Advertisement

Journal of General Internal Medicine

, Volume 28, Issue 5, pp 675–682 | Cite as

Key Barriers to Medication Adherence in Survivors of Strokes and Transient Ischemic Attacks

  • Ian M. KronishEmail author
  • Michael A. Diefenbach
  • Donald E. Edmondson
  • L. Alison Phillips
  • Kezhen Fei
  • Carol R. Horowitz
Original Research

ABSTRACT

BACKGROUND

Even though medications can greatly reduce the risk of recurrent stroke, medication adherence is suboptimal in stroke survivors.

OBJECTIVE

To identify key barriers to medication adherence in a predominantly low-income, minority group of stroke and transient ischemic attack (TIA) survivors.

DESIGN

Cross-sectional study.

PARTICIPANTS

Six hundred stroke or TIA survivors, age ≥ 40 years old, recruited from underserved communities in New York City.

MAIN MEASURES

Medication adherence was measured using the 8-item Morisky Medication Adherence Questionnaire. Potential barriers to adherence were assessed using validated instruments. Logistic regression was used to test which barriers were independently associated with adherence. Models were additionally controlled for age, race/ethnicity, income, and comorbidity.

KEY RESULTS

Forty percent of participants had poor self-reported medication adherence. In unadjusted analyses, compared to adherent participants, non-adherent participants had increased concerns about medications (26 % versus 7 %, p < 0.001), low trust in their personal doctor (42 % versus 29 %, p = 0.001), problems communicating with their doctor due to language (19 % versus 12 %, p = 0.02), perceived discrimination from the health system (42 % versus 22 %, p < 0.001), difficulty accessing health care (16 % versus 8 %, p = 0.002), and inadequate continuity of care (27 % versus 20 %, p = 0.05). In the fully adjusted model, only increased concerns about medications [OR 5.02 (95 % CI 2.76, 9.11); p < 0.001] and perceived discrimination [OR 1.85 (95 % CI 1.18, 2.90); p = 0.008] remained significant barriers.

CONCLUSIONS

Increased concerns about medications (related to worry, disruption, long-term effects, and medication dependence) and perceived discrimination were the most important barriers to medication adherence in this group. Interventions that reduce medication concerns have the greatest potential to improve medication adherence in low-income stroke/TIA survivors.

KEY WORDS

medication adherence stroke transient ischemic attack barriers 

Notes

Acknowledgements

We gratefully acknowledge the East and Central Harlem Community Action Board and the study participants for their generous contributions. Dr. Kronish received support from the National Heart, Lung and Blood Institute (K23 HL098359). Dr. Horowitz, Dr. Goldfinger and Ms. Fei received support from the National Institute of Minority Health and Health Disparities (P60MD00270), and Dr. Horowitz received funding from the National Center for Research Resources (UL1RR029887).

Conflict of Interest

The authors declare that they do not have a conflict of interest.

REFERENCES

  1. 1.
    Heron M, Hoyert DL, Murphy SL, Xu J, Kochanek KD, Tejada-Vera B. Deaths: final data for 2006. Natl Vital Stat Rep. 2009;57:1–134.PubMedGoogle Scholar
  2. 2.
    Sacco RL, Adams R, Albers G, Alberts MJ, Benavente O, Furie K, Goldstein LB, Gorelick P, Halperin J, Harbaugh R, Johnston SC, Katzan I, Kelly-Hayes M, Kenton EJ, Marks M, Schwamm LH, Tomsick T. Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the american heart association/american stroke association council on stroke: co-sponsored by the council on cardiovascular radiology and intervention: the American Academy of Neurology affirms the value of this guideline. Circulation. 2006;113:e409–449.PubMedGoogle Scholar
  3. 3.
    Rothwell PM, Algra A, Amarenco P. Medical treatment in acute and long-term secondary prevention after transient ischaemic attack and ischaemic stroke. Lancet. 2011;377:1681–1692.PubMedCrossRefGoogle Scholar
  4. 4.
    Bushnell CD, Zimmer LO, Pan W, Olson DM, Zhao X, Meteleva T, Schwamm L, Ovbiagele B, Williams L, Labresh KA, Peterson ED. Persistence with stroke prevention medications 3 months after hospitalization. Arch Neurol. 2010;67:1456–1463.PubMedCrossRefGoogle Scholar
  5. 5.
    Khan NA, Yun L, Humphries K, Kapral M. Antihypertensive drug use and adherence after stroke: are there sex differences? Stroke. 2010;41:1445–1449.PubMedCrossRefGoogle Scholar
  6. 6.
    Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353:487–497.PubMedCrossRefGoogle Scholar
  7. 7.
    Mann DM, Woodward M, Muntner P, Falzon L, Kronish I. Predictors of nonadherence to statins: a systematic review and meta-analysis. Ann Pharmacother. 2010;44:1410–1421.PubMedCrossRefGoogle Scholar
  8. 8.
    O’Carroll R, Whittaker J, Hamilton B, Johnston M, Sudlow C, Dennis M. Predictors of adherence to secondary preventive medication in stroke patients. Ann Behav Med. 2011;41:383–390.PubMedCrossRefGoogle Scholar
  9. 9.
    Chambers JA, O’Carroll RE, Hamilton B, Whittaker J, Johnston M, Sudlow C, Dennis M. Adherence to medication in stroke survivors: a qualitative comparison of low and high adherers. Br J Health Psychol. 2011;16:592–609.PubMedCrossRefGoogle Scholar
  10. 10.
    Cox AM, McKevitt C, Rudd AG, Wolfe CD. Socioeconomic status and stroke. Lancet Neurol. 2006;5:181–188.PubMedCrossRefGoogle Scholar
  11. 11.
    Stansbury JP, Jia H, Williams LS, Vogel WB, Duncan PW. Ethnic disparities in stroke: epidemiology, acute care, and post-acute outcomes. Stroke. 2005;36:374–386.PubMedCrossRefGoogle Scholar
  12. 12.
    Sacco RL, Boden-Albala B, Abel G, Lin IF, Elkind M, Hauser WA, Paik MC, Shea S. Race-ethnic disparities in the impact of stroke risk factors: the northern Manhattan stroke study. Stroke. 2001;32:1725–1731.PubMedCrossRefGoogle Scholar
  13. 13.
    Leventhalm H, Benyamini Y, Brownlee S, et al. Illness Perceptions: Theoretical Foundations. In: Petrie KJ, Weinman J, eds. Perceptions of Health and Illness. Amsterdam: Harwood; 1997:19–45.Google Scholar
  14. 14.
    Horne R, Weinman J. Patients’ beliefs about prescribed medicines and their role in adherence to treatment in chronic physical illness. J Psychosom Res. 1999;47:555–567.PubMedCrossRefGoogle Scholar
  15. 15.
    Goldfinger JZ, Kronish IM, Fei K, Graciani A, Rosenfeld P, Lorig K, Horowitz CR. Peer education for secondary stroke prevention in inner-city minorities: Design and methods of the prevent recurrence of all inner-city strokes through education randomized controlled trial. Contemp Clin Trials. 2012Google Scholar
  16. 16.
    Morisky DE, Ang A, Krousel-Wood M, Ward HJ. Predictive validity of a medication adherence measure in an outpatient setting. J Clin Hypertens (Greenwich). 2008;10:348–354.CrossRefGoogle Scholar
  17. 17.
    Krousel-Wood M, Islam T, Webber LS, Re RN, Morisky DE, Muntner P. New medication adherence scale versus pharmacy fill rates in seniors with hypertension. Am J Manag Care. 2009;15:59–66.PubMedGoogle Scholar
  18. 18.
    Holt EW, Muntner P, Joyce C, Morisky DE, Webber LS, Krousel-Wood M. Life events, coping, and antihypertensive medication adherence among older adults: the cohort study of medication adherence among older adults. Am J Epidemiol. 2012;176(Suppl 7):S64–71.PubMedCrossRefGoogle Scholar
  19. 19.
    Svarstad BL, Chewning BA, Sleath BL, Claesson C. The brief medication questionnaire: a tool for screening patient adherence and barriers to adherence. Patient Educ Couns. 1999;37:113–124.PubMedCrossRefGoogle Scholar
  20. 20.
    Furie KL, Kasner SE, Adams RJ, Albers GW, Bush RL, Fagan SC, Halperin JL, Johnston SC, Katzan I, Kernan WN, Mitchell PH, Ovbiagele B, Palesch YY, Sacco RL, Schwamm LH, Wassertheil-Smoller S, Turan TN, Wentworth D. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42:227–276.PubMedCrossRefGoogle Scholar
  21. 21.
    Safran DG, Kosinski M, Tarlov AR, Rogers WH, Taira DH, Lieberman N, Ware JE. The primary care assessment survey: Tests of data quality and measurement performance. Med Care. 1998;36:728–739.PubMedCrossRefGoogle Scholar
  22. 22.
    Stewart AL, Napoles-Springer A, Perez-Stable EJ. Interpersonal processes of care in diverse populations. Milbank Q. 1999;77:305–339. 274.PubMedCrossRefGoogle Scholar
  23. 23.
    Bindman AB, Grumbach K, Osmond D, Komaromy M, Vranizan K, Lurie N, Billings J, Stewart A. Preventable hospitalizations and access to health care. JAMA. 1995;274:305–311.PubMedCrossRefGoogle Scholar
  24. 24.
    Madden JM, Graves AJ, Zhang F, Adams AS, Briesacher BA, Ross-Degnan D, Gurwitz JH, Pierre-Jacques M, Safran DG, Adler GS, Soumerai SB. Cost-related medication nonadherence and spending on basic needs following implementation of medicare part d. JAMA. 2008;299:1922–1928.PubMedCrossRefGoogle Scholar
  25. 25.
    Banks JL, Marotta CA. Outcomes validity and reliability of the modified rankin scale: Implications for stroke clinical trials: A literature review and synthesis. Stroke. 2007;38:1091–1096.PubMedCrossRefGoogle Scholar
  26. 26.
    Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–383.PubMedCrossRefGoogle Scholar
  27. 27.
    Horne R, Weinman J. Patients’ beliefs about prescribed medicines and their role in adherence to treatment in chronic physical illness. J Psychosom Res. 1999;47:555–567.PubMedCrossRefGoogle Scholar
  28. 28.
    Sud A, Kline-Rogers EM, Eagle KA, Fang J, Armstrong DF, Rangarajan K, Otten RF, Stafkey-Mailey DR, Taylor SD, Erickson SR. Adherence to medications by patients after acute coronary syndromes. Ann Pharmacother. 2005;39:1792–1797.PubMedCrossRefGoogle Scholar
  29. 29.
    Phatak HM, Thomas J 3rd. Relationships between beliefs about medications and nonadherence to prescribed chronic medications. Ann Pharmacother. 2006;40:1737–1742.PubMedCrossRefGoogle Scholar
  30. 30.
    Bird ST, Bogart LM, Delahanty DL. Health-related correlates of perceived discrimination in hiv care. AIDS Patient Care STDS. 2004;18:19–26.PubMedCrossRefGoogle Scholar
  31. 31.
    Boarts JM, Bogart LM, Tabak MA, Armelie AP, Delahanty DL. Relationship of race-, sexual orientation-, and hiv-related discrimination with adherence to hiv treatment: a pilot study. J Behav Med. 2008;31:445–451.PubMedCrossRefGoogle Scholar
  32. 32.
    Casagrande SS, Gary TL, LaVeist TA, Gaskin DJ, Cooper LA. Perceived discrimination and adherence to medical care in a racially integrated community. J Gen Intern Med. 2007;22:389–395.PubMedCrossRefGoogle Scholar
  33. 33.
    Dailey AB, Kasl SV, Holford TR, Jones BA. Perceived racial discrimination and nonadherence to screening mammography guidelines: results from the race differences in the screening mammography process study. Am J Epidemiol. 2007;165:1287–1295.PubMedCrossRefGoogle Scholar
  34. 34.
    Kronish IM, Leventhal H, Horowitz CR. Understanding minority patients’ beliefs about hypertension to reduce gaps in communication between patients and clinicians. J Clin Hypertens (Greenwich). 2012;14:38–44.CrossRefGoogle Scholar
  35. 35.
    Johnson RL, Saha S, Arbelaez JJ, Beach MC, Cooper LA. Racial and ethnic differences in patient perceptions of bias and cultural competence in health care. J Gen Intern Med. 2004;19:101–110.PubMedCrossRefGoogle Scholar
  36. 36.
    Piette JD, Heisler M, Horne R, Caleb Alexander G. A conceptually based approach to understanding chronically ill patients’ responses to medication cost pressures. Soc Sci Med. 2006;62:846–857.PubMedCrossRefGoogle Scholar
  37. 37.
    Choudhry NK, Avorn J, Glynn RJ, Antman EM, Schneeweiss S, Toscano M, Reisman L, Fernandes J, Spettell C, Lee JL, Levin R, Brennan T, Shrank WH. Post-myocardial infarction free Rx event and economic evaluation (MI FREEE) trial. Full coverage for preventive medications after myocardial infarction. N Engl J Med. 2011;365:2088–2097.PubMedCrossRefGoogle Scholar
  38. 38.
    Gehi AK, Ali S, Na B, Whooley MA. Self-reported medication adherence and cardiovascular events in patients with stable coronary heart disease: The heart and soul study. Arch Intern Med. 2007;167:1798–1803.PubMedCrossRefGoogle Scholar
  39. 39.
    Rasmussen JN, Chong A, Alter DA. Relationship between adherence to evidence-based pharmacotherapy and long-term mortality after acute myocardial infarction. JAMA. 2007;297:177–186.PubMedCrossRefGoogle Scholar
  40. 40.
    Shi L, Liu J, Koleva Y, Fonseca V, Kalsekar A, Pawaskar M. Concordance of adherence measurement using self-reported adherence questionnaires and medication monitoring devices. PharmacoEconomics. 2010;28:1097–1107.PubMedCrossRefGoogle Scholar
  41. 41.
    Zhang Y, Baik SH, Chang CC, Kaplan CM, Lave JR. Disability, race/ethnicity, and medication adherence among medicare myocardial infarction survivors. Am Heart J. 2012;164:425–433. e424.PubMedCrossRefGoogle Scholar
  42. 42.
    Schoenthaler A, Chaplin WF, Allegrante JP, Fernandez S, Diaz-Gloster M, Tobin JN, Ogedegbe G. Provider communication effects medication adherence in hypertensive African Americans. Patient Educ Couns. 2009;75:185–191.PubMedCrossRefGoogle Scholar
  43. 43.
    Cutrona SL, Choudhry NK, Stedman M, Servi A, Liberman JN, Brennan T, Fischer MA, Brookhart MA, Shrank WH. Physician effectiveness in interventions to improve cardiovascular medication adherence: a systematic review. J Gen Intern Med. 2010;25:1090–1096.PubMedCrossRefGoogle Scholar
  44. 44.
    Ogedegbe G, Chaplin W, Schoenthaler A, Statman D, Berger D, Richardson T, Phillips E, Spencer J, Allegrante JP. A practice-based trial of motivational interviewing and adherence in hypertensive African Americans. Am J Hypertens. 2008;21:1137–1143.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2012

Authors and Affiliations

  • Ian M. Kronish
    • 1
    Email author
  • Michael A. Diefenbach
    • 2
  • Donald E. Edmondson
    • 1
  • L. Alison Phillips
    • 3
  • Kezhen Fei
    • 4
  • Carol R. Horowitz
    • 4
  1. 1.Center for Behavioral Cardiovascular HealthColumbia University Medical CenterNew YorkUSA
  2. 2.Department of UrologyMount Sinai School of MedicineNew YorkUSA
  3. 3.Department of PsychologyThe George Washington UniversityWashingtonUSA
  4. 4.Department of Health Evidence and PolicyMount Sinai School of MedicineNew YorkUSA

Personalised recommendations