Patients Medication Adherence in Chronic Diseases in Zagreb
(Croatia)
J. Culig, J.Boskovic, D.Huml, M.Leppée
Zagreb Institute of Public Health, Zagreb, Croatia
Summary
The patient's medication adherence in chronic diseases is poor. According to the selfadministered standardized adherence questionarre a patient's medication adherence in Zagreb
iz 41%. In chronic cardiovascular diseases it is 38%. In order to improve the patient's
medication adherence an intervention strategy was applied in the high blood cholesterol group
of patients.After the life-style changes were insufficient in lowering blood cholesterol level,
the statin treatment was prescribed. Each patient was informed on the statin efficacy in
lowering blood cholesterol and LDL, and positive effects on HDL. The importance of
medication adherence was stressed and a control tests in six months were appointed. The
most patients visited their health care provider after six months. According to the control
tests the blood cholesterol level decreased in every patient . Also there was a strong tendency
in LDL decrease in the most of patients. HDL changes were more infignificant. A further
study is needed to confirm such intervention strategy in improving patient's medication
adherence in chronic diseases.
Introduction
The adherence is defined as the extent to which the patient corresponds with agreed
recommendations grom the health provider on taking medication. The risk of poor adherence
is increased with th duration and complexity of treatment regimens. The both are
characteristics inherent to the chronic diseases. The optimal outcomes in the patient therapy
require both: the efficacious treatment and the adherence to tose treatment. It is therefore
important to asses acurately the adherence behaviour of patients for effective and efficient
treatment planning. The measuremnt approach is to ask health care providers and patients for
their subjective assesment of the adherence behaviour through the standardized
questionnaires. The different approach is by counting the remaining drug dosage units or
using the electronic device. The overall conclusion is that the patients medication adherence is
poor, less than 50%, and even worse in the specific chronic diseases. The research concerning
the prevalence and correlates of poor adherence to treatment for a specific disease should be
performed.
The aim of the following study was to asses the rate of patient's adherence to drug medication
in chronic diseases in Zagreb (Croatia).Also, the intervention study was planned and
performed as a pilot in the group of high cholesterol patients.
Materials and Methods
The study setting were 171 community pharmacies in the city of Zagreb. The patients with
diagnosed chronic illnesses were asked to fill the standardized questionnaire. The question
concerned the reasons for not taking prescribed medications. The questionnaire was modifed
ACTG Adherence Baseline Questionnaire. Total number of patients accepted to fill the
questionnare was 634, 258 males and 376 females. The number of retired patients was 356
(56% of total) and the number of university degree patients was 237 (37 %). Most of them
(458 /634) acquired cardiovascular chronic diseases and had prescribed relevant drug
medications. The intervention substudy included the 85 high cholesterol patients with
prescribed statins treatment in the equivalent pharmacological dosage schedules. They were
divided into two groups between the two healthcare teams. The life-styles changes ( diet,
exercise) was recommended to each patient. Three months later the blood test were done and
total cholesterol, HDL and LDL determined. The results were shown to the patients, the
statins were prescribed and the goal of treatment explained to each. Six months later the blood
tests were repeated.
Results
The analysis of 634 questionnaires has shown the rate of 41% patients adherence to the
prescribed medication. The patients adherence rate in cardiovascular chronic diseases was
slightly lower (38 %). The statin intervention group consisted of 35 males ( average age 56,8
years) and 50 females ( average age 64,1 years).After the six months of statin treatment the
blood cholesterol level in the males group decreased in average for 2,18 µmol/l, and in the
females group it decreased in average for 2,57 (Figure 1). LDL decreased for 1,26 in average
in the females, and 0,54 in the males. HDL increased for 0,12 in the females in average, but
decreased in the males for 0,13 in average. The influence of age was analysed comparing the
two different age groups ( 0-64 and 65+ ). The level of total blood cholesterol in the younger
dropped in average for 1,86 and in the elderly for 1,74 in average. The number of total drug
medication has been marked as factor of poor adherence. We divided patients in the two
groups: one that was taking 1-3 different drugs included the statins, ane second with 4+ drugs
prescribed. The blood cholesterol level decreased more profoundly in the group with less
medication ( 2,11/1,64). The patients were also analysed according to the main chronic
disease diagnosed. For the purpose of analysis they were divided into two main categories: the
group of hyperlipidaemias and the group of ischaemic cardiac diseases. In the hiperlipidaemia
patients blood cholesterol decreased in average 2,63 µmol/l and LDL decreased in average
1,11. In the ischaemic heart disease patients decrease of blood cholesterol was 1,61 in
average and LDL decreased 1,02 in average.
The results have shown shown a positive influence on the patients medication adherence
behaviour by informing them how the statin treatment adherence could be assesed by
measuring blood cholesterol, HDL and LDL. It is claimed that the personality variables do not
influence a medication adherence significantly. However, in our small pilot study there were
tendencies toward better results in the females, the younger and less complex drug treatment.
Such strategies may be used to improve the patient's medication adherence.
8
7
milimol/L
6
5
4
3
2
1
0
Cholesterol level after lyfe-style
changes (3 months)
Male
Cholesterol level(6 months after)
Female
Figure 1. A blood cholesterol level in the statins prescribed patients
Conclusions
The patient's medication adherence in chronic diseases in Zagreb is poor. The chronic
diseases are permanent, leave residual disability, require special training of the patient for
rehabilitaton and long duration medication. The adherence is the most important factor that
compromises treatment outcome. The patients need advice, support and information from
health proffesionals to be able to understand the importance of adherence to chronic drug
medication. The interventions to improve adherence to medication were more effective when
they included multiple-components such as more convenient care, information, counselling,
reminders, self-monitoring, reinforcement or family therapy. Different strategies to improve
patient's adherence are in use. The health providers ( MD and pharmacist) have improved
their communications skills. They provide information, use „poitive talk“ technique, motivate
and asking patients specific questions about adherence. Patient's personality variables have
not emerged as significant predictors. Illness- relevant cognitions, perception of disease
factors and beliefs about treatment have stronger relationship to adherence. A specific
intervention strategies to improve patient's medication adherence should be applied in chronic
diseases. They should be based on patient education, specific knowledge, beliefs, motivations
and actions.
References
Wilson MG, Edmundson J : Characteristic of adherers of a worksite cholesterol programme.
Health Values, 1993,17:10-20.
Huml D,Stimac D,Culig J, Andabaka I,Tadic I, Portolan M: Improving patient's medication
adherence in chronic diseases. 37th ESCP Symposium, Dubrovnik, Croatia, 21-24 October
2008. Abstract Book, p 90.
Stimac D, Culig J, Sostar Z, Bucalic M.: Cardiovascular Drug Prescribing in Croatia 20012005. Pharmacoepidemiology and Safety 2007; 16 ,Suppl 2, P274.