Patient behavior and the drivers of cardiovascular disease treatment adherence

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Patient behavior and the drivers of cardiovascular disease treatment adherence

Key Message
  • Non-adherence factors may be organized into five categories: socioeconomic, health care team and system-related, disease-related, therapy-related, and patient-related.
  • Behavioral drivers of non-adherence are both intentional and unintentional.
  • Despite extensive research, no single model has yet been shown to be highly accurate in predicting patient adherence.

Treatment adherence offers a significant opportunity for improved outcomes

As noted in previous articles, non-adherence to pharmacological treatments is common among patients with chronic conditions in general and with cardiovascular disease in particular. Non-adherence to medications is a major driver of poorer health outcomes, reduced quality of life, and wasted healthcare resources.1,2,3

The drivers of non-adherence are complex

Non-adherence is a complex issue, making it difficult for health care providers to know when and how to intervene. The World Health Organization has five classifications for non-adherence: socioeconomic, health care team and system-related, disease-related, therapy-related, and patient-related factors.4 Recent interventions using a variety of approaches to address have demonstrated efficacy. These approaches include providing information (individual or group education), behavioral aids (calendar reminders, pill boxes, coaching, etc.), and strategies for improving social support (e.g. family involvement).5,8 Despite extensive research by behavioral and clinical scientists to organize patient-related non-adherence, there is still no comprehensive and widely accepted model. As a result, effective, standardized, and reliable patient-focused interventions remain a significant area of opportunity to improve outcomes,6 and there are useful tools and approaches based on the known drivers of patient behavior that can use to improve adherence.


Patient non-adherence may be intentional or unintentional

Recent studies have sought to characterize the types of non-adherence behavior and its drivers more accurately. In general, two major types of non-adherence have been identified:

  • Intentional non-adherence is deliberate and is largely associated with patient motivation.6 The patient’s decision not to take medication as prescribed may be thought of as a cost-benefit analysis, involving comparison of the perceived concerns (costs) versus benefits of the treatment. This thought process may be influenced by the patient’s beliefs about medication and the patient’s knowledge of the disease.5 In reality, there are many more subtle psychological factors at play, but the patient almost inevitably expresses the decision as a rational one (whether or not it actually is), and physicians can interact with patients at this level.
  • Unintentional non-adherence is driven by a lack of capacity or resources to take medications.6 It includes forgetfulness, regimen complexity, financial difficulty, or physical problems.5

Non-adherence for chronic cardiovascular condition treatments is largely intentional, although some patients do report non-intentional adherence barriers.

Recognizing that adherence is often intentional provides a useful starting point for communication with patients about their adherence. For example, an open conversation with a heart failure patient may reveal that he or she under-estimates their risk for adverse outcomes, and increasing that understanding may increase their motivation to take their medication as prescribed.7 On the other hand, for acute cardiovascular events, unintentional non-adherence may be the primary problem. One study found that in the year following an acute coronary syndrome, unintentional non-adherence was reported three and a half times more frequently compared to intentional nonadherence at 6 and 12 months, a finding supported in other studies of older adults with multiple comorbidities and patients with hypertension.6


Influencing the patient cost-benefit analysis represents an opportunity to improve non-adherence. 

Given the prevalence of non-adherence among patients with chronic conditions, understanding medication decision processes and the cost-benefit analysis driving intentional non-adherence merit further investigation. For example, myocardial infarction survivors risk recurrent events and have an annual death rate of 5%; nevertheless, patient adherence is estimated to be only slightly greater than 50%. Despite the elevated risk for these patients, their adherence behavior indicates both that they do not fully grasp the consequences of not taking their medication, and that factors other than the risk associated with the condition are considered, such as the necessity for, or potential harm associated with, medication use.9 Effective, personalized solutions for improving non-adherence must be based on a comprehensive understanding of this decision-making process,5 as well as a behavioral-science based understanding of how, exactly, humans incorporate risk assessment into their decision-making process. Nudge techniques can be easily employed by physicians and can have a considerable impact on how patients determine the costs and benefits of taking their medication as prescribed. We shall examine these and other techniques in future articles. 

1. Kisa, Adnan & Sabaté, Eduardo & Nuño-Solinís, Roberto. (2003). ADHERENCE TO LONG-TERM THERAPIES: Evidence for action. Eur J Cardiovasc Nurs. 2003 Dec;2(4):323.
2. Pittman, Donald, et al. Adherence to Statins, Subsequent Healthcare Costs, and Cardiovascular Hospitalizations. The American Journal of Cardiology vol. 107,11(2011): 1662-1666. 
3. Brown, Marie T, and Jennifer K Bussell. “Medication adherence: WHO cares?.” Mayo Clinic proceedings vol. 86,4 (2011): 304-14.
4. Bart JF van den Bemt, Hanneke E Zwikker & Cornelia HM van den Ende (2012) Medication adherence in patients with rheumatoid arthritis: a critical appraisal of the existing literature, Expert Review of Clinical Immunology, 8:4, 337-351,
5. Molloy, Gerard, et al. “Intentional and unintentional non-adherence to medications following an acute coronary syndrome: A longitudinal study.” Journal of Psychosomatic Research vol. 75,5(2014): 430-432. 
6. Meraz R. “Medication Nonadherence or Self-care? Understanding the Medication Decision-Making Process and Experiences of Older Adults With Heart Failure.” Journal of Cardiovascular Nursing vol. 35,1(2020): 26–34. 
7. Kripalani, S., et al. “Interventions to enhance medication adherence in chronic medical conditions: a systematic review.” Arch Intern Med. vol. 167,6(2007):540-50. 
8. Keenan, Jan. Improving adherence to medication for secondary cardiovascular disease prevention. European Journal of Preventive Cardiology vol. 24,3S(2017): 29–35.