Tackling medication nonadherence to improve heart failure management and prognosis
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Key takeaways:
- High heart failure hospitalization and mortality rates could be due in part to poor medication adherence.
- A shared approach using multiple strategies may be the best way to combat the trend.
Medication adherence, the extent to which an individual’s behavior corresponds to a health care provider’s recommendations, remains an unaddressed challenge in health care.
A quote by C. Everett Koop, MD, former U.S. surgeon general, captures the importance of medication adherence as “drugs don’t work in patients who don’t take them.”
Heart failure (HF) is associated with significant morbidity, mortality and cost worldwide. Its prevalence in the U.S. is anticipated to increase by from 6.7 million adults to more than 8 million adults, with a projected health care cost increase of 127% to $69.8 billion by 2030.
Importance of medication adherence for patients with HF
Despite the guideline-directed medical therapy (GDMT) available in the armamentarium for HF management, mortality and hospitalization rates remain high, which could in part be attributed to poor adherence.
Medication adherence is associated with numerous benefits including improved quality of life, reduced hospitalizations, prevention of worsened symptoms and decreased mortality. Previous studies have shown that approximately 25% of patients with HF are nonadherent to medications, with 22.1% of nonadherent patients accounting for HF-associated hospital admissions and higher hospitalization rates (HR = 0.45; 95% CI, 0.25-0.52). A systematic review and meta-analysis reported that poor adherence to GDMT in HF leads to increased symptom burden, frequent hospitalization and poor quality of life, resulting in unnecessary health care costs.
A diverse range of factors have been reported to be associated with medication nonadherence among patients with HF, including:
- forgetfulness;
- polypharmacy;
- absence of symptoms;
- age;
- gender;
- disease characteristics;
- type of disease;
- frequency of visits to health care professionals; and
- satisfaction with treatment.
However, one challenge that remains is the lack of a perfect tool for adherence measurement in clinical practice.
‘Multifactorial’ strategies
The 2024 American College of Cardiology Expert Consensus Decision Pathway for Treatment of Heart Failure with Reduced Ejection Fraction suggests a shift toward shared decision-making that focuses on empowering and engaging patients. This new paradigm moves away from counterproductive blame and inappropriate commentary in electronic health records and encourages clinicians to adopt a more holistic approach to address factors such as multiple comorbidities, medication affordability, patient ownership and behavioral techniques to enhance medication adherence.
Effective strategies targeting adherence are multifactorial and should cater to individual patient needs including education, simplification of medication regimens, cost considerations, identification and assessment of socioeconomic barriers, medication reminders, pharmacist utilization and incorporation of behavioral supports. Additional details of the 10 considerations to improve adherence reviewed in the 2024 ACC Expert Consensus Decision Pathway are outlined in the Figure.
Long-range solutions include improving policies by advocating for changes in legislation that lower prescription insurance copays, by using value-based insurance plans that promote cost sharing and by encouraging participation in the CMS Innovation Center’s Beneficiary Engagement and Incentives Models. To mitigate cost, utilization of discount drug lists can be beneficial; however, it can result in patients receiving medications from multiple pharmacies, potentially increasing access issues while simultaneously preventing one pharmacist from reviewing a patient’s complete medication list to assess for drug interactions, duplicate therapy and other potential medication-related problems.
Use of standardized adherence surveys
Self-report tools, such as adherence surveys, offer simple and inexpensive means to assess patient adherence and are well suited for the primary care setting.
Adherence surveys typically target three topics: current adherence, barriers or risks and likelihood of future adherence. Examples of standardized surveys include the eight-item Morisky Medication Adherence Scale (MMAS-8), Medical Outcomes Study Specific Adherence Scale (MOS-SAS) and the five-item Medication Adherence Report Scale (MARS-5). Given the multitude of survey tools available, comparisons of adherence outcomes become challenging, with one study finding weak to moderate concordance between three of these validated measures. These questionnaires can be used in conjunction with other measures of adherence including medication reconciliation, review of pill bottles, pill counts, fill data and relevant drug levels.
Pharmacist integration and adherence outcomes
This guidance underscores the importance of pharmacist integration in managing patients with HF as well as incorporating automatic screening tools to identify and target patients at highest risk for medication nonadherence. A systematic review and meta-analysis evaluating medication adherence reported that pharmacists delivered the most effective interventions to patients in-person, face-to-face with a focus on habit-based over cognitive-based strategies.
A prospective cohort of 95 patients with chronic HF at a national hospital in Vietnam utilized the MMAS-8 to measure adherence at 2 and 4 months after discharge to compare pharmacist intervention (received pharmacist counseling on the third day of admission and 1 week after discharge) vs. standard of care. This study found that the proportion of patients adherent as defined by MMAS-8 score of at least 6 was higher in the intervention group compared with the control group: 97.7% vs. 80.4% at 2 months (P = .01) and 90.2% vs. 71.1% after 4 months (P = .026). An improvement in adherence was noted with a change in MMAS-8 score of 1.8 vs. 0.9 (P = .033) and 1.5 vs. 0.7 (P < .001) in the intervention group vs. the control group at 2 months and 4 months, respectively. Another prospective observational study in 80 patients with HF found that pharmacist intervention significantly increased adherence to self-care behavior and medications as measured using MOS-SAS at 90 days. A threshold of 80% was utilized to define medication adherence on this eight-item questionnaire, which has demonstrated reliability and validity in previously published studies.
Pharmacists can be effectively integrated into care teams to address obstacles related to medication adherence including potential side effects, cost and other access issues in patients with HF using in-person or telehealth modalities. Several studies have shown the benefit of multidisciplinary telehealth and remote monitoring for patients started on multiple classes of medication by reducing the number of required office visits. Historically, pharmacists have utilized telehealth to provide diabetes education, hypertension management and medication counseling. More recently, there is increased involvement of pharmacists in delivery of virtual Medicare chronic care services that are paid as bundled payment to a physician or other qualified provider. However, it is important to check restrictions that may exist within specific states and local jurisdictions regarding telehealth services. Refer to respective board of pharmacy or check for updates on the National Alliance of State Pharmacy Associations (NASPA) or the Center for Connected Health Policy websites. There are some commercial payers that may require pharmacists to have a direct contract with the payer to provide and cover telehealth services. Existing contracts can be updated to explore the addition of telehealth coverage with potential to negotiate payment as fee-for-service or under a value-based payment model. Telehealth can provide a quick and efficient way of increasing access; however, more work is needed to determine optimal billing and reimbursement practices for these services.
Addressing socioeconomic barriers and mental comorbidities
Socioeconomic status (SES) can contribute challenges to medical care, including access to medications, lack of social support and homelessness. Unfortunately, SES is known to negatively affect medication adherence, mortality and readmission rates for patients with HF. In a cohort study that examined associations of SES on clinical outcomes for patients with HF in a country with universal health care, low income was associated with higher risk for all-cause mortality and non-HF readmissions. A retrospective cohort study conducted in New York City found that patients in lower neighborhood-level SES areas had higher rates of nonadherence, up to 57%. In a secondary analysis of the RECODE-HF cohort study, psychological distress (depression and/or anxiety measured through validated questionnaires) and less familiarity with prescribing practitioners were associated with poorer medication adherence. It is important to address barriers to adherence, such as lower SES, access to pharmacies and psychological stressors, while also promoting a shared decision-making model to improve the patient-provider relationship. In addition, other research has suggested that SES factors can be independently linked to clinical outcomes, such as increased mortality, in CVD states outside of HF. By integrating SES components into CVD risk prediction models and targeting interventions such as improving access for low SES populations through utilization of non-physicians, at-risk patients may see improved clinical outcomes.
Medication adherence is complex and requires multifaceted interventions to address inequities in HF care, including individual patient factors and structural, organizational, community and access-related challenges. This prompted the FDA to implement collaborative efforts with other agencies and ongoing campaigns such as Million Hearts Campaign, National Forum for Heart Disease and Stroke Prevention, National Consumer League, and the Duke Adherence Alliance and the Enhanced Adherence Strategic Initiative Consortium. These efforts will help devise strategies to combat systemic issues by targeting education dissemination, patient advocacy, improved uptake of evidence-based practices by providers and reducing health disparities affecting medication adherence.
A four-pillar approach to empower medical organizations to advance racial justice and health equity has been proposed. This includes elevating the problem of racial injustice by acknowledging racial inequity and advocating for policy changes and engaging key stakeholders and encouraging collaboration between medical organizations, community members, insurance and industry. It also includes preparing community members through educational strategies to promote awareness and mitigation strategies and empowering marginalized populations by encouraging diversity within all levels of organizational leadership.
A shared approach
Overall, shifting perspective from medication nonadherence as solely the patient’s responsibility to a shared approach utilizing multiple strategies as discussed can significantly help reduce the disease burden associated with HF. Questionnaires addressing medication adherence not only offer clinicians insight into patients’ adherence, but also highlight the importance of taking medications to the patient. Pharmacists are important health care professionals who can effectively employ and collaborate with other health care providers to implement many of these strategies, whether in-person or via telehealth. Socioeconomic barriers and mental comorbidities should be addressed to optimize patients’ opportunity for adherence success.
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For more information:
Tanvi Patil, PharmD, BCPS, DPLA, is associate chief of pharmacy, clinical services and education, PGY1/PGY2 Pharmacy Residency Program Coordinator, clinical pharmacy practitioner (cardiology) and PHASER Pharmacy Site Champion at SALEM VAMC. Patil can be reached at tanvipatil@gmail.com.
Emily McElhaney, PharmD, BCCP, is a cardiology clinical pharmacy specialist at Cleveland Clinic. McElhaney can be reached at mcelhae@ccf.org.
Julianne M. Fallon, PharmD, BCCP, is a cardiology clinical pharmacy specialist at Cleveland Clinic. Fallon can be reached at fallonj2@ccf.org.
Sarah A. Spinler, PharmD, FCCP, FAHA, FASHP, AACC, BCPS (AQ Cardiology), is the Healio | Cardiology Today Pharmacology Consult column editor. Spinler is professor and chair of the department of pharmacy services in the School of Pharmacy and Pharmaceutical Sciences at Binghamton University. Spinler can be reached at sspinler@binghamton.edu.
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