Can compliance with nonpharmacologic treatments for cardiovascular disease be improved?

doi:10.1016/S0749-3797(99)00157-9

American Journal of Preventive Medicine

Volume 18, Issue 3, April 2000, Pages 253-261

https://doi.org/10.1016/S0749-3797(99)00157-9 Get rights and content

Abstract

Objective: To critically review the literature regarding the effectiveness of interventions aimed at improving cardiovascular patient compliance with nonpharmacologic treatments.

Methods: We searched Medline, Healthplan, and Psychlit from 1985 to 1996; searched the bibliographies of located studies; contacted Australian government departments and nongovernment organizations; and two experts examined the resulting study list. We selected 27 studies, which randomly allocated patients to groups and were published in English, and we evaluated interventions aimed at increasing compliance with nonpharmacologic treatments for cardiovascular disease. These trials were critically appraised against eight methodologic criteria and, subsequently, classified as of good, fair, or poor quality. Information about target groups, samples, trial intervention strategies and their effectiveness were extracted from the 18 good- and fair-quality trials. Interrater reliability was high on the 20% of references that were double-coded.The 18 studies reviewed described the effectiveness of 27 intervention strategies at improving compliance with dietary, smoking-cessation, exercise, weight-loss, stress-reduction, general lifestyle, relaxation, and blood pressure screening programs.

Results: Tentative recommendations were made for or against most trial strategies: partner-focused and structural strategies showed the most consistent benefits, physician-focused strategies were unanimously unsuccessful, and patient-focused strategies were of mixed benefit.

Conclusions: The methodologic quality of many of the located trials was less than optimal. Therefore, further good-quality, randomized trials are necessary to clarify the effectiveness of those strategies identified as potentially useful in this review.

Introduction

M any factors have been linked to low compliance with cardiovascular treatments, including various patient, physician, disease, treatment, setting and patient–physician relationship characteristics.1, 2, 3 Consequently, various interventions have been developed and tested to counteract these factors and to maximize patient compliance with recommended treatments.4, 5, 6 Although the results of these trials are somewhat varied, a consensus appears that multiple-strategy interventions are more effective than single-strategy interventions at increasing compliance, especially with long-term treatments.3, 5, 6, 7, 8, 9 However, little evidence indicates whether all strategies of these complex interventions are required or which, if any, are the most effective. Similarly, many of the trials conducted, and included in subsequent literature reviews, have not been randomized trials, making it difficult to draw firm conclusions from either the studies or the reviews.4, 6, 10 Furthermore, most of the more rigorous reviews of this literature were conducted some time ago, leading to questions about current relevance.1, 5, 11

Therefore, this review aimed to summarize the recent literature regarding the effectiveness of individual intervention strategies, whether trialed alone or as part of complex interventions, at increasing cardiovascular patient compliance with nonpharmacologic treatments.

Section snippets

Data sources

Medline, Healthplan, and Psychlit were searched, from January 1985 to March 1996, for English-language papers including the terms “cardiovascular or heart or hypertens∗” and “interven∗ or study or trial∗” and “patient-compliance” in Medical Subject Headings (MeSH). The resulting large number of citations (1310) was subsequently searched manually for articles investigating interventions to increase cardiovascular patient compliance with nonpharmacologic treatments or reviews of such studies. The

Coding quality assurance

Two independent reviewers assigned identical quality-classification codes for seven of the eight papers double-coded, giving a kappa of 0.82. There was also almost total agreement regarding the sample, intervention, and results information extracted from the included studies.

Study quality and inclusion

A total of 29 potentially relevant intervention studies were located.12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40 Of these, five (17%) nonrandomized

Discussion

This review aimed to critically summarize the evidence and make recommendations regarding the effectiveness of intervention strategies aimed at increasing patient compliance with nonpharmacologic treatments for cardiovascular disease. Unfortunately, the ability to make strong recommendations was hampered by a number of limitations within the studies located.

Supplementary data

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Eleven studies were identified, including 6 RCTs and 5 non-RCTs. The methodological quality of included RCTs was low. There was a moderate improvement in pain (standardized mean difference [SMD]=.52; 95% confidence interval [CI], .14–.89; P=.007; 284 participants) in favor of wearing a brace compared with not wearing a brace for the immediate, within-group comparison. There was a moderate improvement in pain (SMD=.61; 95% CI, .33–.89; P<.001; 206 participants) and a small to moderate improvement in self-reported physical function (SMD=.39; 95% CI, .11–.67; P=.006; 206 participants) in favor of patients receiving a soft brace versus standard care for the prolonged effect, between-group comparison.
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¹: The full text of this article is available via AJPM Online at http://www.elsevier.com/locate/ajpmonline.

²: This review was undertaken on behalf of and funded by the National Heart Foundation of Australia. The authors would like to thank Professor Brian Haynes and Dr. Denise Ruth for reviewing the list of located studies, Kathy Rainbird for double-coding references, Rosemary Omwandho for tirelessly tracking down the numerous references, Anna Di Legge for her substantial assistance with preparing earlier versions of this manuscript, and the many individuals and organizations that assisted in the search for studies.

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Review and Special ArticlesCan compliance with nonpharmacologic treatments for cardiovascular disease be improved?22

Abstract

Introduction

Section snippets

Data sources

Coding quality assurance

Study quality and inclusion

Discussion

Supplementary data

Int J Cardiol

Patient Educ Couns

Patient Educ Couns

J Pediatr Health Care

Prev Med

Soc Sci Med

Am J Prev Med

Am J Prev Med

Patient Educ Couns

Behav Ther

Addict Behav

Prev Med

Am J Prev Med

Compliance in health care

Do we know how to influence patients’ behaviour? Tips to improve patients’ adherence

Fam Pract

A meta-analysis of the effects of psychoeducational care in adults with hypertension

Nurs Res

Optimizing long-term patient compliance

Neurology

Compliancemeasurement and intervention

Curr Opin Psychiatr

Programs to reduce drug errors in the elderlydirect and indirect evidence from patient education

J Geriatr Drug Ther

A comparison of nursing interventions for smoking cessation in adults with cardiovascular health problems

Heart Lung

Review and Special Articles
Can compliance with nonpharmacologic treatments for cardiovascular disease be improved?² ²