Key Issues in Outcomes Research

Medication Adherence
Its Importance in Cardiovascular Outcomes
P. Michael Ho, MD, PhD; Chris L. Bryson, MD, MS; John S. Rumsfeld, MD, PhD

Abstract—Medication adherence usually refers to whether patients take their medications as prescribed (eg, twice daily),
as well as whether they continue to take a prescribed medication. Medication nonadherence is a growing concern to
clinicians, healthcare systems, and other stakeholders (eg, payers) because of mounting evidence that it is prevalent and
associated with adverse outcomes and higher costs of care. To date, measurement of patient medication adherence and
use of interventions to improve adherence are rare in routine clinical practice. The goals of the present report are to
address (1) different methods of measuring adherence, (2) the prevalence of medication nonadherence, (3) the
association between nonadherence and outcomes, (4) the reasons for nonadherence, and finally, (5) interventions to
improve medication adherence. (Circulation. 2009;119:3028-3035.)
Key Words: cardiovascular diseases 䡲 healthcare quality assessment 䡲 medication adherence
䡲 outcomes research

“Drugs don’t work in patients who don’t take them.”
—C. Everett Koop, MD
Adherence has been defined as the “active, voluntary, and
collaborative involvement of the patient in a mutually accept-
able course of behavior to produce a therapeutic result.”1,2
This definition implies that the patient has a choice and that
both patients and providers mutually establish treatment goals
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control of care providers and healthcare systems (eg, pre-
scribing medications at discharge), the achievement of
longer-term therapeutic and outcome goals requires a part-
nership with patients.
To date, measurement of patient medication adherence and
use of interventions to improve adherence are rare in routine
clinical practice. For this reason, medication adherence has
been called the “next frontier in quality improvement” and is

and the medical regimen.1 Medication adherence usually

refers to whether patients take their medications as prescribed
(eg, twice daily), as well as whether they continue to take a
prescribed medication. Medication adherence behavior has
thus been divided into 2 main concepts, namely, adherence
and persistence. Although conceptually similar, adherence
refers to the intensity of drug use during the duration of
therapy, whereas persistence refers to the overall duration of
drug therapy.3,4
Medication adherence is a growing concern to clinicians,
healthcare systems, and other stakeholders (eg, payers) be-
cause of mounting evidence that nonadherence is prevalent
and associated with adverse outcomes and higher costs of
care.5 Medication nonadherence is likely to grow as the US
population ages and as patients take more medications to treat
chronic conditions.6 Moreover, the rise of performance mea-
sures that reward quality based on the attainment of treatment
targets such as blood pressure and low-density lipoprotein
(LDL) levels or outcomes such as 1-year mortality after
hospitalization for conditions like acute myocardial infarction
reinforces the import of longitudinal medication adherence.
Unlike other quality measures that are under more direct
an important part of cardiovascular outcomes research.7 The
goals of the present report are to address (1) different methods
of measuring adherence, (2) the prevalence of medication
nonadherence, (3) the association between nonadherence and
outcomes, (4) the reasons for nonadherence, and finally, (5)
interventions to improve medication adherence.
Methodology of Assessing
Medication Adherence
There are many different methods for assessing adherence to
medications. Osterberg et al5 categorized these methods as
either direct or indirect. Direct methods include directly
observed therapy, measurement of the level of medicine or
metabolite in blood, and measurement of the biological
marker in blood.5 Although these direct methods are consid-
ered to be more robust than indirect methods, there are also
limitations to these direct methods of adherence assessment.
For example, patients may hide pills in their mouth and
discard them later, or there may be variations in metabolism
that can affect serum levels. Furthermore, these direct meth-
ods are not practical for routine clinical use.

The views expressed in this article are those of the authors and do not necessarily represent the views of the US Department of Veterans Affairs.
From the Denver VA Medical Center (P.M.H., J.S.R.), Denver, Colo; University of Colorado Denver (P.M.H., J.S.R.), Denver, Color; Institute for
Health Research (P.M.H., J.S.R.), Kaiser Permanente of Colorado, Aurora, Colo; Puget Sound VA Medical Center (C.L.B.), Seattle, Wash; and University
of Washington (C.L.B.), Seattle, Wash.
Correspondence to P. Michael Ho, MD, PhD, 1055 Clermont St (111B), Denver, CO 80220. E-mail michael.ho@va.gov
© 2009 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIRCULATIONAHA.108.768986

3028

Indirect methods of adherence assessment include patient
questionnaires, self-reports, pill counts, rate of prescription
refills, assessment of the patient’s clinical response, elec-
tronic medication monitors, measurement of physiological
markers, and patient diaries.5 The most commonly used
indirect methods include patient self-report, pill counts, and
pharmacy refills. The Morisky scale is a commonly used,
validated, 4-item self-reported adherence measure that has
been shown to be predictive of adherence to cardiovascular
medications and blood pressure control.8,9 In addition, Gehi et
al10 found that patient self-report of medication nonadherence
was strongly associated with adverse cardiac events, includ-
ing coronary heart disease death, myocardial infarction, and
stroke, on the basis of a single screening question (“In the
past month, how often did you take your medications as the
doctor prescribed?”) among patients with known coronary
artery disease. However, self-report measures can be biased
by inaccurate patient recall or by social desirability, whereby
patients report an overly optimistic estimation of adherence to
their healthcare providers. Pill counts are easy to perform,
have been correlated with electronic medication monitors,
and are frequently used in randomized, controlled clinical
trials to assess medication adherence,11–13 Although simple to
measure, pill counts do not accurately capture the exact
timing of medication taking, and the data can be manipulated
by patients (eg, pill dumping). Each of these methods has
advantages and disadvantages, and the use of a specific
method to measure adherence will depend on the clinical
scenario and availability of the data.
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Electronic pharmacy data are becoming more widely avail-
able, and this is one of the more frequently used methods in
the literature. The act of obtaining refills and the frequency
with which the refills are acquired reflect different aspects of
a patient’s adherence behavior, and adherence based on
pharmacy refill data has been correlated with a broad range of
patient outcomes.14 Currently, the 2 most commonly used
measures of medication adherence based on pharmacy data
are the medication possession ratio and the proportion of days
covered methods, which essentially are defined by the num-
ber of doses dispensed in relation to a dispensing period. The
main difference between these 2 measures is that the maxi-
mum proportion of days covered is 1.0, which indicates full
adherence, whereas the medication possession ratio accounts
for oversupplies and can have a value ⬎1.0.15–19 The use of
pharmacy prescription refill data, however, requires that
patients obtain their medications within a closed pharmacy
system. In addition, the medication possession ratio and
proportion of days covered measures of medication adher-
ence correlate well with the quantity of doses taken but not
the timing of the doses, and the assessment of adherence with
these measures is more difficult when the length of follow-up
varies between patients.12
For medication persistence, there are also multiple com-
monly used measures. These measures can be related to a
specific medication (medication persistence) or a set of
medications (regimen or therapy persistence).18 In addition,
there have been many proposed definitions for medication
persistence, including the anniversary, minimum refills, refill
sequence, or proportion of days covered methods.3 Although
Ho et al Medication Adherence 3029
each measure has its strengths and limitations, there is
currently no general consensus as to the best measure to use
to define adherence or persistence. These studies highlight the
challenges of measuring medication adherence in routine
clinical practice and in research studies given the lack of a
“gold standard” criterion.
On the basis of pharmacy refill data, patients with medi-
cations available 80% of the time have generally been
categorized as adherent in the literature. This dichotomous
cutoff is somewhat arbitrary; however, it has been used for a
majority of the studies in the literature on medication adher-
ence, with data from both observational and randomized,
controlled clinical trials. In addition, adherence based on this
cut point has been associated with both intermediate and hard
outcomes. However, a more recent analysis suggests that
there continues to be reductions in LDL cholesterol and blood
pressure with adherence levels beyond 80% (eg, 80% to
100%), which suggests that the optimal level of adherence
may be higher than current cutoffs.20 Certainly for conditions
such as human immunodeficiency virus or medications such
as oral contraceptives, the 80% cutoff may be too low.
Although the current 80% cutoff appears reasonable for
cardiovascular medications, future studies focused on medi-
cation adherence using pharmacy refill data should report
both continuous measures of adherence and the distribution
of adherent patients based on different dichotomous cutoffs.
The appropriate cutoff will depend on the specific medica-
tion, its formulation (eg, once daily versus twice daily), and
the specific disease condition.
Prevalence of Medication Nonadherence
Nonadherence to medications is common for patients with
cardiovascular diseases. After acute myocardial infarction
hospitalization, Jackevicius et al21 found that almost one
fourth of patients (⬇24%) did not even fill their cardiac
medications by day 7 of discharge. Among patients dis-
charged with prescriptions for aspirin, statin, and ␤-blockers
after acute myocardial infarction, 1 study found that ⬇34% of
patients stopped at least 1 medication and 12% stopped all 3
medications within 1 month of hospital discharge.22 Beyond
the early discharge period, there appears to be a progressive
decline in adherence to prescribed cardioprotective medica-
tions (eg, statins, ␤-blockers) over time. Newby et al23 found
that patient self-report of consistent use of cardiac medica-
tions over 6 to 12 months was low, with approximately three
fourths of patients reporting persistent aspirin use (71%),
whereas less than half reported persistent use of ␤-blockers
(46%), lipid-lowering agents (44%), and all 3 medications
(21%) after diagnosis of coronary artery disease by coronary
angiography. Another study demonstrated that only ⬇40% of
patients were still taking statin medications 2 years after
hospitalization for acute coronary syndrome, and adherence
was even lower for patients taking statins for chronic coro-
nary artery disease.24 Although the transition period from
hospital discharge to the outpatient setting appears to be a
particularly high-risk period, medication nonadherence con-
tinues to decline during the long-term follow-up phase for
coronary artery disease.
 3030 Circulation June 16, 2009
For other cardiovascular conditions, the prevalence of
medication nonadherence varies tremendously depending on
the population studied and the specific medications assessed.
For example, Vrijens et al,25 using medication event monitor
(MEMS) data, found that about half of all patients prescribed
antihypertensive medications stopped taking them within 1
year of the initial prescription. They also found that on any 1
day, patients omitted ⬇10% of the scheduled doses of
medications.25 In contrast, Bramley et al26 found that ⬇75%
of patients on monotherapy for hypertension were highly
adherent, defined as a medication possession ratio of 80% to
100%. Among heart failure patients, studies of medication
adherence have also found widely differing rates of nonad-
herence. For example, 1 study reported persistence rates of
79% for renin-angiotensin inhibitors, 65% for ␤-blockers,
56% for spironolactone, and 83% for statins 5 years after an
index heart failure hospitalization.27 In contrast, the rate of
nonadherence based on pill counts was much lower in the
Candesartan in Heart Failure: Assessment of Reduction in
Mortality and Morbidity (CHARM) randomized, controlled
trial of patients with heart failure, with 11% of patients taking
fewer than 80% of the prescribed pills.28 Although nonadher-
ence to medications is prevalent in cardiovascular popula-
tions, the variability of the methods for assessment of
medication use (eg, self-report or pharmacy refill data) makes
comparisons across studies and across cardiovascular condi-
tions difficult.
Association Between Medication Adherence
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and Outcomes
Many observational studies have evaluated the association
between medication adherence and outcomes. In general,
these studies have focused on medications that have already
been demonstrated in clinical trials to be efficacious and
therefore are trying to assess the effectiveness of these
medications in routine clinical practice. Pharmacy refill data
and patient self-report are the mostly commonly used adher-
ence assessment methods in these studies. High adherence
(defined as medication possession ratio of 80% to 100%) to
antihypertensive medications was associated with higher
odds (odds ratio 1.45, 95% confidence interval 1.04 to 2.02)
of blood pressure control compared with those with medium
or low levels of adherence.26 Similarly, each incremental 25%
increase in proportion of days covered for statin medications
was associated with an ⬇3.8-mg/dL reduction in LDL cho-
lesterol.29 Furthermore, nonadherence to cardiovascular med-
ications has been associated with increased risk of morbidity
and mortality. For example, nonadherence to statins in the
year after hospitalization for myocardial infarction was asso-
ciated with an ⬇12% to 25% increased relative hazard for
mortality.30 In the chronic coronary artery disease setting,
nonadherence to cardioprotective medications (␤-blockers,
statins, and/or angiotensin-converting enzyme inhibitors) was
associated with a 10% to 40% relative increase in risk of
cardiovascular hospitalizations and a 50% to 80% relative
increase in risk of mortality.14 Another study demonstrated
that patients discontinuing clopidogrel within 1 month after
hospital discharge for acute myocardial infarction and drug-
eluting stent placement were significantly more likely to have
an adverse outcome, including rehospitalization and mortal-
ity, in the subsequent 11 months.31 In addition, poor adher-
ence to heart failure drugs was associated with an increased
number of cardiovascular-related emergency department vis-
its.32 These effectiveness studies reinforce the benefits of
cardiovascular medications in routine clinical practice and
highlight the importance of taking these medication as pre-
scribed to optimize patient outcomes.
Healthy Adherer Effect
Although the association between medication nonadherence
and adverse outcomes has been demonstrated in many obser-
vational studies, some concern has been raised that this
association may be, at least in part, related to a “healthy
adherer” effect.33 The healthy adherer effect implies that the
lower risk of adverse outcomes associated with adherence
may be a surrogate marker for overall healthy behavior. This
is supported by post hoc analyses of randomized, controlled
clinical trials in which even adherence to placebo is associ-
ated with better outcomes than for patients who are nonad-
herent to active treatment. These findings were first noted
over 25 years ago in the Coronary Drug Project, which
involved clofibrate.34 In the ␤-blocker Heart Attack Trial,
poor adherence was associated with higher mortality risk
regardless of whether patients were randomized to propran-
olol or placebo.35 Similar findings were demonstrated in the
Canadian Amiodarone Myocardial Infarction Arrhythmia
Trial (CAMIAT) study for sudden death, total cardiac mor-
tality, and all-cause mortality and in the CHARM program for
all-cause mortality.28,36 It appears that patients who take their
medication regularly are also more likely to perform other
healthy behaviors, such as eating properly and exercising
regularly.37,38 These behaviors are often not measured di-
rectly in prospective or retrospective studies.
However, there is also evidence against the healthy adherer
effect being a major factor in observed associations between
medication adherence and outcomes. For example, in a study
of post–myocardial infarction patients by Rasmussen et al,30
the association between adherence to cardiovascular medica-
tions and outcomes in which neither clinical evidence nor
biological plausibility existed was assessed. They found
that adherence to cardiovascular medications was not
associated with hospitalization for lung, prostate, or breast
cancer and concluded that the benefit of adherence was
directly related to the cardiovascular medication rather
than an epiphenomenon of a healthy adherer effect. Al-
though the debate will continue, the medications under
study have often been demonstrated in randomized, con-
trolled clinical trials to be efficacious, and therefore, the
importance of taking these medications as prescribed
should be reinforced.
Association Between Medication Adherence
and Costs
Surprisingly little is known about the association between
medication adherence and healthcare costs in cardiovascular
populations. Sokol et al39 reported that greater adherence to
medications for chronic conditions such as hypertension,
diabetes mellitus, hypercholesterolemia, and heart failure was

associated with higher medication costs but lower nonmedi-
cation medical costs, yielding a net overall reduction in
healthcare costs. A recent evaluation of statin medication
adherence and healthcare costs among patients with coronary
artery disease in a managed care organization demonstrated
that higher medication adherence was associated with higher
pharmacy costs and lower medical costs; however, overall
healthcare costs were similar between nonadherent and ad-
herent patients over several years of follow-up.40 On the basis
of available studies to date, it thus remains unclear whether
medication adherence is associated with lower overall health-
care costs or is “cost neutral” to the healthcare system. Either
way, medication nonadherence is associated with worse
patient outcomes, which supports the need for interventions
to improve medication adherence. Yet, there is a clear need
for more research to better understand the association be-
tween adherence and healthcare costs and for formal cost-
effectiveness evaluations to be embedded in studies of inter-
ventions to improve medication adherence.
A larger number of studies have evaluated the impact of
changing costs of medications on individual patient adher-
ence. Among Medicare⫹Choice beneficiaries, patients who
had drug benefit caps were more likely to be nonadherent to
medications for hypertension, hyperlipidemia, and diabetes.41
In addition, patients with caps on drug benefits had worse
intermediate outcomes (eg, LDL levels and blood pressure)
and higher rates of emergency department visits and nonelec-
tive hospitalizations. In separate studies, changes to out-of-
pocket spending doubled the risk of stopping statin therapy,
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and higher copayments were associated with lower adherence
to statins.42,43 Taira et al44 also showed a graded relationship
between the level of copayment and medication adherence,
with patients more likely to refill medications for antihyper-
tensive medications that had a lower copayment. Finally,
Cole et al45 demonstrated that higher drug copayments for
angiotensin-converting enzyme inhibitors and ␤-blockers
were associated with a small decrease in the medication
possession ratio among patients with heart failure. These
studies suggest that medication costs can have a significant
impact on nonadherence, and future studies are needed to
assess whether lowering medication costs can improve med-
ication adherence and clinical outcomes.
Patterns and Reasons for
Medication Nonadherence
The reasons for poor medication adherence are often multi-
factorial. Nonadherence to medications can be intentional or
nonintentional. Intentional nonadherence is an active process
whereby the patient chooses to deviate from the treatment
regimen.46 This may be a rational decision process in which
the individual weighs the risk and benefits of treatment
against any adverse effects. Unintentional nonadherence is a
passive process in which the patient may be careless or
forgetful about adhering to the treatment regimen. This is also
referred to by Vrijens et al25 as the execution of the prescribed
regimen, or how well patients adhere to the dosing regimen.
On the basis of electronic monitoring data, there are 6 general
patterns of execution: (1) Close to perfect adherence; (2) take
nearly all doses with some timing irregularity; (3) miss an
Ho et al Medication Adherence 3031
Table. Reasons for Medication Nonadherence
Categories of
Nonadherence Examples
Health system Poor quality of provider-patient relationship; poor
communication; lack of access to healthcare;
lack of continuity of care
Condition Asymptomatic chronic disease (lack of physical
cues); mental health disorders (eg, depression)
Patient Physical impairments (eg, vision problems or
impaired dexterity); cognitive impairment;
psychological/behavioral; younger age;
nonwhite race
Therapy Complexity of regimen; side effects
Socioeconomic Low literacy; higher medication costs; poor
social support
occasional single day’s dose, and some timing inconsisten-
cies; (4) take drug holidays 3 to 4 times per year; (5) take drug
holidays monthly or more often and have frequent omissions;
and (6) take few or no doses.5,47 Most deviations in medica-
tion taking are due to omissions of doses or delays in taking
doses. In addition, it is common for patients to improve their
medication-taking behavior shortly before and after an ap-
pointment with a healthcare provider, which has been termed
“white-coat adherence.”5
The World Health Organization has categorized potential
reasons for medication nonadherence into 5 broad groupings
that include patient, condition, therapy, socioeconomic, and
health system–related factors.48 – 62 Examples for each of
these categories are detailed in the Table. Patient factors
associated with medication nonadherence include younger
age, nonwhite race, and depression. Conditions that are
asymptomatic and chronic in nature that require long-term
therapy have also been associated with nonadherence. For
therapy-related factors, the complexity of the regimen and the
perceived or experienced side effects can impact adherence.
Socioeconomic factors such as lower education level and low
health literacy have been correlated with nonadherence.
Although the cost of medications is another important socio-
economic factor, medication nonadherence remains common
even when cost is less of a factor, such as in the Canadian
healthcare system or the US Veterans Health Administration.
Finally, it remains unclear whether these individual factors
can adequately discriminate between patients who are adher-
ent or are not adherent, and this suggests that evaluations of
nonadherence cannot be targeted to specific patient
populations/characteristics.
Next, although patients are often implicated as the cause
for medication nonadherence, healthcare system factors can
also have a significant impact on a patient’s nonadherence to
medications. Makaryus et al63 found that ⬍50% of patients
were able to list all of their medications, and even fewer could
recount the purpose of their medications at hospital discharge,
which suggests that system factors like the educational
process at hospital discharge can impact medication adher-
ence after discharge. Supporting this idea is a prior study that
found that discharge counseling was associated with im-
proved adherence after hospital discharge for myocardial
 3032 Circulation June 16, 2009
infarction.21 Next, Coleman et al64 found that medication
discrepancies, defined as lack of agreement between the
prehospital, discharge, and posthospital medication regimens,
were common after hospital discharge, occurring ⬇15% of
the time. The causes for these discrepancies were just as
likely to be related to system factors (eg, conflicting infor-
mation, incomplete discharge instructions) as to patient
factors. Furthermore, system-level factors such as the bureau-
cratic processes associated with insurance claims can also
influence adherence. In a qualitative study, Bokhour et al65
found that in approximately one third of hypertension-related
visits in which blood pressure was not controlled, the care
provider did not even ask about medication taking, and
closed-ended questions during the visit inhibited discussions
on medications or medication-taking behaviors. Finally,
Svensson et al66 found that adherence to antihypertensive
medication was related to faith in the physician, which
suggests that the quality of the provider-patient relationship
was also an important determinant. Although patients are
central to taking medications as prescribed, there are many
non–patient-related factors that can also affect adherence to
medications.
Interventions to Improve
Medication Adherence
To date, interventions targeting medication adherence have
produced only modest success. In general, unimodal inter-
ventions have been less successful than multimodal interven-
tions, because the reasons for nonadherence are often multi-
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factorial.67–72 Unimodal interventions that have demonstrated
some success include those that reduced the number of daily
doses of medications, used motivational strategies, packaged
medications into special containers (eg, pill boxes or blister
packs), provided more convenient care, educated patients, or
involved monitoring and feedback. For example, Smith et al73
recently published findings of a cluster randomized trial in 4
geographically dispersed health maintenance organizations
that sent informational mailings on ␤-blocker therapy to
patients recently discharged for acute myocardial infarction
and prescribed ␤-blockers. The intervention resulted in an
absolute increase of 4.3% of days covered per month for
␤-blocker medications compared with usual-care patients and
a 17% relative increase in the likelihood of being adherent to
␤-blockers. Although the study findings are positive, it is
unclear whether the modest improvement in adherence will
translate into differences in clinical outcomes.
Multimodal interventions have shown the most promise
and have improved both adherence and outcomes. For exam-
ple, Piette et al74,75 randomized veterans with diabetes melli-
tus to an intervention that consisted of telemonitoring with
interactive voice response technology and weekly nurse
feedback and demonstrated improvements in medication
adherence and diabetes-related symptoms, as well as a trend
for improvement in hemoglobin A1C. For heart failure,
Murray et al76 randomized clinically stable outpatients with a
diagnosis of heart failure to an intensive pharmacist-led
intervention versus usual care and found a 10.9% improve-
ment in adherence to cardiovascular medications. The inter-
vention patients also had fewer emergency department visits
and hospital admissions, as well as lower healthcare costs. In
contrast, Lee et al77 randomized patients to an intervention
composed of patient education, medication reminder packag-
ing, and frequent clinic visits (every 2 months) versus usual
care and showed improvements in medication adherence
(⬇30%) and systolic blood pressure but not LDL cholesterol.
Across these studies, one of the consistent features of suc-
cessful interventions has been regular follow-up with the
healthcare system. Although multimodal interventions are
more likely to be successful than unimodal interventions,
some of the study findings remain mixed with regard to
outcomes, and the complexity of the interventions makes it
difficult to implement them in routine clinical care.
Although observational studies have highlighted oppor-
tunities to improve medication adherence, the implemen-
tation of these interventions in routine clinical practice poses
many hurdles. First, the successful interventions to date have
included multiple components, and the components have
often been heterogeneous, which makes implementation into
routine practice difficult. These multiple components often
require clinical personnel to manage and/or coordinate them,
which increases the cost of implementing the intervention.
Furthermore, because of the current fractured healthcare
system, there are logistical challenges to the coordination of
any intervention between various care providers and across
different healthcare systems. Although integrated health sys-
tems like Kaiser or the Veterans Administration may be able
to overcome these barriers, it remains a significant problem
for the rest of the healthcare system. Finally, current financial
incentives are not aligned with the promotion of the impor-
tance of medication adherence. Until some of these barriers
are lowered, improving medication adherence broadly in
routine clinical practice will remain challenging.
Research and Clinical Implications
There have been great strides made toward a better under-
standing of medication adherence and its impact in clinical
practice; however, more research is needed to address critical
issues in the field. One of these issues is coming to a
consensus on how to uniformly report measures of medica-
tion adherence and persistence. Because of the variety of data
sources and adherence measures, it is often difficult to
compare adherence rates across studies and conditions. A
consensus on the method(s) of measurement will provide
more comparability across studies. Second, prospective stud-
ies focusing on adherence should measure adherence using
different methods to help inform the specific type of nonad-
herence behavior, such as primary nonadherence or problems
with execution of the regimen, because each of these behav-
iors may necessitate a different intervention. Third, new
strategies to improve medication adherence need to be tested
to add to the current knowledge base on how to improve
medication adherence and persistence. These interventions
should focus on improving medication adherence, in addition
to intermediate and hard outcomes. Finally, more research is
needed to better understand the association between adher-
ence and healthcare costs, and there is a need for formal
cost-effectiveness evaluations to be embedded in studies of
interventions to improve medication adherence. Many new

cardiovascular therapies have been introduced in the past
decade that reduce morbidity and mortality, and the next
challenge will be to get patients to take these therapies as
prescribed.
Although research is continuing to enable us to better
understand medication adherence, there is an urgent need to
improve current rates of nonadherence. One of the first steps
is a broader recognition of the problem of medication
nonadherence, given that it is frequently unrecognized. For
example, akin to vital signs obtained for outpatient clinic
visits, a screening question on medication nonadherence can
be incorporated into each visit. Although insensitive, patient
self-report of nonadherence is specific and predicts future
adverse outcomes. For healthcare systems in which pharmacy
records are readily available, a review of the refill frequency
and the date of the last refill may also help identify nonad-
herence. Once medication nonadherence is recognized, care
providers and patients can work collaboratively to develop
patient-specific solutions to address adherence barriers. There
are simple, evidence-based strategies that can be imple-
mented, such as reducing the number of daily doses of
medications, organizing medications in pill boxes, using
motivational interviewing, and educating patients on the
importance of medication adherence.69 In addition, if feasible,
it may be helpful to have clinical personnel follow up with
patients through telephone calls to ensure that patients are
taking their medications as directed, particularly for those
who have a history of nonadherence. This strategy may be
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especially important in the post– hospital discharge setting.
While we await additional evidence from studies, these
strategies can be easily implemented in routine clinical
practice without much additional time or resources to help
patients take their medications as prescribed.
Conclusions
Building on recent improvements in the prescription of
indicated cardiovascular medication to patients, the next step
is to improve adherence to prescribed medications.78 Nonad-
herence to medications is common and is associated with
adverse outcomes. Nonadherence is not solely a patient
problem but is impacted by both care providers and the
healthcare system. As the first step toward improving adher-
ence, there needs to be a broader recognition of the problem
of nonadherence, and once identified, simple strategies
should be implemented in daily practice to improve adher-
ence. Certainly, there are still many challenges in further
understanding the reasons for nonadherence and designing
better interventions to improve adherence; however, getting
patients to take their medication as prescribed is a worthy
goal in order for patients to derive the maximal benefit of
prescribed therapies and is also highly consistent with one
of the Institute of Medicine’s goals of care of patient
centeredness.79
Sources of Funding
Drs Ho and Bryson are supported by Veterans Administration Health
Service Research and Career Development.
Ho et al Medication Adherence 3033
Disclosures
None.
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