Noncompliance factors of congestive heart failure patients readmitted in cardiac care units

Transcription

1 Iranian Journal of Critical Care Nursing Fall 2009, Volume 2, Issue 3; Noncompliance factors of congestive heart failure patients readmitted in cardiac care units Hekmatpou D. 1 PhD, Mohammadi E. * PhD, Ahmadi F. 2 PhD, Arefi S. H. 3 MD * Department of Nursing, Faculty of Medical Sciences, Tarbiat Modarres University, Tehran, Iran; 1 Department of Nursing, Faculty of Nursing & Midwifery, Arak University of Medical Sciences, Arak, Iran; 2 Department of Nursing, Faculty of Medical Sciences, Tarbiat Modarres University, Tehran, Iran; 3 Department of Cardiovascular Diseases, Tehran University of Medical Sciences, Tehran, Iran Abstract Aims: Noncompliance of cardiac patients is one of the most important challenges in controlling the cardiac diseases and readmission in cardiac care units. This study was performed to explore the compliance concept and effective factors on occurring noncompliance in readmitted patients with congestive heart failure. Methods: Using qualitative research, 42 CHF patients with readmission during 6 months (November 2007 until April 2008) were interviewed in two educational hospitals affiliated to Tehran University of Medical Sciences. Data were analyzed based on content analysis method. Results: Doing any unscientific action for establishing wellbeing is the meaning of compliance in patients; whereby the patients applied it as a strategic solution for resolving their main concern providing comfort in daily life. Primary codes revealed three themes of preventive factors related to the patient and his/her family, preventive factors related to treatment and medical team and preventive factors related to socioeconomic problems as effective factors on occurring noncompliance which were the main causes of non-compliance in CHF patients. Conclusion: By applying qualitative research the compliance definition and noncompliance predisposing factors are revealed more completely. Defining the meaning of compliance and effective factors on noncompliance in patients should be considered before discharge in order to prevent readmissions. Keywords: Congestive Heart Failure, Non Compliance, Qualitative Study Introduction Compliance is a part of individual behavior which is concordant with care instructions and suggestions [1]. Compliance in the field of health care is often associated with the individual s ability in maintaining behaviors in association with care plan and includes complete use of drugs, on time presence in the pre-set programs, following up of disease and making necessary changes in health behaviors; otherwise, there will be no compliance. In fact, noncompliance is a voluntary and conscious decision by which patient does not follow or obey professional instructions of the therapist [2]. Lehane and McCarthy believe that despite abundant researches in the past five decades concerning compliance, little progress has been made in solving this health problem. They pointed out that 30 to 50% of medications are not used according to prescription, and this has led to lack of drugs effectiveness along with adverse outcomes and increased health care costs [1]. Ulfvarson et al. said that drug noncompliance leads to treatment inefficacy and increase in risk of recurrence, pain and unwanted suffering and increase of costs. They declared, by investigating 200 patients in the internal ward with average drug number of 7 per day, that only 30% of patients have drug compliance [3]. Congestive heart failure (CHF), a progressive cardiac disease that accompanies with cardiac dysfunction, salt and water retention and peripheral circulatory disorders, has affected more than a million elderly adults in the United States [4]. Congestive heart failure s treatment is complicated and varied, and patients should daily take a large number of drugs that this issue increases the complexity of the treatment [5]. Mac Murray avows that despite recent improvements in medical treatments, yet, the prevalence of CHF is increasing [6]. Cardiovascular diseases are considered the first death-leading cause in Iran. On the other hand, it is estimated that the number of patients with congestive heart failure is almost 3500 people per hundred thousand. This disease is a single cardiovascular disease which is increasing in terms of incidence and prevalence [7]. In Iran, cardiovascular disease, especially congestive heart failure is prevalent and based on existing findings the rate of noncompliance in patients which is high. Parsa-Yekta et al. found, by studying 150 patients with coronary heart disease, that only 28% of patients follow the prescription [8]. Abbasi et al. studied 380 patients with hypertension * Correspondence; emohamadus@yahoo.com Received 2009/11/29; Accepted 2010/01/21

2 Non-compliance factors of congestive heart failure patients readmitted in cardiac care units and claimed that the compliance and following the low-fat and low-salt diet is weak in 40% of patients [9]. Due to diuretics use, patients suffering from congestive heart failure should show serum sodium and potassium decrease, but this rate is high in most patients, which implies the noncompliance and disobeying physician s order for diuretics [10]. Use of tobacco, alcoholic beverages, tea, and stress at home and work place in patients with acute MI is significantly higher than control group (p<0.05) which shows noncompliance in lifestyle improvement [11]. Various forms of noncompliance (medical, diet and lifestyle) and its prevalence in patients with heart disease has been noted and studied, but the meaning of noncompliance and effective factors among involved individuals has rarely been considered in Iran and other countries simultaneously from the viewpoint of individuals live experiences (including patients, families, doctors and nurses). This study was conducted with the aim of explaining the definition of compliance and factors affecting noncompliance among patients with congestive heart failure who are repeatedly readmitted for severe dyspnea and lower limbs edema in critical units such as cardiac care units. Methods In this theoretic study, the concept of compliance and factors that affect noncompliance in patients with congestive heart failure and the interactive and social nature of compliance concept were analyzed using qualitative methods along with content analysis approach by approval of research and ethics committee of Tarbiat-Modarres University s School of Medical Sciences [12, 13]. All interviews were recorded after obtaining written consents and sampling was done with purposive method. 17 patients, 7 family members, 10 nurses and 8 cardiologists were interviewed during 6 months (November 2001 till March 2008) for collection of rich and relevant data. Research was performed in two educational hospitals affiliated to Tehran University of Medical Sciences. Selection of two places for the research can increase the quality and depth of research findings. After explaining the aim of research for participants of the study, the interview was conducted by mutual conversation method. The duration of interviews with family members, nurses and physicians was about 60 minutes and about 30 minutes with patients. Performance of nurses and physicians during morning shifts was observed. All observations were recorded for further use. Data saturation occurred after the 40th participant interview, but data collection and analysis continued till new information was not obtained from interviews and existing data. Data analysis was done simultaneously and continuously, so that each interview was typed word by word, reviewed and codified and then the next interview was done. In coding, conceptual units were extracted from participants speech and expressions which indicated their experiences. Then the codes which were expressing a single subject based on similarity and proportion were put in a category or class, and categories and subcategories were compared. More abstract contents or compartments were extracted [13]. Reminders were used for completing the categories and permanent analysis process of data, and multiresources data collection was used in order to achieve data accuracy. Also, in order to increase the validity of codes, all content of interviews and categories list were reviewed by other colleagues and due to control process by other members, the initial coding of each interview in the early stage of analysis were returned to the interviewee to confirm its correctness or inaccuracy and if confirmed, codes were known as valid and the codes which did not express their point of view, were revised. Sampling with maximum variance (selection of subjects from two specialized hospitals with various participants in terms of age, sex; experience, cultural, economical and social level, etc.) along with theoretical sampling led the credit to be increased. On the other hand, the validity of findings was confirmed by giving various categories to some faculty members and comparing their opinions and interpretations, which showed high agreement. Results 512 initial codes was obtained from the total 42 interviews based on content analysis of the data which were achieved through interviews and in the field notes, and considering overlapping of the codes and their merging, 45 codes were produced. In the analysis process, these codes formed 3 contents that included Hindering factors related to patient and family, "Hindering factors related to treatment and care team, "Hindering economical and social factors as the reasons of noncompliance (figure1).

3 Hekmatpou D. et al. Compliance (any unscientific action that support the sense of wellbeing by patient) Hindering economical and social factors Hindering factors related to treatment and care team Hindering factors related to patient and family Medication, food noncompliance and lack of lifestyle improvement Readmission of patient in cardiac care units Figure 1- The concept of compliance, the factors which affect noncompliance and its outcomes in patients with congestive heart failure Also, the concept of compliance for these patients was any unscientific action that helps individual to experience the sense of wellbeing in everyday life. Patients sought and defined compliance in any attempt and taking any unscientific action and behavior which creates the sense of wellbeing, joy and cheer. The main concern and trouble of patients with congestive heart failure was how to provide comfort in their daily life and that in any way, remove the problems and acute complications of the disease which cause the loss of this feeling in them. In this regard, all of their efforts and behaviors such as referring to physicians and probably hospitalization and disobeying the orders, resorting to other physicians, self-treatment and using local and traditional methods could be justified and explained in relation to attempt or seeking the sense of wellbeing (patient 11: I gave up my medications. I did not care their stopping. One time I prepared them again, but I quit after 2 or 3 months Instead, I took opium by this way I felt better and regained my energy. a) Hindering factors related to patient and family: the codes associating with this content were more related to the behavior of patients and sometimes their family and close friends and included indifference toward the noncompliance issue, lack of knowledge, selftreatment, inappropriate lifestyle, mental and emotional problems that all participants of the research acknowledged their existence. Indifference to subject of noncompliance was acknowledged by all participants in the study so that all of them emphasized the existence of this indifference and considered it as an important factor in readmission (Patient 5: I do not like to be worried or bound up with something. It did not matter to be hospitalized I did not go on a diet or avoid anything... I didn t care observation or following any diet, I did not like to take all medications. When my feet were swollen I referred to hospital for it, I knew that I did not comply. Doctor 4: that patient has been hospitalized several times in since all patients are not bound to following treatment comments, they don t care about the issue being indifferent toward compliance has been an ordinary habit for them). medication noncompliance due to getting tired from drug use, insistency in complete eating of tablets, taste use of medications, forgetting (deliberate or unintentional) of drug use, etc. were among very important codes which were confirmed and mentioned by all participants of the study ( patient13: I didn t take my tablets correctly, I stealthy didn t eat some pills and told my daughter that I ve taken them; I was tired of taking the pills...i have taken pills for years, I'm tired, I cannot easily swallow the pills and this is why I simply evade from taking the pills). Self-treatment due to wrong conception about drugs and treatment, expectations that are far from mind and wrong behaviors were confirmed as the most important reasons for noncompliance in this study, so that patients follow the sense of wellbeing for themselves and provide comfort in their daily life (physician 6: the patient do not take the pills or she/he

4 Non-compliance factors of congestive heart failure patients readmitted in cardiac care units thinks or imagines that these are the pills that worsen her/his condition; he stops them all and may take Valerian). Mental and psychological problems in the form of depression, hopelessness of definite treatment of disease and feeling of weakness due to disease have caused noncompliance and also lack of patient cooperation with treatment team. On the other hand, the family is under a doubled pressure, too, and because of abundant problems may be affected by depression and do not cooperate with the patient (patient 10: I do not have any hope for future...they told me that we cannot do anything for you anymore. I am tired of treatment, how many tablets should I take... I do not like to continue treatment, I do not want to pay out anymore; doctor4: patient s family becomes very tired and suffers from the overload in life and for patient s family it is a misery and tragedy which continues until discharge time; sometimes family members also suffer from depression. b) Hindering factors related to treatment and care team: various drugs prescription, prescribing of high doses of medication regardless of patient s condition and diet and lifestyle modification, were the codes related to treatment content of this disease that participants often stated. Most patients complained of excessiveness of drugs and thought that if the drugs were finished, they will feel better, but it was not as this way and for this reason they evaded from the continuation of the treatment; also, diet modification and lifestyle adjustments which are the requirements of CHF treatment were not pleasant for them either and this made them disobey treatment orders (physician7 : patients medications have different doses; so, high doses and the great number of pills cause noncompliance in them ; doctor 5: patient thinks that after taking e.g. 200 tablets he has become better and so does not continue his treatment...they think that their treatment is completed and their course has been over). Inefficacy of treatment and referring to different doctors, repeated visits by various physicians and the incidence of drug interferences, were admitted by all participants of the study and considered it very important in patients noncompliance (doctor 4: unfortunately referring to several doctors is very frequent in Iran; since patients are free and can refer to anywhere they want of course because they remain futile and have various medication bags, they confuse the drugs). c) Hindering economic and social factors: All participants especially patients and their families acknowledged the presence of severe economical problems and the lack of sufficient social support in society and as a result, disability in preparing and purchasing cardiac drugs and necessary equipment (patients 7, 8, 10 and 11: due to financial difficulties I did not follow up my treatment, I did not buy drugs ; attendant 5: we are on the fourth floor, we don t even have oxygen capsule more importantly our financial situation is not so satisfactory for continuing all therapeutic orders.) Discussion Studied patients of this study, due to poor knowledge and lack of self-care and the noncompliance issue being normalized, avoided from medication and food compliance, exercise and activity to usual extent. They believed more in self-treatment for creating the sense of wellbeing. They acknowledged that opium and nutrient foods give them the sense of wellbeing. They reduced or stopped medication willingly and sometimes increased it and did not observe salt confinement. These measures may be not based on scientific documentation and physician orders and do not create the short term effects of sense of wellbeing, but ultimately and in the long run can cause many negative and unwanted consequences including readmission. This definition of compliance differs from that of literature and clinic. For Bennett complete and correct compliance or devotion of pharmaceutical and food diet is the essential part of self management in CHF that can lead to longer life and reduction of readmission and promotion of the quality of life [5]. Based on the obtained data from this study, numerous factors affecting noncompliance such as indifference toward noncompliance consequences, lack of knowledge, self-treatment, and mental and emotional problems of patients and families are more related to the patient himself that corresponds with the results of previous researches. Researches have shown that patients who are confronted with various obstacles, such as lack of social support, less follow their care programs [15]. Indifference toward the consequences of noncompliance had been due to negative attitude of patient towards medications and believing in their ineffectiveness and this challenge has been mentioned in a descriptive study in Iran. Parsa Yekta et al. reported after studying 150 patients that the rate of positive attitude toward taking medications in 48.61% of patients is weak and 62.83% have negative attitude toward medications [8]. The Lack of knowledge and noncompliance about food and medications due to dietary habits, insistency, getting tired of limitations etc. also were observed in the findings of the present

5 Hekmatpou D. et al. study which correspond with those of other studies. Lennie et al. in their study on 145 patients with CHF reported that only 25% of patients obey their prescribed diet [16]. Also, eating without observing any diet and medication noncompliance make the condition of CHF patients more serious and this can be due to insufficient knowledge of patient [17]. Studied patients with congestive heart failure are aware of the benefits of low sodium diet but insipidity of low-salt food is the main cause of noncompliance [5]. According to the results of the study by Farahani et al. salt and fat intake among heart patients is high due to food habits and patients believe that opium use is effective on disease treatment and developing a sense of wellbeing can also control their stress [18] which is consistent with the results of this study. In this study, self-treatment was done due to acquaintances and friends' recommendations and often patients themselves, and it was due to considering the illness unimportant, lack of sensitivity to repeated hospitalization and indifference toward noncompliance from therapeutic orders. In fact, patients attempted to use opium by this belief that this measure will result in providing the sense of wellbeing in them. 83.3% of patients hospitalized in cardiac wards, perform self-treatment and this is due to being indifferent to noncompliance [19]. Despite the depression and lack of family support, patient does not obey therapeutic instructions; in this study, also, for above mentioned reasons, patients did not obey therapeutic orders and sometimes clearly expressed their lack of cooperation. Van Der Wal et al. after studying 954 patients suffering from congestive heart failure put down that these patients have depression symptoms and patients with depressive signs and low awareness face more barriers for compliance from therapeutic recommendations in congestive heart failure [20]. Content analysis showed that prescription of various drugs and high dose of drugs regardless of patients' condition, were of undeniable factors of the noncompliance, which is consistent with results of similar studies. Mac Murray believes that the reasons of the failure in CHF treatments, including prescription of drugs lower than the required level or vice versa, excessive prescription of drugs, fearing the complications treatment, weak medication compliance and drug complications [6]. Shirafkan et al. acknowledge by studying 145 patients that inappropriate medical treatment regardless of patient's condition, with 75.8%, is the most common aggravating cause of CHF [21]. Patients of the present study admitted that prescription of excessive medications and various kind of pills regardless of patient s condition (age, willingness to use, the ability of eating pills, sensory disturbances such as visual weakness and amnesia and limitations of diet in congestive heart failure etc.) caused the lack of compliance that has been reported in the results of Farahani et al. [18]. On the one hand, participants of the study confirmed the uselessness of referring to primary physician and repeatedly referring to several physicians with different scientific experience levels and increase in probability of drug interference, lack of training the patient by health care team and not making patient ready for self-care after discharge. All these factors greatly confused patients and families and reported as the causes of noncompliance that is confirmed by findings of other studies. Cortis et al. found that patients with congestive heart failure, have the least understanding of the heart failure and selfcare, and even many of them relate their disease symptoms to old age and believe that they cannot do anything for these symptoms [22]. Shidfar et al. by conducting an interventional study on 180 patients with heart disease found that willingness to selftreatment (stopping medications) due to fear of unpleasant side effects of drugs and lack of knowledge is evident [23]. Khosravi et al. who studied 200 patients with heart disease believe that less than half of CHF patients take medication while 87.5% of them are under physician's surveillance; on the one hand, only 25% of these patients take their drugs regularly [24]. In the mentioned studies incomplete duty performance of health care team in preparation of patient for obeying therapeutic orders and continuity of self-treatment are clearly acknowledged, which these results have also been confirmed by this study. Content analysis showed that all participants especially patients and their families acknowledged severe economic problems and lack of sufficient social support and thus the inability to prepare and buy cardiac medications, incomplete buying of the prescribed drugs, lack of care facilities outside the hospital and low quality of life, which all caused noncompliance in the studied patients and their repeated hospitalization. These findings are confirmed by other studies. Dabbagh et al. estimate the hospitalization cost of 384 patients with heart disease in 2004 equal to 400 billion Rials, which imposes high economical pressure on family and society [25]. In a descriptive-analytical study by Schwarz and Elman on 156 patients and their caregivers with an interview in the seventh to tenth day after discharge from the hospital, numerous patients and families due to needing help, were suffering from stress. On the other

6 Non-compliance factors of congestive heart failure patients readmitted in cardiac care units hand, the high age of patients and their cognitive and functional disorders lead to increase in family and caregivers' burden [26]. Rahnavard et al. report after studying the quality of life of 184 patients with CHF, that the maximum percentage of given units had poor life quality in physical (44.6%), psychological (47.3%) and economic-social (49.5%) dimensions [27]. Shojai et al. concluded after studying 250 patients with CHF, that only 23.6% of them have good quality of life [28]. These results show that most patients with congestive heart failure and their families are not in good and eligible condition in terms of socio-economical status and spending and continuity of the treatment. Since in this study the experiences of hospitalized patients and employed persons in private or charity hospitals have not been considered and other points or categories may be expressed with regard to the special culture and condition of these patients and treatment team, this issue is considered as the limitation of the study. Conclusion The difference in compliance definition by patients and treatment team, and disposing factors for noncompliance are more completely manifested by a qualitative study and in depth and concurrent investigation of patients, their families, nurses and physicians, so that understanding and the insight toward these factors and knowing the concept of compliance among patients, namely self-treatment for sense of wellbeing can be considered as the foundation of decision making and care planning and therapeutic strategies for solving this health problem, reduction of readmission rate in critical wards such as cardiac care units and preparing patients and their families for self-treatment. Acknowledgement: Researchers consider it necessary to express their appreciation and gratitude to all participants of the study who delivered their experiences sincerely, and director of studied educational hospitals and Medical College Research Committee of Tarbiat-Modarres University. 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