The impact of non-adherence on cardiovascular disease treatments: higher costs and worse outcomes

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Cardiovascular

Cardiovascular

The impact of non-adherence on cardiovascular disease treatments: higher costs and worse outcomes

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Key Messages 

  • Medication non-adherence is pervasive and costly, with annual cost estimates totaling $290 billion and €1.25 billion in the US and Europe. 
  • Poor adherence to cardiovascular disease treatments is associated with worse outcomes, including increased risk of mortality, hospitalization and recurrent cardiovascular events.

 

Pharmacological treatments represent a significant opportunity area.

Medication adherence is a key factor for the effectiveness of pharmacological therapies, particularly for cardiovascular disease and other chronic conditions.1  Cardiovascular diseases are a global problem, and more than 80% of cardiovascular disease deaths occur in low- and middle-income countries.2  There is significant evidence demonstrating that pharmacological treatments improve cardiovascular outcomes, including reduced risk of costly acute events such as myocardial infarction, stroke and hospitalization.1 Nevertheless, non-adherence to cardiovascular disease treatments is pervasive.3

Treatment non-adherence is a global issue driving negative outcomes and increased costs.

Non-adherence to medications is associated with negative outcomes, including medical and psychosocial disease complications, reduced quality of life, and wasted healthcare resources.3

The magnitude of costs associated with non-adherence is staggering: annual cost estimates for the US and Europe total $290 billion and €1.25 billion, respectively.4  In the UK, non-adherence is believed to cost the NHS more than £500 million per year.5  Studies in the US indicate that medication non-adherence is the cause of 10% of hospitalizations and 23% of nursing home admissions in older adults, with the typical non-adherent patient requiring three extra medical visits per year and generating an additional $2000 in treatment costs per annum.4,6

Specific information on non-adherence in developing countries is not available; however, given that secondary prevention medicines are often difficult to access and afford in many of these countries, non-adherence trends, and thus healthcare utilization and cost, can reasonably be expected to be worse.2

Improving adherence to cardiovascular disease treatments would reduce disease costs.

Adherence to cardiovascular disease treatments is in line with global trends in other pathologies, and is estimated to be approximately 50%.9 Poor adherence to cardiovascular disease treatments is associated with worse outcomes, including increased risk of mortality, hospitalization or recurrent cardiovascular events.7  According to one estimate, 125 000 avoidable deaths occur each year due to poor adherence to cardiovascular disease treatment.6 Regarding costs, one study showed that patients who were nonadherent to statins  had total healthcare costs as high as $900 more and an increased likelihood of a related hospitalization compared to adherent patients.8  Likewise, adherence to statins has been shown to lower total healthcare costs, with increased medication costs offset by lower medical costs and lower risk of hospitalization.9  According to one estimate, improving patient adherence to statins in the U.S. could save the healthcare system more than $3 billion each year.8

"…non-adherence is the cause of 10% of hospitalizations and 23% of nursing home admissions in older adults, with the typical non-adherent patient requiring three extra medical visits per year and generating an additional $2 000 in treatment costs per annum."

Addressing cardiovascular disease indirect costs is a significant opportunity area.

Information on indirect costs both for cardiovascular diseases more broadly and for non-adherence specifically is limited; however, the trends are not positive. One study in the US calculated a 61% increase in indirect costs due to lost productivity associated with cardiovascular disease, from $172 billion in 2010 to $276 billion in 2030.10  The indirect cost burden is expected to be particularly high in developing countries, where working class populations are more affected by cardiovascular disease. For example, in Sub-Saharan Africa, half of cardiovascular deaths occur in the 30–69 years age group, at least ten years earlier than in developed countries.2 In Russia, cardiovascular disease is the leading cause of death for men aged 45 and older.11   While the economic impact has not been measured, the loss of someone who is often the family bread-winner can be devastating for the family and have implications for society as a whole.  Simple behavioral interventions that can alleviate cardiovascular disease symptoms and avoid complications therefore have significant potential to reduce indirect costs and improve quality of life.

 

Improving cardiovascular disease trends requires a comprehensive understanding of adherence drivers.

The magnitude of cardiovascular disease coupled with the negative impact of non-adherence demands a solution; at the same time, factors influencing adherence are multiple and complex. Initiatives to improve adherence must be rooted in a comprehensive understanding of the different adherence actors and their respective drivers. Physicians have a key role to play in affecting patient adherence – both to medication and to lifestyle recommendations.  In future articles we will examine in detail exactly what those behavioral drivers are and provide tools to healthcare professionals to help them “nudge” patient behavior towards adherence.  Just as physicians must make the proper clinical diagnosis and treatment decision, they can have a considerable impact on outcomes by making the right behavioral diagnosis and treatment choices.  This will be the objective of future articles.

References
1. Brown, Marie T, and Jennifer K Bussell. “Medication adherence: WHO cares?.” Mayo Clinic proceedings vol. 86,4 (2011): 304-14. doi:10.4065/mcp.2010.0575 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3068890/
2. Gheorghe, Adrian et al. “The economic burden of cardiovascular disease and hypertension in low- and middle-income countries: a systematic review.” BMC public health vol. 18,1 975. 6 Aug. 2018, doi:10.1186/s12889-018-5806-x
3. 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. https://apps.who.int/medicinedocs/pdf/s4883e/s4883e.pdf
4. Cutler, Rachelle Louise et al. “Economic impact of medication non-adherence by disease groups: a systematic review.” BMJ open vol. 8,1 e016982. 21 Jan. 2018, doi:10.1136/bmjopen-2017-016982 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5780689/
5. Taylor, Lynne. “Drug Non-Adherence.” PharmaTimes, PharmaTimes Media Limited, 19 Feb. 2013, www.pharmatimes.com/news/drug_non-adherence_costing_nhs_500m_a_year_1004468.
6. Lynch, Shalini S. “Adherence to Drug Treatment - Drugs.” MSD Manual Consumer Version, MSD Manuals, Aug. 2019, www.msdmanuals.com/home/drugs/factors-affecting-response-to-drugs/adherence-to-drug-treatment.
7. Kronish, Ian M, and Siqin Ye. “Adherence to cardiovascular medications: lessons learned and future directions.” Progress in cardiovascular diseases vol. 55,6 (2013): 590-600. doi:10.1016/j.pcad.2013.02.001
8. Pittman, Donald, et al. Adherence to Statins, Subsequent Healthcare Costs, and Cardiovascular Hospitalizations. The American Journal of Cardiology vol. 107,11(2011): 1662-1666. doi:10.1016/j.amjcard.2011.01.052. www.ajconline.org/article/S0002-9149%2811%2900465-6/fulltext#secd15069848e1078.
9. Iuga, Aurel O, and Maura J McGuire. “Adherence and health care costs.” Risk management and healthcare policy vol. 7 35-44. 20 Feb. 2014, doi:10.2147/RMHP.S19801
10. Heidenreich, Paul A., et al. “Forecasting the Future of Cardiovascular Disease in the United States.” Circulation, American Heart Association, vol. 123,8(2011): 933–944. doi:10.1161/CIR.0b013e31820a55f5. www.ahajournals.org/doi/full/10.1161/CIR.0b013e31820a55f5?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed&amp. 
11. Vyzhutovich, Valery. “Lawless Heart? Topic with Professor of the Russian Economic School Irina Denisova.” Russian Gazette, RGRU, Feb. 2019, rg.ru/2019/02/27/denisova-bolshe-50-smertej-v-rf-sviazany-s-zabolevaniiami-serdca-i-sosudov.html.