Editorial |
Concordance with heart failure medications: what do patients think?
Email: f.d.r.hobbs{at}bham.ac.uk
The need for effective diagnostic and treatment strategies in heart failure is immense: the condition occurs in at least 2.3% of the adult population over 45,1 rising to 4% in over 75 year olds.1 Symptomatic heart failure has a major impact on patients and healthcare systems: its prognosis for patients after hospital diagnosis is worse than breast or prostate cancer,2 it has a major impact on quality of life3 for patients and treatment costs are second only to stroke, mainly due to high admission rates.4 Fortunately, there is a large evidence base to guide treatment of heart failure, with European5 and American6 guidelines advising physicians on the initiation of ACE inhibitors,7 and ß-blockers8 in most patients with heart failure due to left ventricular systolic dysfunction (LVSD), spironolactone9 in those with severe heart failure, or surgery where significant valve disease exists.
Unfortunately, despite this well-disseminated evidence base, repeated surveys illustrate the gap between evidence and practice, with many patients failing to get up-titrated on treatment doses and discontinuing therapies within months of starting.10 This problem is not confined to heart failure with evidence that only between 30 and 60% of patients, dependent on country, are still taking lipid-lowering drugs at 12 months,11 despite these drugs having lower rates of side-effects compared to most chronic medications, and only 45% of patients take more than 80% of their statins and anti-hypertensives by as soon as 6 months of initiation.12 Both physician and patient factors influence drug concordance, including factors such as pill load, ordering of medication, and side-effect profiles.
More recent data have implicated lack of patient knowledge of their condition and understanding of their treatments as important factors that may influence patient concordance with medication.13 In terms of patient factors, various studies have shown improved outcomes in heart failure patients from outreach programmes, of sometimes major complexity, led by nurses or pharmacists.14 Importantly, though none of these studies have tested which components of the intervention drive the improvement in outcome, the one constant across all of the various strategies trialled was an element of better information for patients and carers on the need to take medications and recognizing the signs of worsening heart failure.
Further evidence on patient understanding of disease and perceptions on drugs is explored by Field et al. in this issue reporting a study of 37 patients reported by their GPs as suffering heart failure who were interviewed about their knowledge of their treatment.15 Though the study was limited by small numbers, case selection and non-validation of the diagnosis, the findings provide further insight into the dynamics of the doctor patient interface in this major chronic disorder where ongoing therapy provides significant patient and health system gains. They found that patients could be clustered into three levels of participatory knowledge in their ongoing care with only a minority (9 of 37) apparently knowledgeable on their treatments, with the remainder providing minimal or inaccurate information on the drugs they were taking and why. Such information gaps must influence the ability of patients to make informed decisions on staying on therapy and altering treatment when their condition worsens. Trusting or leaving all aspects of treatment to the doctor (28 of 38), more likely amongst the elderly and non-professional cases, is sub-standard care—we need better methods of reinforcing patient (and carer) participation in their ongoing care and practical tools or markers on whether patient understanding is complete or not. Starting with heart failure is a safe bet, given the complexities of medication, but these aspirations are relevant to all chronic disorders.
Notes
Richard Hobbs FD. Concordance with heart failure medications: what do patients think? Family Practice 2006; 23: 607–608.
References
1 Davies MK, Hobbs FDR, Davis RC, Kenkre JE, Roalfe AK, Hare R, Wosornu D, Lancashire RJ. (2001) Prevalence of left ventricular systolic dysfunction and heart failure in the general population: main findings from the ECHOES (Echocardiographic Heart of England Screening) Study. Lancet 358:439–445.[CrossRef][Web of Science][Medline]
2 Ho KKL, Anderson KM, Kannel WB, Grossman W, Levy D. (1993) Survival after onset of congestive heart failure in Framingham Heart Study subjects. Circulation 88:107–115.
3 Davis R, Hobbs FDR, Kenkre JE, Roalfe AK, McLeod S, Hare R, Davies M. (1998) Quality of life in heart failure, as measured by SF-36 health status questionnaire. Eur Heart J 19:S639.
4 Gillum RF. (1993) Heart and Stroke Facts. Am Heart J 126:1042–1047.[CrossRef][Web of Science][Medline]
5 The Task Force on Heart Failure of the European Society of Cardiology. (1995) Guidelines for the diagnosis of heart failure. Eur Heart J 16:741–51.
6 American College of Cardiology/American Heart Association. (1995) Guidelines for the evaluation and management of heart failure. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Evaluation and Management of Heart failure). Circulation 92:2764–84.
7 Garg R and Yusuf S. (1995) for the Collaborative Group on ACE Inhibitor Trials. Overview of randomised trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. JAMA 273:1450–56.
8 CIBIS-II Investigators and Committees. (1999) The Cardiac Insufficiency Bisoprolol Study II. Lancet 353:9–13.[CrossRef][Web of Science][Medline]
9 Pitt B, Zannad F, Remm WJ, Cody R, Castaigne A, Perez A, Palensky J, Wittes J. (1999) for the Randomised Aldactone Evaluation Study Investigators. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. N Engl J Med 341:709–717.
10 Houghton AR and Cowley AJ. (1997) Why are angiotensin converting enzyme inhibitors under-utilised in the treatment of heart failure by general practitioners? Int J Cardiol 59:7–10.[CrossRef][Web of Science][Medline]
11 Yang CC, Jick SS, Testa MA. (2003) Discontinuation and switching of therapy after initiation of lipid-lowering drugs: the effects of comorbidities and patient characteristics. Br J Clin Pharmacol 56:184–91.[CrossRef][Web of Science][Medline]
12 Benner JS, Glynn RJ, Mogun H, Neumann PJ, Weinstein MC, Avorn J. (2002) Long-term persistence in use of statin therapy in elderly patients. JAMA 288:4455–61.
13 Hobbs FDR and Erhardt L. (2002) Acceptance of guideline recommendations and perceived implementation of coronary heart disease prevention among primary care physicians in five European countries: the Reassessing European Attitudes about Cardiovascular Treatment (REACT) survey. Family Practice 19:6596–604.
14 Rich MW, Gray DB, Beckham V, Wittenberg C, Luther P. (1996) Effect of a multidisciplinary intervention on medication compliance in elderly patients with congestive heart failure. Am J Med 101:3270–6.[CrossRef][Web of Science][Medline]
15 Field K, Ziebland S, McPherson A, Lehman R. (2006) ‘Can I come off my pills now?' A qualitative analysis of heart failure patients’ understanding of their medication. Family Practice 23:624–30.
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