Top 3 cardiovascular patient compliance challenges

Staying compliant with a prescribed treatment regimen gives cardiovascular disease patients the best chance of improving their heart health and reducing future incidences of cardiac events. Still, research has shown that most patients fall short in complying with their treatment plans, says Robert Vogel, MD, cardiologist and clinical professor of medicine, University of Colorado, Denver.

For example, a study in the Journal of General Internal Medicine found high discontinuance rates among patients who had been prescribed an angiotensin-converting enzyme inhibitor after a heart attack:

• 7% stopped within one month;

• 22% stopped within six months; and

• 50% stopped after two years.

Another study in JAMA Internal Medicine found that only one-third of heart attack patients who were referred to a cardiac rehabilitation program attended. This is particularly troubling given research suggesting that patient participation in a cardiac rehabilitation program after myocardial infarction reduces the risk of long-term hospital readmission by 25% and death by 42%.

Why noncompliance is rampant

MurthyPatients tend to be more compliant when a medication or a lifestyle makes them feel better, says Sandhya Murthy, MD, cardiologist, Montefiore Einstein Center for Heart and Vascular Care, Bronx, New York. But because high blood pressure and high cholesterol-which can lead to heart attack-are asymptomatic conditions, patients won’t feel any change by taking medication.

In addition, “Patients may not enroll or attend a cardiac rehabilitation program if they view it as inconvenient or find a lack of support from their employer or family,” Vogel says. “For some patients, getting transportation to a pharmacy, physician office, or cardiac rehabilitation center make adherence difficult. Cost, logistics, a treatment’s side effects, a treatment’s complexity, and other patient comorbidities may also come into play.”

The nature and strength of the doctor-patient relationship is also a factor, as is the physician’s ability to communicate. When physicians educate patients about their illness, patients tend to be more empowered-which in turn improves compliance. “No one likes to be told what to do,” Murthy says. “But when a patient understands that medication will prevent long-term vascular damage that can lead to heart attack, strokes, and so forth, they are more likely to comply.”

Next: Improving medication adherence

Improving medication adherence

Healthcare providers can help patients identify ways to reduce barriers for treatment compliance. For example, if a patient has access to a mail-order pharmacy, patients can get a 90-day supply of their medications delivered automatically to their home-eliminating the need to call in the prescription and make a trip to the pharmacy, Vogel says.

MarcusConsolidating a patient’s medical regimen by giving fixed-dose combination medications in one pill can reduce challenges related to taking too many medicines, adds Lee Marcus, MD, MS, FACC, founder, Preventive Cardiology of New York, located in Manhattan.

Montefiore-Einstein Center for Heart and Vascular Care initiated a program in which patients meet with a pharmacist to discuss the role of each prescription.

“A complex regimen can be daunting,” Murthy says. “Therefore, we use the clinic as a way to simplify their regimen, as well as offer education about the benefits of each medication.”

Encouraging lifestyle and diet changes

Breaking poor habits can be difficult. But research in the Journal of Applied Physiology has shown that making changes, particularly eating a healthier diet and increasing exercise, have dramatically reduced high low-density lipoprotein cholesterol, high glucose, and hypertension-all risk factors of heart disease.

Murthy often refers patients to a cardiac rehabilitation program. This is essentially a structured gym with monitoring. Rehabilitation medicine doctors and an experienced physiatrist guide the patient through various exercises. Most insurance companies will pay for this service, given that it is now well-recognized that regular exercise can significantly reduce the number of healthcare dollars spent in the future.

VogelTaking this a step further, Vogel recommends referring patients to an intensive cardiac rehabilitation (ICR) program such as Pritikin ICR. Ordinary cardiac rehabilitation programs are covered by Medicare for up to 36 initial sessions, which primarily consist of exercise. ICR offers double this number-up to 72 sessions-consisting of both exercise and education on diet and maintaining a healthy mindset, providing patients with a good platform for implementing and maintaining a heart healthy lifestyle.

At Montefiore-Einstein Center, dedicated nutritionists meet with patients and review meal plans tailored to their medical conditions in detail. “This invaluable service can be very helpful in laying the groundwork for a healthy diet,” Murthy says. “I encourage a patient’s family to participate in this meeting as well because oftentimes the strategy is only effective if the whole family participates in the change.”

Next: Getting patients to stick to regular check-ups

Getting patients to stick to regular check-ups

Murthy has found that compliance with clinic visits improves if the patient feels a connection with the provider. “I tell patients that I am going to try my hardest to keep them healthy, but that I can’t do it alone,” she says. “When the patient feels responsible for their health, it again leads to a sense of empowerment-which in turn leads to increased compliance with visits.”

Another quick and easy strategy that providers can use is to make a follow-up phone call. “It seems quite simple-but a phone call to review progress after the initial visit can work well to solidify the physician-patient relationship and build trust,” Murthy says.

Physicians who attentively listen to patients and address their concerns, while carefully educating them about the reasons for their decisions and the disease process being treated, are likely to have the highest success rate with patient compliance, Marcus says. Patients should be strongly encouraged to ask questions, gain a thorough understanding of their illness, and leave the office satisfied that they are adequately educated and prepared to make informed decisions about adhering to their physician’s recommendations.

Karen Appold is a medical writer in Lehigh Valley, Pennsylvania.