CLINICAL
NEWS JACC in a FLASH
important determinations of outcome.”
Statin adherence is inversely associated
with low-density lipoprotein cholesterol
levels and mortality after ACS.
Measuring non-adherence is challenging, and many health providers often fail
to recognize or inquire about it. Current
measurement practices, such as questioning patients, counting pills or refills, and
electronic monitoring, can be unreliable,
objective, and costly. Reliable measurement and implementation of adherence
improvements measures will require
strong clinical care partnerships between
multiple providers, pharmacies, caregivers and patients, according to the authors.
Factors that may influence adherence include demographics and socioeconomic factors, lifestyle habits, time
since last provider visits, adverse effects
of therapy, and complex medication
regiments. Those with lower incomes,
black or Hispanic women, those without
access to a caregiver, and patients with
higher copays are more likely to discontinue statin treatment. However, there
are interventions that may improve
adherence among these patient groups.
Educational programs and materials—
such as instructional checklists, drug fact
pamphlets and national campaigns promoting disease awareness—have proven
to be beneficial in the past. The authors
also encourage providing information in
the patient’s native language. Additionally, policy changes such as full coverage
for preventative medications after MI
have shown improved adherence. Other
patient barriers to care include belief
systems, forgetfulness, expectations
of treatment, and lack of noticeable
benefits, while health-system barriers
include access to appointments, continuity of care, limited prescription refills,
and priorities of comorbidities.
To counteract these barriers, Sperling and colleagues recommend that
providers gather data on the patient’s
insurance coverage, social support and
the role of the caregiver. They should
assess the risk for medication nonadherence, evaluate any reasons for
forgetfulness, and consider the expectation of the treatment outcome that is
more important to the patient. Teambased approaches may be necessary to
gather this information if there are time
constraints. Outpatient nurse-management protocols and pharmacy outreach
programs may also help with medication monitoring and adherence.
Lifestyle factors associated with
non-adherence include obesity, smoking,
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alcohol consumption, and the presence of comorbidities. It is important
for providers, health care systems, and
family members to support and facilitate
necessary behavior changes. Cardiac
rehabilitation has shown to have significant impact on morbidity and mortality
following MI and revascularization. Not
only to patients show improved physical
activity and nutrition, they also demonstrate a >30% improvement in statin
therapy adherence. Depression may also
lead to a lack of statin adherence, so it
is therefore important to be mindful
of signs and symptoms. The quality of
the patient-provider relationship is also
important as it can lead to improved
communication and trust.
As adherence is greatest 5 days prior
to and following a doctor’s appointment—
a phenomenon dubbed “white coat
adherence”—Sperling and colleagues suggest that surveillance through electronic
prescription-filing records and the use of
reminder trigger systems, like cell phone
alerts and text messages, may increase
adherence by reminding patients not
only to take their medications, but also to
remind them to fill their prescriptions.
Many patients resist statin therapy
over worries of adverse side effects.
However, trials have shown only a slight
increase in side effects when compared
to placebo. For those who do demonst