Author + information
- Judith Z. Goldfinger, MD∗ ()
- ↵∗Reprint requests and correspondence:
Dr. Judith Z. Goldfinger, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, New York 10029.
Low rates of adherence to medication and unhealthy lifestyle behaviors limit the efficacy of primary and secondary prevention for cardiovascular disease. Like many trainees, cardiology fellows in our program predominantly see low-income patients. However, when patients do not take their medications, we should not assume that cost is the sole reason, as other possible factors can impact adherence. These other factors become especially important when they are related to a patient’s knowledge, attitude, or culture. Instead of being seen as barriers to care, they should be recognized as an opportunity for the physician to engage with the patient and strengthen the provider-patient relationship.
Cost can contribute in overt ways, such as lapsed insurance coverage, inability to pay for a nonformulary drug, or a missing prior authorization. However, financial issues may have even more insidious effects. For instance, to stretch a prescription’s life just a little longer, patients may take a drug less frequently than prescribed or cut a pill in one-half.
Patients simply may forget to take their medications, and it can be difficult to know when this is a cause for concern. More than occasional forgetting may point to an undiagnosed cognitive impairment, which could be rectified with simple measures, like a pillbox that indicates days of the week or the use of a smartphone alarm as an electronic reminder. If these are not adequate, a patient may require verbal reminders from a family member or from a home attendant. Patients may be embarrassed to admit that they need these kinds of reminders, and providers often have to ask repeatedly, in different ways, to draw them out.
Also, patients may decline to take their medications because of concerns that stem from “too little information.” In my clinic panel, a woman with prior renal cell carcinoma is afraid to take any medications for her symptomatic atrial fibrillation because she is worried about losing her remaining renal function. One male patient is concerned that the number of milligrams is “too high” for his angiotensin-receptor blocker compared with his beta-blocker. It is often determined that these patients have low health literacy and could benefit from education about their medications. In addition, it is important to validate their concerns and earn their trust, because this empowers them to work with you to make better health decisions and to achieve agreed-upon goals.
Conversely, there are the “too much information” patients who also could benefit from a frank conversation with their physicians and validation of their concerns. That was true of 1 male patient with coronary artery disease and carotid disease who stopped taking his statin because of media coverage about the risk of incident diabetes with statins. Other patients became concerned about media coverage related to the risk of bleeding with oral anticoagulants, which led some to suggest that they no longer wanted to take this medication. These patients benefit when their physician spends time discussing their concerns and provides relevant medical information to help them make the best informed decisions about risks and benefits.
The risk-benefit calculation may be different for the physician than it is for the patient. The patient weighs his or her understanding of the need for the medication against the risk of taking the medication. This understanding is affected by the physician’s ability to explain, the patient’s ability to comprehend, and what the patient hears from family, friends, coworkers, the local pharmacist, and even Internet search engines. Of these influencers, a patient spends the least amount of time with his or her physician. Understanding and working within this framework can help physicians build a better rapport with their patients or at least can create some common ground.
Other patients simply do not self-identify as patients and do not want to join the club of “sick people” who require regular use of medications for chronic conditions. These patients inquire why they cannot just take their antihypertensive medication when they “feel” that their blood pressure is high. It is easy to understand that you take an antipyretic for fever, an anti-inflammatory for joint pain, or an antibiotic for an infection. In these conditions, you feel better when taking the medication, and then you can stop taking it when it is done working. Medications for chronic conditions and cardiovascular risk factors, like hypertension or diabetes, are quite the opposite. Most patients cannot feel the symptoms of their diseases. If not for the blood pressure cuff in our offices or the laboratory results that we show them, many would not be aware that they even have these conditions. It may be helpful to spend time explaining the importance of risk reduction as well as explaining how managing these conditions can prevent or delay the development of cardiovascular disease.
Finally, medications may simply make patients’ lives more difficult. Furosemide may ameliorate dyspnea, but it also may require an older person to curtail his or her activities to remain near a bathroom. If the physician only asks about dyspnea relief and not about how the medications are affecting the patient’s life and quality of life, he or she may not find this information.
All of these scenarios are layered over our patients’ socioeconomic and cultural backgrounds. The institution at which I train straddles the border between 1 of the wealthiest neighborhoods in New York City, the Upper East Side, and 1 of the poorest, East Harlem. Our clinic patients largely come from East Harlem, a predominantly black and Latino neighborhood that has some of the highest rates of smoking, obesity, sedentary lifestyle, and diabetes in New York City. Adults in East Harlem have twice the poverty rate and lower education rates compared with the rest of the city (1). Economic burdens and limited education likely contribute to decreased medication adherence, but are not the full story; the high rates of cardiovascular risk factors and disease make the need for adherence that much more urgent.
Patients may not be able to quote these statistics, but they are more than aware of their own socioeconomics and of the high rates of disease they see in their families and communities. This knowledge can be overwhelming, leaving some patients to feel resigned or fatalistic. As cardiologists, we know that some risk factors are not modifiable, but others are. We also know that great gains can be achieved by modifying risk factors and by adhering to medications that have been proven effective for primary and secondary prevention of cardiovascular disease. We have the ability to bring this knowledge to our patients.
In training programs, we are largely sheltered from the economic burdens seen in clinical practice. Instead, the fellows have a relatively luxurious 3-h clinic session in which they see only 4 to 6 patients. If ever there was a time to devote to patient barriers to medication adherence, and to appropriate, personalized education, this is it.
- American College of Cardiology Foundation
- Olson E.C.,
- Van Wye G.,
- Kerker B.,
- et al.