload
↑ Afterload
↓ Heart function
Ventricular hypertrophy and remodeling
↓ Exercise tolerance
↑ Hospitalization and mortality
Activation of renin-angiotensin-aldosterone system
↓ Heart function
Ventricular hypertrophy and remodeling
Sodium retention
↑ Hospitalization and mortality
Activation of sympathetic nervous system
↓ Heart function
↑ Heart rate
↑ Blood pressure
Ventricular remodeling
↑ Ventricular arrhythmias
↓ Exercise tolerance
↑ Hospitalization and mortality
↓ Heart muscle contraction
↑ Heart rate
↑ Atrioventricular node conduction
↓ Exercise tolerance
↑ Hospitalization
Signs of fluid retention (rales, S3 heart sound, edema, jugular
venous pressure elevation, weight gain, ↓serum sodium level)
Symptoms of fluid overload (dyspnea, orthopnea, paroxysmal
nocturnal dyspnea, fatigue)
↑ Electrolytes (potassium, magnesium)
↑ Blood pressure
↑ Hospitalization
↑ Low-density lipoprotein cholesterol
Loss of pleiotropic benefits
Only in heart failure.
Consequences of
Nonadherence
Poor adherence to medication
regimens in patients with heart failure and after myocardial infarction
accounts for substantial morbidity
and mortality. In retrospective
reviews and small prospective
studies,25 33% to 69% of medicationrelated US hospital admissions
were attributed to poor medication adherence. In retrospective
studies,26 poor adherence with prescription medications was a contributing factor in 20% to 64% of
rehospitalizations for heart failure.
Early readmission is widely used as
an indicator of inpatient quality of
care. According to one study,27 twothirds of hospital readmissions for
heart failure could be avoided by
delivery of high-quality inpatient
care. In particular, readmissions
were due to medication nonadherence (24%), diet nonadherence
(24%), inappropriate treatment
(16%), and failure to seek care
(19%). Most of these causes are
avoidable and can be addressed by
proper care and discharge planning.
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The consequences of nonadherence after myocardial infarction
can be illustrated by study findings.
In a retrospective analysis28 of the
Beta Blocker Heart Attack Trial,
researchers evaluated the relationship between treatment adherence
and mortality after myocardial infarction in 2175 patients. Patients with
poor adherence (took ≤75% of prescribed β-blocker) had a 2.5- to 3.1fold increased risk of dying within 1
year compared with patients with
higher adherence rates. Interestingly,
poor adherers had an increased risk
for death whether they were taking
propranolol or placebo, suggesting
that poor adherence with a β-blocker
was indicative of nonadherence to
other prescribed therapies.
In a study29 of drug adherence
and mortality in 31 455 survivors
of myocardial infarction who filled
prescriptions for statins and βblockers, patients were divided
into 3 adherence categories: high
(≥80% of days covered), intermediate
(40%-79% of days covered), and low
(<40% of days covered). After 1 year,
compared with the high-adherence
group, low adherers to statin therapy
had a 25% increased risk of mortality, and intermediate adherers had
a 12% increase. A similar association
between adherence and mortality
was observed for β-blockers.29
In a study30 of primarily patients
after myocardial infarction, adherence was measured by the fill frequency (number of prescriptions
filled during the observation period
divided by months of observation)
of a statin prescription. Patients with
a fill frequency of 80% or higher were
half as likely as nonadherent patients
(fill frequency, ≤60%; P=.047), to
experience a subsequent myocardial
Medication use
Figure In multivariate analysis, increased risk of mortality during follow-up after
myocardial infarction in patients who discontinued medications compared with
patients who continued medications. On y axis, 1 refers to no increase in mortality
risk and no reduction in mortality risk, 2 refers to a doubling or 2-fold increase risk
of mortality, 3 refers to a tripling or 3-fold increase risk of mortality, and so on.
Based on data from Ho et al.31
infarction. In the subset of patients
younger than 65 years, the associated risk reduction of a subsequent
myocardial infarction was 86% for
the adherent group compared with
the nonadherent group (P=.001).30
Finally, in a multivariable survival
analysis,31 patients who discontinued
all medication therapy (used 0 of 1,
2, or 3 pills) had a 3.8-fold increased
risk for mortality. The Figure shows
mortality risk by discontinuation of
specific medication therapies.
An association between medication adherence and mortality has
been detected in patients with heart
failure. In the double-blind, randomized, controlled clinical trial Candesartan in Heart Failure: Assessment
of Reduction in Mortality and Morbidity (CHARM),32 the efficacy of
candesartan, an angiotensin receptor
blocker, was compared with placebo
for a median of 38 months in 7599
patients with heart failure. Good
adherence was defined as taking
more than 80% of the study medication over time. After adjustment for
predictive factors (demographics,
physiological and severity-of-illness
variables, smoking history, and number of concomitant medications),
good adherence was associated
with lower all-cause mortality in all
patients (P<.001). Moreover, good
medication adherence in patients
with heart failure was associated
with a lower risk of death than was
poor adherence (took ≤80% of study
medication), irrespective of assigned
treatment (P < .001 in both treatment
groups).32 The researchers postulated that good adherence with an
angiotensin receptor blocker extended
to adherent behaviors in other prescribed therapies.
CRITICALCARENURSE Vol 28, No. 5, OCTOBER 2008 57
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Barriers to Adherence
Despite its importance, adherence
to medication therapy is an aspect
of patients’ care that is often overlooked and should be reevaluated
as a crucial part of cardiovascular
management.33 Therapy-related factors (ie, those that can be altered by
a medication change) that influence
nonadherence include adverse effects,
polypharmacy, frequent dosing, and
cost34-36 (Table 2). Other reasons for
nonadherence are poor communication and education about the importance of therapy at the time of
discharge, complexity of drug regimens, and failure to initiate therapy
in the hospital when the patient is
most likely to relate the drug to
health.33,37 In-hospital initiation of
medications has a dramatic effect
on long-term treatment rates and
patients’ adherence.37 Patients who
start taking agents in the hospital
are more likely to stay on therapy
because of the perceived importance
of medications and often have more
dialogue with physicians and nurses
about medications, including a discussion about possible adverse effects.37,38
Medication Complexity
As newer lifesaving medications
become available, morbidity and
mortality risks decrease; however,
the complexity of regimens increases.
Specifically, the complexity of drug
regimens is increasing among patients
with heart failure and after myocardial infarction.39 According to data
from the National Heart Care Project,
the mean number of heart failure
prescriptions and doses per day were
7.5 and 11.1, respectively, from 2000
to 2001. After adjustment for patient,
physician, and hospital characteristics, compared with data for 1998
Table 2
Factors that influence medication nonadherence
Failure to initiate therapy during hospitalization
Poor communication and education at discharge of the importance of medications
Complexity of medication regimen
Polypharmacy
Frequent dosing
Medication cost
Adverse effects
Lack of knowledge about possible adverse effects
to 1999, data from 2000 to 2001
reflected a 12% increase in the mean
number of medications prescribed
to patients with heart failure.40 Complexity of drug regimens of patients
with heart failure and the concomitant cost of the regimens are major
contributors to medication nonadherence. Several investigators41-44
have found an inverse relationship
between the number of daily doses
and the rate of medication adherence.
Reduction of prescribed medication
dosing from 3 and 4 times daily to
once daily significantly improved
medication adherence (P=.008 and
P<.001, respectively).41 Patients with
heart failure and other cardiovascular conditions can benefit from changing regimens from taking medication
2 or 3 times a day to taking it once a
day.41-44 Reducing the number of daily
doses was effective in increasing
adherence with antihypertensive
medication from 8% to 19.6%.42 Oncedaily dosing was also associated
with higher adherence to antihypertensive medication than was twicedaily dosing.43 Among patients with
heart failure and after myocardial
infarction, fewer pills per day can
improve adherence.45
Recent availability of a once-daily
formulation of carvedilol, carvedilol
CR, allows consideration for reducing the daily number of pills required.
Guidelines of the American College
of Cardiology and the American Heart
Association include recommendations
that long-term β-blocker therapy be
started and continued indefinitely
in all survivors of acute myocardial
infarction who do not have absolute
contraindications46,47 and in patients
with mild to severe heart failure.48
Use of once-daily carvedilol CR rather
than the twice-daily formulation may
improve adherence. Algorithms for
switching from non–evidence-based
β-blockers to once-daily evidencebased agents are available.49 Nurses
can advocate for changes in therapy
when warranted and advanced practice nurses can promote improved
care and adherence by switching to
once-daily evidence-based agents.
Similarly, ACE inhibitors are available in once-daily and multidose
(twice-daily and 3 times daily) formulations.
Nurses must not only understand the dosing equivalents of
agents given once daily and more
than once a day within the same
class but also must plan timing of
doses so that long-acting drugs do
not peak at the same time and result
in adverse effects such as dizziness,
lightheadedness, and fatigue. Pocket
cards can be used as a guide to help
plan a medication program that
meets patients’ social needs and
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also prevents untoward adverse
effects. The pocket card can include
details such as starting dose, titration
schedule for increasing the dose,
target and maximum doses, and
time to peak effects, as previously
reported,50 or the card can be a simple
table that separates drugs commonly
used in specific cardiovascular conditions by time to peak effects
(Table 3 is an example for patients
with stage C or D heart failure).
One potential solution to reduce
the complexity of medication therapy and reduce the number of pills
required is to use polypills that are
taken once daily. Polypills that
combine multiple drugs such as
aspirin, a β-blocker, an ACE inhibitor,
a statin, a thiazide diuretic, and/or
antiplatelet medication are more
common in Europe than in the
United States. Polypills have the
advantage of ensuring the delivery
of 2 or more evidence-based medicines in a single pill and bypassing
the possibility that general practitioners may miss prescribing 1 or
more ingredients.51 A combination
product can simplify therapy and
may promote medication compliance. In the United States, 3 mixedtarget combination pills such as a
statin plus a calcium channel blocker,
a statin plus aspirin, and an antihypertensive plus a thiazide diuretic
have been approved. The use of
polypills that concomitantly target
medical conditions without increasing the number of pills required can
improve outcomes in some patients.
In addition to regimen complexity, other issues, including the cost
of medications and adverse effects,
may prevent patients from adhering
to therapies. Nurses should be aware
of the effect that these and other
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Table 3 Evidence-based medications commonly used in the treatment of stage C
and stage D heart failure categorized by time to peak effect
Time to peak effects, h
>2 to 4
>4 to 6,
unless indicated
Metolazone
Hydrochlorothiazide
Eplerenone
Carvedilol
Ramipril
Captopril
Bisoprolol
Enalapril
<1 to 2
Loop diuretics
Hydralazine/isosorbide
dinitrate combination
Candesartan
Fosinopril
Trandolapril
Quinapril
Spironolactone (1-3 h)
Valsartan
Lisinopril (7 h)
Metoprolol
succinate (6–12 h)
Carvedilol CR
Digoxin (1-5 h)
barriers can have on achieving the
optimal benefits of a medication.
Cost of Medications
Even if a patient is receiving the
best therapies available at the time
of discharge, medications work only
when patients remember to take
them and can afford them. The
complexity of medication management for patients with heart failure
poses a financial burden, especially
on elderly patients. Drug costs are
increasing at a rate greater than those
of any other health care expenditure.40 According to the National
Heart Care Project,40 from 2000 to
2001, the mean annual cost of medications prescribed to patients with
heart failure was $3832, an increase
of 24% over that of 1998 to 1999. In
a study52 of 138 patients, the cost of
medications for patients with heart
failure increased as the severity of
the disease advanced to New York
Heart Association class II and class
III heart failure. The overall mean
monthly cost of medications for all
heart failure patients was $438;
patients with class II and class III
heart failure had the highest monthly
costs: $541 and $514, respectively.
Patients with heart failure often
have comorbid conditions that may
require additional medications and
thus increase financial costs.
Nurses should be knowledgeable
about the costs of drugs, because
Medicare Part D coverage is likely to
require substantial out-of-pocket
expenditures.40 If financial strain
causes a patient to skip or miss doses,
then a less complex drug regimen
(ie, once-daily dosing) and the use
of generic medications should be
considered. Patients’ discharge education should include a discussion
of the costs of medications and a plan
for drug payment. Nurses and other
health care professionals, such as
social workers, can be instrumental
in ensuring that patients understand
the complexities of a medication
regimen and are financially able to
maintain the medication plan of care.
Adverse Effects
The adverse effects of medications
contribute largely to nonadherence
to a heart failure regimen. Nurses
should be aware of and communicate potential adverse effects of all
CRITICALCARENURSE Vol 28, No. 5, OCTOBER 2008 59
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medications, because early recognition of adverse effects may help
reduce difficulties in following medical prescriptions. Nurses should
inform patients about the possibility
of adverse events associated with
switching from short-acting, more
than once a day dosing to long-acting,
once-daily dosing. If adherence was
poor with therapy that required
more than 1 pill a day and is expected
to improve when the number of pills
per day decreases, close monitoring
may be necessary.
In a study36 of medication adherence and the beliefs of patients with
heart failure, the most frequently
identified benefit of adherence was
Research54 on the effect on outcomes of 6 months of visits to a nursemanaged heart failure clinic indicated
that readmissions, length of stay, and
severity of illness could be reduced
by intensive nurse-patient interaction.
At the beginning of the study, only
40% of patients were able to articulate 1 desired effect and 2 adverse
effects of their medication; after 1
year of intervention by a clinic nurse,
82% of patients were able to recall
this information. The success of the
program was attributed to 4 key factors: (1) development of a trusting
relationship between the nurse and
patient, which the authors thought
encouraged adherence to therapies;
nurses to assure patients that following the medication plan of care
may produce transient adverse effects
but can improve functional status,
quality of life, time to rehospitalization, and survival. Additionally,
patients need to feel comfortable
contacting their nurse caregiver or
other health care providers when
questions about adverse effects arise
so that patients have a clear understanding of medication use when
adverse effects occur and can adhere
to the medication schedule.
Although the barriers to execution of a medication plan for patients
with heart failure are considerable,
they are not insurmountable. Barriers
Nurses should take an active role in assessment,
education, care planning, and strategic implementation
efforts that support patients’ optimal self-care behaviors
and promote medication adherence.
decreasing the chance of being hospitalized, and the most commonly
reported barrier was disruption of
sleep. Compared with patients who
are unaware of the potential adverse
effects of a medication, patients who
are aware (and are told whether the
adverse effects are transient or not)
may fare better because they have
appropriate expectations. Increasing evidence53 supports the use of
strategies to enhance self-efficacy
(the belief that one can follow the
regimen) and therapeutic efficacy
(the belief that the treatment actually works) as important factors to
improve adherence. Thus, empowering patients with as much education and control as possible should
improve adherence.
(2) close monitoring of weight and
proper intervention with diuretic or
other therapy if needed; (3) dietary
assessment and restructuring; and
(4) identification of and assistance
with any financial situation that
would preclude a patient from adhering to therapy.
In literature on exercise in heart
failure, patients cite physical symptoms (pain, dizziness), lack of energy
(weakness, fatigue), and poor motivation as reasons for poor adherence
to exercise therapy. In a study55 of
self-care behaviors, including exercise behaviors, 30% of elderly people
with heart failure reported that they
had stopped exercising after heart
failure was diagnosed. The literature
on exercise underscores the need for
to adherence due to a patient’s perception of therapy are best addressed
by patient-specific interventions
that include open communication
and education strategies.36 Nurses
are paramount to the success of
patients’ education by offering discharge instruction and ongoing
education that result in better
patient self-care.56
Role of Nurses in
Increasing Adherence
Patients may be reluctant to tell
a physician how often they miss a
dose of medication or take the
medication at the wrong time, yet
researchers found that only 10% of
patients were fully adherent (based
on self-report) with medications as
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prescribed.26 When medication levels cannot be obviously detected by
using laboratory tests (eg, glucose
levels for diabetes therapy), it is difficult to ascertain whether patients
are adherent to therapy. Therefore,
it is incumbent on the prescriber to
stress the importance of medication
adherence and to make an effort to
simplify the treatment regimen so
that patients take prescribed medications. Nurses should take an active
role in assessment, education, care
planning, and strategic implementation efforts that support patients’
optimal self-care behaviors and
promote medication adherence.
The most recent Heart Failure
Society of America consensus guidelines57 for patients with chronic heart
failure state that nurses are the primary providers of education on heart
failure. Considerable attention should
be focused on ensuring patients’
understanding and improving longterm adherence. Critical and intermediate care nurses play a role in
both regards. Nurses work collaboratively with other team members
to ensure that medications are prescribed. Before discharge, nurses are
often responsible for educating
patients about how to take prescription drugs according to the plan of
care. In addition, nurses assess
patients’ understanding of self-care
principles associated with optimal
care for heart failure. Although
education is only 1 factor related to
optimal self-care, adherence and
understanding of self-care expectations provide part of the foundation
of success.
Nurses can play an integral role
in improving patients’ outcomes
and self-care by educating patients
about the complexities of medication
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therapies (including expected transient adverse effects), the potential
of adverse events, and the importance of maintaining therapy. Patients
who receive limited counseling
about medications may be less likely
than those who receive more counseling to adhere to their prescribed
regimen. When physicians prescribe
a new medication for a patient, they
may not communicate critical elements of medication use that might
contribute to misunderstandings
about medication directions or
necessity and, in turn, lead to the
patient’s failure to take medications
as directed.58 The roles of clinical
nurses and physicians can be complementary, with nurses providing
education to patients before discharge
to promote greater medication
adherence. The first several weeks
of treatment are a critical time
when many patients discontinue
medications,22 and ongoing nursing
interventions that affect adherence
early can improve long-term health
outcomes.59 These interventions
include patient education, patient
reminders to take medications (eg,
using a pill box for each day of the
week and time of day), clinical visits,
telephone calls, and simplifying the
drug regimen60-62 (Table 4).
The value of nurse-physician
collaboration in education was
illustrated in an education program
to improve clinical outcomes in
patients with heart failure who were
about to be discharged from the
hospital. In a randomized, controlled
trial63 of 223 patients, a 1-hour, 1-on1, nurse educator–delivered education session that provided details
about the pharmacological plan of
care (rationale for drug use, mechanism of action of diuretic medica-
tions, avoidance of nonsteroidal
anti-inflammatory drugs, and what
to do if symptoms worsened) was
added to the standard discharge
process (list of medications, dosages,
and instructions for taking the drugs).
Compared with patients who received
standard care, patients who participated in the teaching session had a
35% lower risk for rehospitalization
or death at 6-month follow-up (P=
.02). The total cost of care (including
the nurse-led education intervention)
at 6-month follow-up for patients in
the education group was $2823
lower than the cost of care for patients
in the control group (P=.04). Moreover, patients in the education group
were more likely to adhere to ACE
inhibitor therapy at 3 months and
β-blocker therapy at 1 month than
were patients in the control group.63
Nurse-led management
approaches are effective in managing a variety of chronic conditions.
In one intervention for patients
with heart failure, an experienced
cardiac nurse educator conducted
an education program that included
both comprehensive discharge planning and immediate outpatient
reinforcement through nurse home
health care.56 The 6-month readmission rate for patients who did not
receive the intervention was nearly
4 times higher than the rate for those
who did (44.2% vs 11.4%; P=.01).
At discharge, patients with heart
failure can enter into a less standardized system of self-reliant chronic
care. Thus, nurses are challenged to
provide patients with ongoing support after discharge and simplified
dosing regimens to improve medication adherence.
In a study64 of elderly patients,
discharge planning and home follow-
CRITICALCARENURSE Vol 28, No. 5, OCTOBER 2008 61
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Table 4
Role of nurses in improving medication adherence
Nurse-physician collaboration in patients’ care and education during hospitalization
In-hospital initiation of medications
In-hospital titration of vasodilating medications (angiotensin-converting enzyme
inhibitor/angiotensin receptor blocker) to target doses on the basis of large, multicenter, randomized, controlled trials
Development of a trusting relationship and open communication between nurse and
patient
Nurse-directed patient education
Comprehensive counseling about discharge medications
Rationale for use in heart failure or after myocardial infarction
Dose, how to take, when to take
Anticipated or transient adverse effects
Serious adverse effects
When to contact a health care provider
Which health care provider to contact
What to do if a dose is skipped
Food, other drugs, or over-the-counter therapies that could affect drug effectiveness
Nurse education: educating the educator
Medication algorithms on how to use drugs: when to consider new agents
Pocket cards that provide details of how drugs may interact
Inclusion of patients’ family members in education session(s)
Review of medications
Review of possible adverse effects and serious adverse effects
Social services consultation and discharge planning
Assessment of patients’ financial ability to purchase prescribed medications
Use of generic drugs
Simplifying drug regimen
Once-daily dosing
Medication pill boxes: how to use
Patient handouts/written materials
Polypills
Outpatient reinforcement of educational information
Patient reminders: written, telephone
Home visits
Clinical visits
up by advanced practice nurses were
effective in reducing the risk of hospital readmissions. The nurses were
responsible for discharge planning
while the patients were hospitalized
and substituted for visiting nurses
during the first 4 weeks after each
patient’s discharge. In contrast,
control patients received routine
discharge planning and standard
home care consistent with Medicare
regulations. By week 24 after the
discharge from the hospital, patients
in the intervention group were less
likely than patients in the control
group to be readmitted at least once
(20.3% vs 37.1%; P<.001), had fewer
multiple readmissions (6.2% vs 14.5%;
P=.01), and spent fewer days in the
hospital (1.5 vs 4.1 days per patient;
P<.001). Improved outcomes were
achieved at reduced costs. Total
Medicare reimbursements for health
services were about $1.2 million in
the control group and about $600 000
in the intervention group (P<.001).64
Studies65-67 have shown that
patients randomly assigned to nurse
practitioners for primary care followup do not differ in health outcome,
resource utilization, and costs from
patients assigned to physicians.
However, patients’ satisfaction has
been higher with nurse-managed
care than with physician-managed
care because nurses tend to provide
longer consultations and more information to patients.67 In an evaluation68 of the effectiveness of a nurse
case management program to control hypercholesterolemia, compared
with patients who received enhanced
primary (physician) care, significantly
more patients who received nursemediated care achieved goal levels
of low-density lipoprotein cholesterol (P=.008). Favorable changes in
lipids and lipoproteins were accompanied by improvements in dietary
and exercise patterns in the nursemediated program, a reflection of
greater adherence to national guidelines.68 Likewise, patients with
hypertension had better control of
blood pressure when supervised
and monitored by specially trained
nurses than when given usual community-based care.69,70
A nurse-directed multidisciplinary intervention program for elderly patients with heart failure
that consisted of comprehensive
patient and family education,
dietary prescription, social service
consultation and discharge planning, medication review, and intensive follow-up led to improved
morbidity outcomes at 3 months.71
Specifically, the control group who
received conventional care had 44%
more readmissions than did the
62 CRITICALCARENURSE Vol 28, No. 5, OCTOBER 2008
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group who received nurse-directed
care (P = .02). In particular, heart
failure readmissions were reduced
by 56% in the nurse-directed care
group (P=.04).71 Because of the
overall reduction in hospital admissions, the overall cost of care was
$460 less per patient in the intervention group.
In summary, evidence clearly
indicates that education and management of patients by nurses
improves the patients’ medication
adherence and leads to improved
self-care, better clinical outcomes,
and reduced medical costs.
Conclusions
Adherence to pharmacological
therapies in patients with heart failure and after myocardial infarction
is poor, leading to worsening disease
severity and rehospitalization. Nurses
can increase the use of lifesaving
therapies by implementing treatments at discharge and using oncedaily agents that result in easier
regimens, decreased drug costs,
improved adherence, and better
outcomes. Advanced practice nurses
should prescribe once-daily agents
whenever possible to avoid complicated regimens. Numerous barriers
to medication adherence include
complex medication regimens, poor
patient education, medication cost,
and adverse effects. Nurses can play
a key role in optimizing patients’
quality of life by assessing potential
•
d tmore
To learn more about medication adherence,
read “Cardiac Transplantation: A Second
Chance for Extending Life” by Laurie G.
Futterman and Louis Lemberg in the American Journal of Critical Care, 2008;17:168-172.
Available at www.ajcconline.org.
http://ccn.aacnjournals.org
barriers to medication adherence
and implementing comprehensive
strategies to increase adherence. CCN
13.
eLetters
14.
Now that you’ve read the article, create or contribute to an online discussion about this topic
using eLetters. Just visit http://ccn.aacnjournals
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15.
16.
17.
Financial Disclosures
None reported.
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64 CRITICALCARENURSE Vol 28, No. 5, OCTOBER 2008
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CE Test Test ID C0853: Improving Medication Adherence in Chronic Cardiovascular Disease
Learning objectives: 1. Recognize the barriers to adherence of medication regimens for chronic cardiovascular patients 2. Describe strategies that nurses can
implement to increase patient medication regimen compliance 3. Understand the correlation between medication regimen compliance and patient safety
1. According to the Duke Databank for Cardiovascular Disease, which
contains data on patients with coronary artery disease from 1995 to
2002, patients self-reported the highest medication compliance for
which of the following?
a. β-blockers
b. Lipid-lowering agents
c. Aspirin
d. Angiotensin-converting enzyme inhibitors
2. Which of the following describes why patients who start taking
agents in the hospital are more likely to stay on therapy?
a. Patients want to keep friends and family happy.
b. In the hospital there is often more dialogue with physicians and nurses
about medications and expected side effects.
c. Patients understand that medication adherence will allow them to
return to past lifestyle behaviors.
d. Adequate education occurs only in the hospital.
3. Which of the following are 2 major contributors to medication nonadherence?
a. Medication regimen complexity and concomitant costs
b. Side effects of medications and family support
c. Multiple daily doses and poor education about the regimen
d. Number of different medications prescribed and family support with
adherence
4. Which of the following is most important when decreasing the number of daily doses of medications to increase adherence?
a. The patient’s home schedule
b. Potential side effects of the medication
c. The patient’s ability to understand his or her medication regimen
d. Timing of drugs so that multiple medications do not peak at the same
time
5. What are polypills?
a. Special agents designed for patients who are already adherent with
therapies
b. A term that describes patients who are on multiple drug regimes per day
c. A drug that combines multiple drug therapies
d. Agents that are created to decrease common side effects
6. Which of the following describes how drug costs are changing?
a. Increasing at a rate greater than any other health expenditure
b. Decreasing annually
c. Decreasing with the increasing severity of the illness
d. Requiring less out-of-pocket expenditure
7. Which one of the following is a frequently identified barrier to medication
adherence in patients with heart failure?
a. Increasing frequency of hospitalization
b. Adequate education about the treatment regimen
c. Disruption of sleep
d. Decreasing the chance of being hospitalized
8. After 6 months of visits to a nurse-managed heart failure clinic, which of the
following outcomes were found by researchers?
a. Patient adherence with medication regimens decreased as visits increased.
b. Hospital readmissions, length of stay, and severity of illness were reduced.
c. Hospital readmission increased but length of stay decreased.
d. Severity of illness improved only in the sickest patients.
9. How should nurses support patients’ optimal self-care behaviors and promote medication adherence?
a. By providing assessment, education, care planning, and strategic implementation of activities that are known to promote adherence
b. By encouraging patient exercise since active patients are more adherent to care
expectations
c. By promoting families to take over medication delivery and by encouraging
adherence flexibility
d. By requesting that physicians educate patients
10. Evidence indicates that delivery of patient education and disease management by nurses leads to which of the following?
a. Increased medical costs
b. Better patient outcomes
c. Improved medication adherence
d. B and C
Test answers: Mark only one box for your answer to each question. You may photocopy this form.
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2. K a
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3. K a
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4. K a
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5. K a
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6. K a
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7. K a
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8. K a
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9. K a
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10. K a
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Test ID: C0853 Form expires: October 1, 2010 Contact hours: 1.0 Fee: AACN members, $0; nonmembers, $10 Passing score: 7 correct (70%) Category: A, Synergy CERP B
Test writer: Pamela Shellner, RN, BSN, MA
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