Review: intensified patient care may improve adherence to lipid-lowering medication in primary or secondary prevention of CV disease
Dr A Schedlbauer, University of Nottingham, Nottingham, UK;
Are interventions for improving adherence to lipid-lowering medications (LLMs) effective for primary or secondary prevention of cardiovascular (CV) disease in ambulatory settings?
Medline, CINAHL, EMBASE/Excerpta Medica, Cochrane Central Register of Controlled Trials, and PsycINFO (searched in Nov 2005); reference lists; authors; and experts.
Study selection and assessment:
randomised controlled trials (RCTs) in any language that compared interventions to increase adherence to LLMs (eg, nicotinic acid or niacin, anion-exchange resins, statins) with no intervention or usual care in adults for primary or secondary prevention of CV disease in ambulatory care settings. Quality assessment of individual studies was based on avoidance of selection, performance, attrition, and detection biases according to criteria from the Cochrane Reviewers’ Handbook; studies were categorised as low (all criteria met), moderate (⩾1 criteria partly met), or high risk of bias (⩾1 criteria not met). 9 RCTs (n = 6069, mean age 49–64 y based on 7 RCTs) met the selection criteria and had moderate to high risk of bias. 2 RCTs evaluated simplified drug regimens, 2 evaluated patient information and education (videotapes, booklets, newspapers handed out by pharmacists, and newsletters sent by mail), 4 evaluated intensified patient care (telephone reminder and written material), and 1 evaluated a complex behavioural approach (small group training with information sent by post). Results were not pooled because of significant heterogeneity among studies.
included adherence to LLM, measured indirectly (eg, pill count, prescription refill rate, electronic monitoring), directly (eg, tracer substances in blood or urine), or subjectively (eg, patient self-report in diaries or interviews).
A simplified drug regimen (1 RCT) and intensified patient care (3 RCTs) improved adherence to LLMs at ⩾6 months; a complex behavioural approach did not differ from usual care (table). Results from 1 RCT (n = 455) are not included because they were derived from a subgroup analysis and analysis was not adjusted for clustering.
Intensified patient care may improve adherence to lipid-lowering medications for primary or secondary prevention of cardiovascular disease in ambulatory settings.
Schedlbauer A, Schroeder K, Fahey T. How can adherence to lipid-lowering medication be improved? A systematic review of randomized controlled trials. Fam Pract 2007;24:380–7.
Clinical impact ratings: Cardiology 6/7; Family/General practice 6/7; General/Internal medicine 5/7; Patient education 6/7
The systematic review by Schedlbauer et al makes an important contribution to our understanding about adherence to LLMs, primarily because of gaps in knowledge to guide adherence interventions. Despite evidence that LLMs reduce CV morbidity and mortality, the review raises more questions about how those results can be best achieved. As the authors note, this is because of the poor quality of studies available for review, short follow-up periods, and selection bias towards younger men.
Nurses engage in patient education aimed at promoting adherence to prescribed LLMs in patients at risk of a first or subsequent CV event. Thus, adherence issues are relevant for nurses in acute care settings who discharge patients to their homes after an acute CV event and nurses in primary care and community outpatient clinics. In the review, the best improvement in adherence to LLMs was achieved with “intensified patient care”—combinations of written information and individual telephone calls. In ⩾1 of these studies, telephone calls were made by a pharmacist. This raises questions about which professionals or combinations of professionals are best placed to implement interventions promoting adherence.
The results of this review suggest that multimodal and patient-centred interventions to promote adherence are worth pursuing. However, such approaches may not be the most feasible or economically viable, and no economic evidence was presented. Until more compelling evidence exists, caution is advised in adopting complex interventions aimed at increasing adherence to LLMs, given the incurred costs for patients and healthcare systems.