Can we improve adherence to preventive therapies for cardiovascular health?

Although mortality rates from cardiovascular disease (CVD) declined by 26% from 1995 to 2005,1 it remains the leading cause of death for US adults. The American Heart Association (AHA) set a 2020 impact goal to “improve the cardiovascular health of all Americans by 20% while reducing deaths from CVD and stroke by 20%.”2 To this end, the AHA recommended prevention as a first-line strategy and identified “life’s simple seven,”3 lifestyle behaviors and risk factors described in Table 1, which, if appropriately followed or adhered to, will improve cardiovascular health.2 Adherence refers to the extent to which patient behaviors align with clinical recommendations.4 The prevention behaviors offered by the AHA can be categorized as follows: (1) lifestyle behaviors, (2) screening, and (3) medication use. Lifestyle behaviors include a healthy diet, maintaining a healthy weight, engaging in physical activity, and not smoking. Screenings include those for blood pressure, lipid levels, and diabetes mellitus. Medication use refers to over-thecounter medications such as aspirin and prescription medications such as lipid-lowering agents and antihypertensive medications. Adherence to preventive therapies is suboptimal. For example, only 5% of adults engage in the recommended amount of physical activity.5 In comparison, about 43% of adults with a history of CVD or equivalent CVD risk take statins6 and 57% of adults 25 years old had their cholesterol tested at least once in the past 5 years.7 High-risk lifestyle behaviors are most prevalent in populations with limited income and education, ethnic/racial minority populations, and in low-income communities.8,9 The challenge is even more complicated because having multiple risk factors is common.10 A 2001 National Health Interview Survey reported a clustering of smoking, obesity, physical inactivity, and excessive alcohol intake (41% of US adults had 2 and 17% had 3).8 Increased adherence to preventive therapies would greatly improve cardiovascular health, leading to reduced health disparities and healthcare costs.11 Adherence to Preventive Therapies for Cardiovascular Health Is a Complex Process Influenced by Multiple Factors To improve adherence to preventive therapies, we must first understand the multiple levels that influence adherence. Within the healthcare system, adherence to preventive therapies is affected by patients, clinicians, and systems.12 The Expanded Chronic Care Model (ECCM), an adaptation of the original CCM, provides a helpful framework for understanding how to integrate healthcare system–based approaches with communitybased health promotion efforts.13 The CCM contains 4 components: (1) self-management, (2) delivery system design, (3) decision support, and (4) information systems. The ECCM added 3 components relevant to the community: (1) building public health policy, (2) creating supportive environments, and (3) strengthening community action (Figure 1). We review each of the components of the ECCM and provide examples of how they can be implemented to improve adherence to preventive therapies (Table 2). Self-management refers to an individual’s ability to manage their preventive health behaviors with an emphasis on building skills and capabilities. A successful selfmanagement program recognizes and addresses individual and social determinants affecting an individual’s ability to develop skills and capabilities and to perform behaviors. Individual determinants include psychosocial factors such as negative emotional states (eg, depression) and stressors that adversely affect the development of CVD, the prognosis of patients with CVD, and adherence to preventive therapies.14 Specific social determinants such as race, ethnicity, or educational level should be addressed in self-management programs by tailoring interventions to a specific group.15 Delivery system design involves expanding the focus of the healthcare system to support delivery of health care and health promotion in communities. The original CCM focuses on providing clinical care using a team-based approach and expanding care to include preventive behaviors. This approach uses clinicians with unique skills for addressing behavioral change, such as nutritionists, psychologists, and