Disease Management & Health Outcomes

, Volume 12, Issue 6, pp 377–383 | Cite as

Improving Treatment Regimen Adherence in Coronary Heart Disease by Targeting Patient Types

  • Robin S. Turpin
  • Jeffrey B. Simmons
  • Janice F. Lew
  • Charles M. Alexander
  • Marie A. Dupee
  • Patricia Kavanagh
  • Ellen R. Cameron
Leading Article


Patient adherence to a treatment plan is central to the control of coronary heart disease (CHD) and in the prevention of complications; it is reported to be the single most important challenge in the management of CHD and related conditions. The following article provides an overview of adherence in CHD, with particular emphasis on two important theories of behavior change: the ‘Health Belief Model’ and the ‘Transtheoretical Model’. Three types of individuals are discussed in relation to these theories: (i) patients who are non-adherent (5–10% of the CHD population); (ii) patients who are partially adherent (30–40% of the CHD population); and (iii) patients who are near-optimally adherent (50–60% of the CHD population). Adherence predictor strategies and recommended interventions for each of these groups are provided in table format. Disease management tools and resources that assist in targeting interventions to the unique adherence needs of these three very different groups are also listed. It was our conclusion that regardless of the interventions that are utilized in CHD management programs, understanding the differences between partially adherent, non-adherent, and near-optimally adherent patients, and targeting interventions to these groups, can optimize the impact of CHD interventions.


Coronary Heart Disease Patient Adherence Health Belief Model Transtheoretical Model Adherent Patient 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



The authors gratefully acknowledge Beth Bridges, Steve Teutsch, Camelot Ives, Douglas Jordan, and Thomas McCready for their assistance with this project, and Marc Berger and Peter Nebenfuhr for their continued support of this initiative. No sources of funding were used to assist in the preparation of this review. The authors have no conflicts of interest that are directly relevant to the content of this review. The authors are employees and stockholders of Merck & Co., Inc.


  1. 1.
    NCQA. The state of managed care quality, 2002. Washington, DC: NCQA, 2002Google Scholar
  2. 2.
    National Cholesterol Education Program. ATP III final report. Circulation 2002; 106: 3359Google Scholar
  3. 3.
    American Heart Association. Compliance action program. Dallas (TX): AHA, 2002Google Scholar
  4. 4.
    Ellis WM. Compliance action program: an opportunity to fight the nation’s leading cause of death. J Am Pharm Assoc (Wash) 2001; 41(4): 623–5Google Scholar
  5. 5.
    Taylor H, Leitman R. Harris Interactive Health Care News. Out-of-pocket costs are a substantial barrier to prescription durg compliance [online]. Available from URL: [Accessed 2004 Aug 13]
  6. 6.
    Urquhart J. Partial compliance in cardiovascular disease: risk implications. Br J Clin Pract Suppl 1994; 73: 2–12PubMedGoogle Scholar
  7. 7.
    Benner JS, Gwynn RJ, Mogun H, et al. Long-term persistence in use of statin therapy in elderly patients. JAMA 2002; 288(4): 455–61PubMedCrossRefGoogle Scholar
  8. 8.
    Cramer JA. Effect of partial compliance on cardiovascular medication effectiveness. Heart 2002; 88: 203–6PubMedCrossRefGoogle Scholar
  9. 9.
    Rudd P. Compliance with antihypertensive therapy: a shifting paradigm. Cardiol Rev 1994; 2(5): 230–40CrossRefGoogle Scholar
  10. 10.
    Vermeire E, Hearnshaw H, Van Royen P, et al. Patient adherence to treatment: three decades of research: a comprehensive review. J Clin Pharm Ther 2001; 26: 331–42PubMedCrossRefGoogle Scholar
  11. 11.
    Turpin RS, Jungkind K, Salvucci L. The HEDIS Performance NAVIGATOR for controlling high blood pressure: a resource to assist health plans improve patient adherence. Dis Manag Health Outcome 2003; 6(1): 43–51Google Scholar
  12. 12.
    Rimer BK, Glanz K, Lerman C. Contributions of public health to patient compliance. J Community Health 1991; 16(4): 225–40PubMedCrossRefGoogle Scholar
  13. 13.
    Svensson S, Kjellgren KI, Ahlner J, et al. Reasons for adherence with antihypertensive medication. Int J Cardiol 2000; 76: 157–63PubMedCrossRefGoogle Scholar
  14. 14.
    Rybacki JJ. Improving cardiovascular health in postmenopausal women by addressing medication adherence issues. J Am Pharm Assoc (Wash) 2002; 42: 63–73CrossRefGoogle Scholar
  15. 15.
    Ghandi SK, Xiaodong K. Quality-of-life measures in the evaluation of antihypertensive drug therapy: reliability, validity and quality-of-life domains. Clin Ther 1996; 18(6): 1276–95CrossRefGoogle Scholar
  16. 16.
    Rand CS. Measuring adherence with therapy for chronic diseases: implications for the treatment of heterozygous familial hypercholesterolemia. Am J Cardiol 1993; 72: 68D–74DPubMedCrossRefGoogle Scholar
  17. 17.
    Ockene IS, Hayman LL, Pasternak RC, et al. Adherence issues and behavior changes: achieving a long-term solution. J Am Coll Cardiol 2002; 40(4): 579–651CrossRefGoogle Scholar
  18. 18.
    Donovan JL, Blake DR. Patient non-compliance: deviance or reasoned decisionmaking? Soc Sci Med 1992; 34(5): 507–13PubMedCrossRefGoogle Scholar
  19. 19.
    Carruthers SG. Assimilating new therapeutic interventions into clinical practice: how does hypertension compare with other therapeutic areas?. Am Heart J 1999; 138(3 Pt 2): S256–60CrossRefGoogle Scholar
  20. 20.
    Strecher VJ, Rosenstock IM. The Health Belief Model. In: Glanz K, Lewis FM, Rimer BK, editors. Health behavior and health education: theory, research and practice. San Francisco (CA): Jossey-Bass, 1997: 41–59Google Scholar
  21. 21.
    Prochaska JO. The transtheoretical model and stages of change. In: Glanz K, Lewis FM, Rimer BK, editors. Health behavior and health education: theory, research and practice. San Francisco (CA): Jossey-Bass, 1997: 60–83Google Scholar
  22. 22.
    LaRosa JH, LaRosa JC. Enhancing drug compliance in lipid-lowering treatment. Arch Fam Med 2000; 9: 1169–75PubMedCrossRefGoogle Scholar
  23. 23.
    Avorn J, Monette J, Lacour A, et al. Persistence of use of lipid-lowering medications. JAMA 1998; 279(18): 1458–62PubMedCrossRefGoogle Scholar
  24. 24.
    Guilbert R, Leduc N, Fournier P, et al. What factors determine whether individuals found to have hypercholesterolemia at mass screening accept advice to visit their physician. Public Health 1999; 113: 105–10Google Scholar
  25. 25.
    Sung JC, Nichol MB, Venturini F, et al. Factors affecting patient compliance with antihyperlipidemic medications in an HMO population. Am J Manag Care 1998; 4: 1421–30PubMedGoogle Scholar
  26. 26.
    Jackevicius CA, Mandani M, Tu JV. Adherence with statin therapy in elderly patients with and without acute coronary syndromes. JAMA 2002; 288(4): 462–7PubMedCrossRefGoogle Scholar
  27. 27.
    Kiortsis DN, Giral P, Bruckert E, et al. Factors associated with low compliance with lipid-lowering drugs in hyperlipidemic patients. J Clin Pharm Ther 2000; 25: 445–51PubMedCrossRefGoogle Scholar
  28. 28.
    Pettinger MB, Waclawiw MA, Davis KB, et al. Compliance to multiple interventions in a high risk population. Ann Epidemiol 1999; 9(7): 408–18PubMedCrossRefGoogle Scholar
  29. 29.
    Wannemacher J, Schepers GP, Townsend KA. Antihypertensive medication compliance in a Veterans Affairs healthcare system. Ann Pharmacother 2002; 36: 986–91PubMedCrossRefGoogle Scholar
  30. 30.
    Shaw E, Anderson JG, Maloney M, et al. Factors associated with noncompliance of patients taking antihypertensive medications. Hosp Pharm 1995; 30(3): 206–7Google Scholar
  31. 31.
    Brown CM, Segal R. The effects of health and treatment perceptions on the use of prescribed medication and home remedies among African American and white American hypertensives. Soc Sci Med 1996; 43(6): 903–17PubMedCrossRefGoogle Scholar
  32. 32.
    Glazer KM, Emery CF, Frid DJ, et al. Psychological predictors of adherence and outcomes among patients in cardiac rehabilitation. J Cardpulm Rehabil 2002; 22(1): 40–6CrossRefGoogle Scholar
  33. 33.
    Dusing R. Changes in antihypertensive therapy: the role of adverse effects and compliance. Blood Press 1998; 7: 313–5PubMedCrossRefGoogle Scholar
  34. 34.
    Feldman R, Bacher M, Campbell N, et al. Adherence to pharmacologie management of hypertension. Can J Public Health 1998; 89(5): I16–8PubMedGoogle Scholar
  35. 35.
    Small RE, Freeman-Arnold SB, Goode JV, et al. Evaluation of the total costs of treating elderly hypertensive patients with ACE inhibitors: a comparison of older and newer agents. Pharmacotherapy 1997; 17(5): 1011–6PubMedGoogle Scholar
  36. 36.
    Caro JJ, Speckman JL. Existing treatment strategies: does noncompliance make a difference?. J Hypertens 1998; 16 Suppl. 7: S31–4Google Scholar
  37. 37.
    Insull W. The problem of compliance to cholesterol altering therapy. J Intern Med 1997; 241: 317–25PubMedCrossRefGoogle Scholar
  38. 38.
    Caro JJ. Stepped care for hypertension: are the assumptions valid?. J Hypertens 1997; 15 Suppl. 7: S35–9Google Scholar
  39. 39.
    Rizzo JA, Simons WR. Variations in compliance among hypertensive patients by drug class: implications for health care costs. Clin Ther 1997; 19(6): 1446–57PubMedCrossRefGoogle Scholar
  40. 40.
    Mancia G, Failla M, Grappiola A, et al. Present and future role of combination treatment in hypertension. J Cardiovasc Pharmacol 1998; 31 Suppl. 2: S41–4PubMedCrossRefGoogle Scholar
  41. 41.
    Iskedjian M, Einarson TR, MacKeigan LD, et al. Relationship between daily dose frequency and adherence to antihypertensive pharmacotherapy: evidence from a meta-analysis. Clin Ther 2002; 24(2): 302–16PubMedCrossRefGoogle Scholar
  42. 42.
    Bailey JE, Lee MD, Somes GW, et al. Risk factors for antihypertensive medication refill failure by patients under Medicaid managed care. Clin Ther 1996; 18(6): 1252–62PubMedCrossRefGoogle Scholar
  43. 43.
    Ren XS, Kazis LE, Lee A, et al. Identifying patient and physician characteristics that affect compliance with antihypertensive medications. J Clin Pharm Ther 2002; 27: 47–56PubMedCrossRefGoogle Scholar
  44. 44.
    Rudd P. Compliance with antihypertensive therapy: raising the bar of expectations. Am J Manag Care 1998; 4(7): 957–66PubMedGoogle Scholar
  45. 45.
    Newell SA, Bowman JA, Cockburn JD. A critical review of interventions to increase compliance with medication-taking, obtaining medication refills, and appointment-keeping in the treatment of cardiovascular disease. Prev Med 1999; 29: 535–48PubMedCrossRefGoogle Scholar
  46. 46.
    Burke LE, Dunbar-Jacob JM, Hill MN. Compliance with cardiovascular disease prevention strategies: a review of the research. Ann Behav Med 1997; 19(3): 239–63PubMedCrossRefGoogle Scholar
  47. 47.
    McInnes GT. Integrated approaches to management of hypertension: promoting treatment acceptance. Am Heart J 1999; 138(3): S252–5CrossRefGoogle Scholar
  48. 48.
    Patton K, Meyers J, Lewis BE. Enhancement of compliance among patients with hypertension. Am J Manag Care 1997; 3 (11): 1693–8PubMedGoogle Scholar
  49. 49.
    Wilkening BJ. Patients’ and physicians’ assessment of risks associated with hypertension and benefits from treatment. J Cardiovasc Risk 1998; 5(3): 161–6CrossRefGoogle Scholar
  50. 50.
    Cramer JA. Consequences of intermittent treatment for hypertension: the case for medication compliance and persistence. Am J Manag Care 1998; 4(22): 1563–8PubMedGoogle Scholar
  51. 51.
    Mitka M. Cardiologists like statins: more than patients do. JAMA 2001; 286(22): 2799–800PubMedCrossRefGoogle Scholar
  52. 52.
    Applegate WB. Elderly patients’ adherence to statin therapy. JAMA 2002; 288(4): 495–7PubMedCrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2004

Authors and Affiliations

  • Robin S. Turpin
    • 1
  • Jeffrey B. Simmons
    • 1
  • Janice F. Lew
    • 1
  • Charles M. Alexander
    • 1
  • Marie A. Dupee
    • 1
  • Patricia Kavanagh
    • 1
  • Ellen R. Cameron
    • 1
  1. 1.Outcomes Research & ManagementMerck & Co., Inc.USA

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