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Critical Care Nurse. 2008;28: 54-64
Copyright © 2008 by the American Association of Critical-Care Nurses.
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Clinical Article
CE Article

Improving Medication Adherence in Chronic Cardiovascular Disease

Nancy M. Albert, RN, PhD, CCNS, CCRN, NE-BC

Nancy M. Albert is the director of Nursing Research and Innovation, Nursing Institute, and a clinical nurse specialist at George M. and Linda H. Kaufman Center for Heart Failure, Cleveland Clinic Foundation, Cleveland, Ohio.

To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.

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To learn more about medication adherence, read "Cardiac Transplantation: A Second Chance for Extending Life" by Laurie G. Futterman and Louis Lemberg in the American Journal of Critical Care, 2008;17:168–172.[Free Full Text] Available at www.ajcconline.org.

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Financial Disclosures
None reported.

This article has been designated for CE credit. A closed-book, multiple-choice examination follows this article, which tests your knowledge of the following objectives:

  1. Recognize the barriers to adherence of medication regimens for chronic cardiovascular patients
  2. Describe strategies that nurses can implement to increase patient medication regimen compliance
  3. Understand the correlation between medication regimen compliance and patient safety

Corresponding author: Nancy M. Albert, RN, PhD, Director, Nursing Research and Innovation, Nursing Institute, 9500 Euclid Ave, Mail Code P32, Cleveland, OH 44195 (e-mail: albertn{at}ccf.org).

Despite recent advances in therapeutic management of patients with heart failure and those who have had a myocardial infarction, prognosis remains poor once a patient has been hospitalized. On the basis of a 44-year follow-up of the Framingham Heart Study of the National Heart, Lung, and Blood Institute, the mortality rate is almost 80% at 8 years after diagnosis of heart failure.1 Among approximately 18 000 Medicare recipients who were hospitalized with heart failure, 44% were readmitted within 6 months.2 Outcomes after myocardial infarction are no more optimistic: 11% to 32% of patients with new or recurrent myocardial infarction die within 1 year, 14% to 32% of patients experience reinfarction within 5 years, and 1% to 6% experience sudden death.1 Patients at high risk after myocardial infarction, such as those with left ventricular systolic dysfunction, have an even poorer prognosis, with a 4- to 5-fold higher risk of inpatient mortality compared with patients without systolic dysfunction.3–5

Data from recent large-scale registries6–8 have indicated that lifesaving therapies are underused in cardiovascular patients. Compounding the difficulties of suboptimal care is the problem of poor adherence to medications, which is often overlooked. Although researchers may have unique definitions of the term "therapy adherence," high percentages of cardiovascular patients are nonadherent in several areas, including taking medications (31%–58%), attending follow-up appointments (16%–84%), and following diet recommendations (13%–76%).9 In one study10 of 1291 patients after myocardial infarction and/or with heart failure, the self-reported medication nonadherence rate was 66%. In a retrospective cohort of 7247 patients with heart failure, on the basis of prescription claims files, only 10% were adherent to therapy after 1 year.11

The reasons for poor prognosis in patients with heart failure and in those who have left ventricular systolic dysfunction after myocardial infarction are multifactorial. In a prospective study12 of 280 patients with advanced heart failure, researchers applied 4 prognostic models to determine predictors of mortality. Data on a total of 27 variables were collected, and patients were followed up for 4 years to determine survival and the sensitivity and specificity of each model for predicting mortality. The results indicated that current models had limited predictive power and that many component characteristics of each model did not have independent prognostic significance. Interestingly, the most powerful factors predictive of mortality were increasing age, ischemic cause of cardiomyopathy, history of cardiomyopathy (vs new onset), ankle edema, decreased peak oxygen consumption, and no prescription for a β-blocker.12 Because β-blocker therapy was the only class of medication predictive of survival, it is imperative that nurses play a critical role in ordering medications and promoting medication adherence to improve clinical outcomes.

In this article, I describe the problem of medication adherence in patients with heart failure and those with left ventricular systolic dysfunction after myocardial infarction and discuss ways that nurse-based management can increase medication adherence. Critical care, intermediate-telemetry, and general care nurses have multiple opportunities to improve the adherence essential to optimizing health-related clinical outcomes.


   Medication Nonadherence
Top
 Medication Nonadherence
Consequences of Nonadherence
 Barriers to Adherence
 Role of Nurses in...
 Conclusions
 PRIME POINTS
 References
 
Heart failure and myocardial infarction require long-term use of medications to reduce morbidity and mortality. Clinical management often involves multiple drugs to reduce mortality (eg, an angiotensin-converting enzyme [ACE] inhibitor, a β-blocker, and an aldosterone inhibitor plus or minus aspirin, a statin, and warfarin as indicated) and others to ameliorate signs and symptoms (eg, digoxin, diuretics, and nitrates). Nonadherence to prescribed medications can result in many problems, including poor blood pressure control, pathologic changes and signs and symptoms associated with worsening cardiac function, hospitalization, and mortality13–21 (Table 1Go).


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  		Table 1 Potential outcomes of nonadherence to evidence-based medications commonly used to treat patients with clinical heart failure and patients with left ventricular systolic dysfunction after myocardial infarction

 
Despite advances in treating patients with heart failure and after myocardial infarction, treatment regimens are only beneficial if patients adhere to their prescribed therapy. Adherence rates, however, are suboptimal. In a multicenter analysis22 of more than 17 000 patients who were prescribed β-blockers after a myocardial infarction and had health insurance and prescription drug coverage, only 45% were adherent (defined as prescription claims covering ≥75% of days) to β-blockers by 1 year after discharge; the biggest decrease in adherence occurred between 30 and 90 days. Adherence to statin therapy among patients after myocardial infarction was also poor; the 2-year adherence rate was 40%.23

Information from the Duke Databank for Cardiovascular Disease for the years 1995 to 2002 was used to assess the annual prevalence and consistency of self-reported use of aspirin, β-blockers, lipid-lowering agents, and combinations of the 3 drugs in patients with coronary artery disease and of ACE inhibitors in patients with and without heart failure.24 At the end of the study, rates of self-reported medication use by patients with coronary artery disease were highest for aspirin (83%); next were lipid-lowering agents (63%), β-blockers (61%), aspirin and a β-blocker (54%); the lowest was for use of all 3 (39%). Rates of consistent (ie, reported on ≥2 consecutive follow-up surveys and then through death, withdrawal from the study, or end of the study) medication use followed a similar pattern: aspirin (71%), β-blocker (46%), lipid-lowering agent (44%), aspirin and β-blocker (36%), and 21% for all 3 medications. Use of an ACE inhibitor among patients with heart failure was 51%; consistent use was only 39%. Overall, consistent use was associated with lower adjusted mortality, although survival remained suboptimal.24


   Consequences of Nonadherence
Top
 Medication Nonadherence
 Consequences of Nonadherence
Barriers to Adherence
 Role of Nurses in...
 Conclusions
 PRIME POINTS
 References
 
Poor adherence to medication regimens in patients with heart failure and after myocardial infarction accounts for substantial morbidity and mortality. In retrospective reviews and small prospective studies,25 33% to 69% of medication-related US hospital admissions were attributed to poor medication adherence. In retrospective studies,26 poor adherence with prescription medications was a contributing factor in 20% to 64% of rehospitalizations for heart failure. Early readmission is widely used as an indicator of inpatient quality of care. According to one study,27 two-thirds of hospital readmissions for heart failure could be avoided by delivery of high-quality inpatient care. In particular, readmissions were due to medication nonadherence (24%), diet nonadherence (24%), inappropriate treatment (16%), and failure to seek care (19%). Most of these causes are avoidable and can be addressed by proper care and discharge planning.

The consequences of nonadherence after myocardial infarction can be illustrated by study findings. In a retrospective analysis28 of the Beta Blocker Heart Attack Trial, researchers evaluated the relationship between treatment adherence and mortality after myocardial infarction in 2175 patients. Patients with poor adherence (took ≤75% of prescribed β-blocker) had a 2.5- to 3.1-fold increased risk of dying within 1 year compared with patients with higher adherence rates. Interestingly, poor adherers had an increased risk for death whether they were taking propranolol or placebo, suggesting that poor adherence with a β-blocker was indicative of nonadherence to other prescribed therapies.

In a study29 of drug adherence and mortality in 31 455 survivors of myocardial infarction who filled prescriptions for statins and β-blockers, patients were divided into 3 adherence categories: high (≥80% of days covered), intermediate (40%–79% of days covered), and low (<40% of days covered). After 1 year, compared with the high-adherence group, low adherers to statin therapy had a 25% increased risk of mortality, and intermediate adherers had a 12% increase. A similar association between adherence and mortality was observed for β-blockers.29

In a study30 of primarily patients after myocardial infarction, adherence was measured by the fill frequency (number of prescriptions filled during the observation period divided by months of observation) of a statin prescription. Patients with a fill frequency of 80% or higher were half as likely as nonadherent patients (fill frequency, ≤60%; P=.047), to experience a subsequent myocardial infarction. In the subset of patients younger than 65 years, the associated risk reduction of a subsequent myocardial infarction was 86% for the adherent group compared with the nonadherent group (P=.001).30 Finally, in a multivariable survival analysis,31 patients who discontinued all medication therapy (used 0 of 1, 2, or 3 pills) had a 3.8-fold increased risk for mortality. The FigureGo shows mortality risk by discontinuation of specific medication therapies.


Figure 1
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  		Figure In multivariate analysis, increased risk of mortality during follow-up after myocardial infarction in patients who discontinued medications compared with patients who continued medications. On y axis, 1 refers to no increase in mortality risk and no reduction in mortality risk, 2 refers to a doubling or 2-fold increase risk of mortality, 3 refers to a tripling or 3-fold increase risk of mortality, and so on.

 
An association between medication adherence and mortality has been detected in patients with heart failure. In the double-blind, randomized, controlled clinical trial Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity (CHARM),32 the efficacy of candesartan, an angiotensin receptor blocker, was compared with placebo for a median of 38 months in 7599 patients with heart failure. Good adherence was defined as taking more than 80% of the study medication over time. After adjustment for predictive factors (demographics, physiological and severity-of-illness variables, smoking history, and number of concomitant medications), good adherence was associated with lower all-cause mortality in all patients (P<.001). Moreover, good medication adherence in patients with heart failure was associated with a lower risk of death than was poor adherence (took ≤80% of study medication), irrespective of assigned treatment (P < .001 in both treatment groups).32 The researchers postulated that good adherence with an angiotensin receptor blocker extended to adherent behaviors in other prescribed therapies.


   Barriers to Adherence
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 Medication Nonadherence
 Consequences of Nonadherence
 Barriers to Adherence
Role of Nurses in...
 Conclusions
 PRIME POINTS
 References
 
Despite its importance, adherence to medication therapy is an aspect of patients’ care that is often overlooked and should be reevaluated as a crucial part of cardiovascular management.33 Therapy-related factors (ie, those that can be altered by a medication change) that influence nonadherence include adverse effects, polypharmacy, frequent dosing, and cost34–36 (Table 2Go). Other reasons for nonadherence are poor communication and education about the importance of therapy at the time of discharge, complexity of drug regimens, and failure to initiate therapy in the hospital when the patient is most likely to relate the drug to health.33,37 In-hospital initiation of medications has a dramatic effect on long-term treatment rates and patients’ adherence.37 Patients who start taking agents in the hospital are more likely to stay on therapy because of the perceived importance of medications and often have more dialogue with physicians and nurses about medications, including a discussion about possible adverse effects.37,38


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  		Table 2 Factors that influence medication nonadherence

 
Medication Complexity
As newer lifesaving medications become available, morbidity and mortality risks decrease; however, the complexity of regimens increases. Specifically, the complexity of drug regimens is increasing among patients with heart failure and after myocardial infarction.39 According to data from the National Heart Care Project, the mean number of heart failure prescriptions and doses per day were 7.5 and 11.1, respectively, from 2000 to 2001. After adjustment for patient, physician, and hospital characteristics, compared with data for 1998 to 1999, data from 2000 to 2001 reflected a 12% increase in the mean number of medications prescribed to patients with heart failure.40 Complexity of drug regimens of patients with heart failure and the concomitant cost of the regimens are major contributors to medication nonadherence. Several investigators41–44 have found an inverse relationship between the number of daily doses and the rate of medication adherence. Reduction of prescribed medication dosing from 3 and 4 times daily to once daily significantly improved medication adherence (P=.008 and P<.001, respectively).41 Patients with heart failure and other cardiovascular conditions can benefit from changing regimens from taking medication 2 or 3 times a day to taking it once a day.41–44 Reducing the number of daily doses was effective in increasing adherence with antihypertensive medication from 8% to 19.6%.42 Once-daily dosing was also associated with higher adherence to antihypertensive medication than was twice-daily dosing.43 Among patients with heart failure and after myocardial infarction, fewer pills per day can improve adherence.45

Recent availability of a once-daily formulation of carvedilol, carvedilol CR, allows consideration for reducing the daily number of pills required. Guidelines of the American College of Cardiology and the American Heart Association include recommendations that long-term β-blocker therapy be started and continued indefinitely in all survivors of acute myocardial infarction who do not have absolute contraindications46,47 and in patients with mild to severe heart failure.48 Use of once-daily carvedilol CR rather than the twice-daily formulation may improve adherence. Algorithms for switching from non–evidence-based β-blockers to once-daily evidence-based agents are available.49 Nurses can advocate for changes in therapy when warranted and advanced practice nurses can promote improved care and adherence by switching to once-daily evidence-based agents. Similarly, ACE inhibitors are available in once-daily and multidose (twice-daily and 3 times daily) formulations.

Nurses must not only understand the dosing equivalents of agents given once daily and more than once a day within the same class but also must plan timing of doses so that long-acting drugs do not peak at the same time and result in adverse effects such as dizziness, lightheadedness, and fatigue. Pocket cards can be used as a guide to help plan a medication program that meets patients’ social needs and also prevents untoward adverse effects. The pocket card can include details such as starting dose, titration schedule for increasing the dose, target and maximum doses, and time to peak effects, as previously reported,50 or the card can be a simple table that separates drugs commonly used in specific cardiovascular conditions by time to peak effects (Table 3Go is an example for patients with stage C or D heart failure).


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  		Table 3 Evidence-based medications commonly used in the treatment of stage C and stage D heart failure categorized by time to peak effect

 
One potential solution to reduce the complexity of medication therapy and reduce the number of pills required is to use polypills that are taken once daily. Polypills that combine multiple drugs such as aspirin, a β-blocker, an ACE inhibitor, a statin, a thiazide diuretic, and/or antiplatelet medication are more common in Europe than in the United States. Polypills have the advantage of ensuring the delivery of 2 or more evidence-based medicines in a single pill and bypassing the possibility that general practitioners may miss prescribing 1 or more ingredients.51 A combination product can simplify therapy and may promote medication compliance. In the United States, 3 mixed-target combination pills such as a statin plus a calcium channel blocker, a statin plus aspirin, and an antihypertensive plus a thiazide diuretic have been approved. The use of polypills that concomitantly target medical conditions without increasing the number of pills required can improve outcomes in some patients.

In addition to regimen complexity, other issues, including the cost of medications and adverse effects, may prevent patients from adhering to therapies. Nurses should be aware of the effect that these and other barriers can have on achieving the optimal benefits of a medication.

Cost of Medications
Even if a patient is receiving the best therapies available at the time of discharge, medications work only when patients remember to take them and can afford them. The complexity of medication management for patients with heart failure poses a financial burden, especially on elderly patients. Drug costs are increasing at a rate greater than those of any other health care expenditure.40 According to the National Heart Care Project,40 from 2000 to 2001, the mean annual cost of medications prescribed to patients with heart failure was $3832, an increase of 24% over that of 1998 to 1999. In a study52 of 138 patients, the cost of medications for patients with heart failure increased as the severity of the disease advanced to New York Heart Association class II and class III heart failure. The overall mean monthly cost of medications for all heart failure patients was $438; patients with class II and class III heart failure had the highest monthly costs: $541 and $514, respectively. Patients with heart failure often have comorbid conditions that may require additional medications and thus increase financial costs.

Nurses should be knowledgeable about the costs of drugs, because Medicare Part D coverage is likely to require substantial out-of-pocket expenditures.40 If financial strain causes a patient to skip or miss doses, then a less complex drug regimen (ie, once-daily dosing) and the use of generic medications should be considered. Patients’ discharge education should include a discussion of the costs of medications and a plan for drug payment. Nurses and other health care professionals, such as social workers, can be instrumental in ensuring that patients understand the complexities of a medication regimen and are financially able to maintain the medication plan of care.

Adverse Effects
The adverse effects of medications contribute largely to nonadherence to a heart failure regimen. Nurses should be aware of and communicate potential adverse effects of all medications, because early recognition of adverse effects may help reduce difficulties in following medical prescriptions. Nurses should inform patients about the possibility of adverse events associated with switching from short-acting, more than once a day dosing to long-acting, once-daily dosing. If adherence was poor with therapy that required more than 1 pill a day and is expected to improve when the number of pills per day decreases, close monitoring may be necessary.

In a study36 of medication adherence and the beliefs of patients with heart failure, the most frequently identified benefit of adherence was decreasing the chance of being hospitalized, and the most commonly reported barrier was disruption of sleep. Compared with patients who are unaware of the potential adverse effects of a medication, patients who are aware (and are told whether the adverse effects are transient or not) may fare better because they have appropriate expectations. Increasing evidence53 supports the use of strategies to enhance self-efficacy (the belief that one can follow the regimen) and therapeutic efficacy (the belief that the treatment actually works) as important factors to improve adherence. Thus, empowering patients with as much education and control as possible should improve adherence.

Research54 on the effect on outcomes of 6 months of visits to a nurse-managed heart failure clinic indicated that readmissions, length of stay, and severity of illness could be reduced by intensive nurse-patient interaction. At the beginning of the study, only 40% of patients were able to articulate 1 desired effect and 2 adverse effects of their medication; after 1 year of intervention by a clinic nurse, 82% of patients were able to recall this information. The success of the program was attributed to 4 key factors: (1) development of a trusting relationship between the nurse and patient, which the authors thought encouraged adherence to therapies; (2) close monitoring of weight and proper intervention with diuretic or other therapy if needed; (3) dietary assessment and restructuring; and (4) identification of and assistance with any financial situation that would preclude a patient from adhering to therapy.

In literature on exercise in heart failure, patients cite physical symptoms (pain, dizziness), lack of energy (weakness, fatigue), and poor motivation as reasons for poor adherence to exercise therapy. In a study55 of self-care behaviors, including exercise behaviors, 30% of elderly people with heart failure reported that they had stopped exercising after heart failure was diagnosed. The literature on exercise underscores the need for nurses to assure patients that following the medication plan of care may produce transient adverse effects but can improve functional status, quality of life, time to rehospitalization, and survival. Additionally, patients need to feel comfortable contacting their nurse caregiver or other health care providers when questions about adverse effects arise so that patients have a clear understanding of medication use when adverse effects occur and can adhere to the medication schedule.

Although the barriers to execution of a medication plan for patients with heart failure are considerable, they are not insurmountable. Barriers to adherence due to a patient’s perception of therapy are best addressed by patient-specific interventions that include open communication and education strategies.36 Nurses are paramount to the success of patients’ education by offering discharge instruction and ongoing education that result in better patient self-care.56


   Role of Nurses in Increasing Adherence
Top
 Medication Nonadherence
 Consequences of Nonadherence
 Barriers to Adherence
 Role of Nurses in...
Conclusions
 PRIME POINTS
 References
 
Patients may be reluctant to tell a physician how often they miss a dose of medication or take the medication at the wrong time, yet researchers found that only 10% of patients were fully adherent (based on self-report) with medications as prescribed.26 When medication levels cannot be obviously detected by using laboratory tests (eg, glucose levels for diabetes therapy), it is difficult to ascertain whether patients are adherent to therapy. Therefore, it is incumbent on the prescriber to stress the importance of medication adherence and to make an effort to simplify the treatment regimen so that patients take prescribed medications. Nurses should take an active role in assessment, education, care planning, and strategic implementation efforts that support patients’ optimal self-care behaviors and promote medication adherence.

The most recent Heart Failure Society of America consensus guidelines57 for patients with chronic heart failure state that nurses are the primary providers of education on heart failure. Considerable attention should be focused on ensuring patients’ understanding and improving long-term adherence. Critical and intermediate care nurses play a role in both regards. Nurses work collaboratively with other team members to ensure that medications are prescribed. Before discharge, nurses are often responsible for educating patients about how to take prescription drugs according to the plan of care. In addition, nurses assess patients’ understanding of self-care principles associated with optimal care for heart failure. Although education is only 1 factor related to optimal self-care, adherence and understanding of self-care expectations provide part of the foundation of success.

Nurses can play an integral role in improving patients’ outcomes and self-care by educating patients about the complexities of medication therapies (including expected transient adverse effects), the potential of adverse events, and the importance of maintaining therapy. Patients who receive limited counseling about medications may be less likely than those who receive more counseling to adhere to their prescribed regimen. When physicians prescribe a new medication for a patient, they may not communicate critical elements of medication use that might contribute to misunderstandings about medication directions or necessity and, in turn, lead to the patient’s failure to take medications as directed.58 The roles of clinical nurses and physicians can be complementary, with nurses providing education to patients before discharge to promote greater medication adherence. The first several weeks of treatment are a critical time when many patients discontinue medications,22 and ongoing nursing interventions that affect adherence early can improve long-term health outcomes.59 These interventions include patient education, patient reminders to take medications (eg, using a pill box for each day of the week and time of day), clinical visits, telephone calls, and simplifying the drug regimen60–62 (Table 4Go).


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  		Table 4 Role of nurses in improving medication adherence

 
The value of nurse-physician collaboration in education was illustrated in an education program to improve clinical outcomes in patients with heart failure who were about to be discharged from the hospital. In a randomized, controlled trial63 of 223 patients, a 1-hour, 1-on-1, nurse educator–delivered education session that provided details about the pharmacological plan of care (rationale for drug use, mechanism of action of diuretic medications, avoidance of nonsteroidal anti-inflammatory drugs, and what to do if symptoms worsened) was added to the standard discharge process (list of medications, dosages, and instructions for taking the drugs). Compared with patients who received standard care, patients who participated in the teaching session had a 35% lower risk for rehospitalization or death at 6-month follow-up (P= .02). The total cost of care (including the nurse-led education intervention) at 6-month follow-up for patients in the education group was $2823 lower than the cost of care for patients in the control group (P=.04). Moreover, patients in the education group were more likely to adhere to ACE inhibitor therapy at 3 months and β-blocker therapy at 1 month than were patients in the control group.63

Nurse-led management approaches are effective in managing a variety of chronic conditions. In one intervention for patients with heart failure, an experienced cardiac nurse educator conducted an education program that included both comprehensive discharge planning and immediate outpatient reinforcement through nurse home health care.56 The 6-month readmission rate for patients who did not receive the intervention was nearly 4 times higher than the rate for those who did (44.2% vs 11.4%; P=.01). At discharge, patients with heart failure can enter into a less standardized system of self-reliant chronic care. Thus, nurses are challenged to provide patients with ongoing support after discharge and simplified dosing regimens to improve medication adherence.

In a study64 of elderly patients, discharge planning and home follow-up by advanced practice nurses were effective in reducing the risk of hospital readmissions. The nurses were responsible for discharge planning while the patients were hospitalized and substituted for visiting nurses during the first 4 weeks after each patient’s discharge. In contrast, control patients received routine discharge planning and standard home care consistent with Medicare regulations. By week 24 after the discharge from the hospital, patients in the intervention group were less likely than patients in the control group to be readmitted at least once (20.3% vs 37.1%; P<.001), had fewer multiple readmissions (6.2% vs 14.5%; P=.01), and spent fewer days in the hospital (1.5 vs 4.1 days per patient; P<.001). Improved outcomes were achieved at reduced costs. Total Medicare reimbursements for health services were about $1.2 million in the control group and about $600 000 in the intervention group (P<.001).64

Studies65–67 have shown that patients randomly assigned to nurse practitioners for primary care follow-up do not differ in health outcome, resource utilization, and costs from patients assigned to physicians. However, patients’ satisfaction has been higher with nurse-managed care than with physician-managed care because nurses tend to provide longer consultations and more information to patients.67 In an evaluation68 of the effectiveness of a nurse case management program to control hypercholesterolemia, compared with patients who received enhanced primary (physician) care, significantly more patients who received nurse-mediated care achieved goal levels of low-density lipoprotein cholesterol (P=.008). Favorable changes in lipids and lipoproteins were accompanied by improvements in dietary and exercise patterns in the nurse-mediated program, a reflection of greater adherence to national guidelines.68 Likewise, patients with hypertension had better control of blood pressure when supervised and monitored by specially trained nurses than when given usual community-based care.69,70

A nurse-directed multidisciplinary intervention program for elderly patients with heart failure that consisted of comprehensive patient and family education, dietary prescription, social service consultation and discharge planning, medication review, and intensive follow-up led to improved morbidity outcomes at 3 months.71 Specifically, the control group who received conventional care had 44% more readmissions than did the group who received nurse-directed care (P = .02). In particular, heart failure readmissions were reduced by 56% in the nurse-directed care group (P=.04).71 Because of the overall reduction in hospital admissions, the overall cost of care was $460 less per patient in the intervention group.

In summary, evidence clearly indicates that education and management of patients by nurses improves the patients’ medication adherence and leads to improved self-care, better clinical outcomes, and reduced medical costs.


   Conclusions
Top
 Medication Nonadherence
 Consequences of Nonadherence
 Barriers to Adherence
 Role of Nurses in...
 Conclusions
PRIME POINTS
 References
 
Adherence to pharmacological therapies in patients with heart failure and after myocardial infarction is poor, leading to worsening disease severity and rehospitalization. Nurses can increase the use of lifesaving therapies by implementing treatments at discharge and using once-daily agents that result in easier regimens, decreased drug costs, improved adherence, and better outcomes. Advanced practice nurses should prescribe once-daily agents whenever possible to avoid complicated regimens. Numerous barriers to medication adherence include complex medication regimens, poor patient education, medication cost, and adverse effects. Nurses can play a key role in optimizing patients’ quality of life by assessing potential barriers to medication adherence and implementing comprehensive strategies to increase adherence.


   PRIME POINTS
Top
 Medication Nonadherence
 Consequences of Nonadherence
 Barriers to Adherence
 Role of Nurses in...
 Conclusions
 PRIME POINTS
References
 


   References
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 Medication Nonadherence
 Consequences of Nonadherence
 Barriers to Adherence
 Role of Nurses in...
 Conclusions
 PRIME POINTS
 References
 

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