Medication Taking in Coronary Artery Disease: A Systematic Review and Qualitative Synthesis

Medication Taking in Coronary Artery Disease: A Systematic Review and Qualitative Synthesis by Rashid et al (Annals of Family Medicine May-June 2014) raises a number of valid points concerning medication adherence by studying patients' perceptions; several other recently published articles, including a broad systematic review by Brown and Bussell,(2) are more inclusive of the many variables linked to medication adherence.

Many variables have been identified by studies on adherence with medications.(1,2,3,4) In addition to the importance of a strong physician-patient relationship with good communication, as identified by Rashid, frequent dosing, costly medications, chronic or asymptomatic conditions and gaps in health literacy have also been shown to be key determinants. (1,2,3,4,8) The detailed review by Brown and Bussell (2) outlines such variables to medication adherence of cardiovascular drugs and includes a table of web-based resources to help providers address these barriers. The Brown and Bussell review article identified these broad categories affecting medication adherence:

Systems related: In a study of medication regimen complexity, adherence to recommended medications rapidly decreases with an increased number of different forms of medication, varied routes of intake, increased number of doses per day and special instructions. (3) In the US, cost and lack of adequate health insurance coverage and infinite formularies also affect which medications are purchased. (4)

Patient related: Complex patient care studies identify that patients readiness to engage in their care, social support, mental illness, cultural beliefs, the strength of relationship between provider and patient, fragmented healthcare systems, and, in the US, insurance/financial issues all affect how a patient sees and treats their condition. (5,6) Health literacy with teach-back can increase compliance; videos and training information are available online to help one learn these skills. (7)

Provider related: Time spent on meaningful use, charting to document work done for billing and drug formularies de jour with burdensome prior authorizations may lead to less patient education and less time to review the evidence together. Constructing a patient-driven plan with guidance from a knowledgeable health provider who educates, assesses the patient's barriers and strengths, and is involved longitudinally may increase the likelihood of medication adherence.

Sincerely, Justin Osborn, MD, Assistant Professor, Department of Family Medicine, University of Washington, 331 NE Thornton Place, Box 358732, Seattle, WA 98125
Christopher Sanford, MD, MPH, DTM&H, Associate Professor, Depts. of Family Medicine and Global Health, University of Washington

References:
1) Osterberg L, Blaske T. Adherence to Medication NEJM 2005; 353:487-497
2) Brown M, Bussell J. Medication Adherence: WHO Cares? Mayo Clin Proc. April 2011;86(4):304-314.
3) McDonald M, Peng T, Sridharan S. Automating the Medication Regimen Complexity Index. J Am Inform Association. 2012 00:1-7.
4) Dunlay S, et al. Medication adherence among community-dwelling patients with heart failure. Mayo Clin Proc. 2011 Apr;86(4):273-81.
5) Peek C, Baird M, Coleman E. Primary care for patient complexity, not only disease. Families, Systems, & Health. Dec 2009;27(4):287-302.
6) Sturmberg J, Martin C, Katerndahl D. Systems and Complexity Thinking in the General Practice Literature: An Integrative , Historical Narrative Review. Ann Fam Med. Jan 2014;12(1):66-74.
7) http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/healthliteracytoolkit.pdf
8) http://www.nice.org.uk/nicemedia/pdf/CG76FullGuideline.pdf

Competing interests: None declared