Patient expectations on lipid-lowering drugs

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Abstract

Objective

The objective of this study was to assess expectations of effect when using statins in a treatment population. Further the aim was to examine factors, including history and concurrent risk of coronary heart disease, associated with a higher and lower treatment belief.

Methods

Eight hundred and twenty-nine (829) Swedish patients using statins completed postal questionnaires about their health, life style, cardiovascular risk factors and expectation of the treatment. Expected treatment benefit was used as outcome measurement.

Results

A medical history of coronary heart disease did not affect treatment expectations. Patients with a high risk of cardiovascular disease reported a slightly lower expectation of the treatment effect at a 10-year perspective (p < 0.01) but not at shorter time perspectives. Low satisfaction with the explanation of the purpose of the treatment and a poor perceived control of own health was associated with a more negative view on treatment benefit.

Conclusion

The rationale applied by physicians prescribing statins does not seem to relate to the patients’ expectations, whereas factors relating to the patient–physician relationship, the social situation and the perceived control of health seem to affect patient belief.

Practice implications

The association between patients’ poor satisfaction of treatment explanation and a low belief in treatment benefits emphasizes the importance of the patient–physician communication. It is suggested that clinical tools are developed in order to identify patients with poor belief in treatment benefit since tailored education for this group might reduce the risk of non-compliance and subsequently reduce the risk of coronary heart disease.

Introduction

Cardiovascular disease is a major cause of mortality and morbidity in most Western countries, which to a high degree is believed to be avoidable [1]. Several large randomized studies have documented that the use of lipid-lowering therapy with statins (hydroxymethylglutaryl-CoA reductase inhibitors) reduces the risk of coronary events over a wide range of cholesterol levels and in different populations [2], [3]. There is consistent evidence that patients with a previous history of coronary heart disease (CHD) are those most likely to benefit, whereas the effect in the primary prevention of CHD is less effective [4]. Current treatment guidelines stress the importance of a multi-factorial risk assessment and risk reducing interventions particularly in high-risk patients (secondary prevention) where there is a high likelihood of benefit of the treatment, rather than treating single risk factors where the overall risk is estimated to be low [5], [6], [7], [8]. According to the third Report of National Cholesterol Education Program (NECP III) the population eligible for treatment is considerably altered due to new LDL-cholesterol target levels.

It is demonstrated that the long-term adherence to statin treatment, as for most chronic and life-long treatments, is poor and substantially declining over time [9], [10].

Although good data exist on treatment effect based on the results in clinical trials, there is no definite way to predict the preventive effect in a single patient event although measurable effect on surrogate measurements, such as laboratory samples, is good. The treatment decision is, therefore, initiated on the assumption that the use of a drug might avoid or delay a cardiovascular event and that this positive effect exceeds the potential adverse effects that might follow treatment. The patients’ trust in the treatment's capability to improve or maintain health is believed to be a factor crucial to long-term compliance [11], [12].

There is a general lack of awareness of cardiovascular risk factors in different European populations [13], [14]; patients and doctors have different perceptions of the risk of cardiovascular disease [15], which might lead to a sub-optimal physician–patient communication [16]. Patients want to be involved in treatment decisions and informed about treatment alternatives [17] and it is shown that patients’ motivation to take a medication depends on several factors. These include patient attitudes and understanding of the disease and its long-term effect on well-being [11], [18], concurrent other medication [19], the presence of cardiovascular risk factors, the patients’ belief when the treatment is considered necessary [20] as well as the effect of the drug on surrogate measurements such as serum cholesterol levels [21], [22].

Patients seem to have difficulty interpreting the preventive effect when it is described in absolute or relative terms [23], [24]. Moreover, evidence suggests that the terms used to communicate the treatment benefits of a drug affect the prescribing situation; the willingness among general practitioners to recommend a lipid-lowering drug in a hypothetical case largely depends on how the efficacy in terms of risk reduction is presented [25].

Several factors, including knowledge, attitudes and expectations, affect both the doctors’ willingness to recommend a lipid-lowering treatment and the patients’ motivation to follow the advice. However, published data are limited on what patients expect from their treatment in terms of benefit and what influences belief in preventive pharmacological treatment despite its hypothesized essential impact on adherence.

The aim of this cross-sectional study was to investigate expectations on statin treatment and factors that are associated with a higher and lower treatment expectation. One main objective was to investigate whether a history of ischemic heart disease and a higher risk of future ischemic heart disease (by means of concurrent risk factors) affect the patient's confidence in the treatment benefits.

Section snippets

Methods

A total of 1000 postal questionnaires were distributed the 27 of May 2004 to every pharmacy (n = 59) within the two nearby counties of Uppsala and Gävleborg in central Sweden. All questionnaires included in the analysis were returned within a month. The number of questionnaires distributed was proportional to the prescription turnover at each pharmacy. The pharmacists were instructed to invite every patient consecutively who visited the pharmacy to have their prescription for a statin prepared.

Results

The average age of the study population was 64.9 years (S.D. 9.7) and consisted of slightly more men (54.0%) than women (46.0%). In the total group 60.3% of patients did not report a medical history of ischemic heart disease (myocardial infarction or angina), therefore receiving their treatment as primary prevention of cardiovascular disease. Thus, the corresponding figure for secondary preventive treatment was 39.7%. Significantly more women than men had no history of CHD and were, hence,

Discussion and conclusion

The main purpose of this study was to assess treatment expectations in patients using statins and factors that might influence this. The aim was to examine both the overall expected effect in a treated population as well as the perceived likeliness of an individual benefit. One of the principal questions was to explore whether a history of ischemic heart disease and the individual risk status affects patient expectations.

Conflict of interest

None.

Acknowledgements

We would like to acknowledge the National Corporation of Swedish Pharmacies and the staff at the pharmacies in Uppsala and Gävleborg for their assistance with the distribution of questionnaires and Gunilla Burell and Lars Nilsson for valuable reflections on the late version manuscript. We are also grateful to all the respondents for sharing their views about their health and health beliefs.

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