ОРИГИНАЛЬНЫЕ ИССЛЕДОВАНИЯ ASSESSING FACTORS THAT FORM PATIENT ’ S ATTITUDE TO TREATMENT PRECEDING HOSPITALIZATION FOR ACUTE CORONARY SYNDROM ( DATA OF QUESTIONNAIRE WITHIN THE LIS REGISTER )

Yu.V. Lukina1*, M.L. Gynzburg2, V.P. Smirnov2, S.Yu. Martsevich1,3, N.P. Kutishenko1,3, A.V. Fokina2, E.V. Daniels2 1State Research Centre for Preventive Medicine Petroverigsky per. 10, Moscow, 101990 Russia 2Lyubertsy Regional Hospital No2 Oktyabr’skiy prospect 338, Moscow Region, Lyubertsy, 140006 Russia 3I.M. Sechenov First Moscow State Medical University Trubetskaya ul. 8-2, Moscow, 119991 Russia

Authors' information: Yulia V. Lukina  WHO defines adherence to treatment as adequacy of patient's behavior concerning drugs intake, diet and/or other lifestyle modifications to doctor's or other healthcare practitioner's recommendations [1].
The term "compliance" was the most frequent one for last decades [2], however currently majority of doctors prefer the term "adherence", because "compliance" means that patient passively follows doctor's recommendations, and treatment strategy is not based on cooperation between patient and doctor [3,4].
According to WHO data (2003) insufficient adherence to therapy is one of the most actual medical and social problems, and is mostly associated with prolonged treatment of chronic diseases.Up to 50% of patients with arterial hypertension, bronchial asthma, atherosclerosis with hyperlipidemia, diabetes mellitus, epilepsy and other diseases discontinue prescribed treatment by themselves [1,5].
Poor treatment adherence is dangerous due to severe consequences.It is known that interruption in treatment regimen for myocardial infarction and hypercholesterolemia increases mortality in patients with cardiovascular diseases [6], irregular antiepileptic and antipsychotic drugs intake results in generalized seizures, increases risk of psychosis and schizophrenia relapse [7].Poor adherence to anti-osteoporotic drugs increases risk of fractures and significantly worsens quality of life [8].
Solution of the problem of insufficient adherence to treatment is impossible without determination of the most significant factors of such adherence.About 250 factors anyhow responsible for patient's attitude to treatment regimen have been identified by now.Basically, treatment adherence is a result of compound interaction between such factors, combination of which changes in the course of a disease and may significantly differ in long-term stages and initial ones [9].So, determination of the factors which form patients' attitude to treatment and most sig-Согласно определению ВОЗ приверженность лечениюэто степень соответствия поведения человека в отношении приема лекарственных средств, соблюдения диеты и/или других изменений образа жизни по рекомендациям врача или другого медицинского работника [1].
This analysis is a part of the Lyubertsy study of mortality (LIS) -the register of patients, undergone acute myocardial infarction in Lyubertsy district of Moscow region.According to LIS data ACE inhibitors were the only drugs that had influence on long-term life prognosis in the patients [10].Probably, one of reasons for such results was not only inadequate prescription of necessary drugs by doctors (statins and antiplatelet agents) but also poor patients' adherence to prescribed treatment.To accept this hypothesis a register of patients admitted during a year to the cardiology unit of Lyubertsy Hospital for acute coronary syndrome (ACS) was designed.A special questionnaire for patients was developed to find out what treatment were patients receiving before the reference hospitalization, evaluate adherence to the prescribed treatment and determine the main factors that formed attitude of the patients to the therapy and effected their adherence.
The aim of the study: to reveal the most significant factors that form patient's attitude to treatment and factors of adherence to treatment preceding hospitalization in patients with ACS.

Material and methods
A total of 272 patients (aged 31-89 years): 157 men and 115 women gradually admitted to the Cardiology Unit of the Lyubertsy Regional Hospital №2 for ACS from 20.12.2011 to 19.12.2012 were enrolled in the study.Acute myocardial infarction was diagnosed in 181 patients and unstable angina -in 91.
The protocol of the study was approved by a local ethical committee of the Lyubertsy Regional Hospital №2.All the patients signed the informed consent on participation in the study.
All the patients during their admission were asked to fill up a special questionnaire.The questionnaire included the passport data, Morisky-Green test (the valid test that includes 4 questions estimating treatment adherence) [11], questions concerning existence of risk factors (smoking, alcohol consumption, level of physical activity) and questions which allowed to revel the main factors decreasing patients' treatment adherence.Moreover, the questionnaire included questions on regularity of patient's medical supervision, awareness of patients about their diseases, indices of health (such as blood pressure, cholesterol and glucose levels) and sources of this information, "theoretic" adherence of the patients -readiness to modify lifestyle and to intake prescribed drugs for long time as recommended by the doctor and the information on truly received medications [12].рапии.В целом приверженность отражает сложное взаимодействие этих факторов, конфигурация сочетаний которых меняется в динамике заболевания и на отдаленных этапах может существенно отличаться от начальной [9].Таким образом, определение факторов, формирующих отношение больных к лечению и оказывающих наибольшее влияние на приверженность терапии, представляется актуальной проблемой, решению которой было посвящено данное исследование.

Results
The mean age of the patients was 63.6±12.6 years.One third of the patients (n=91) had general secondary education, every fourth patient had higher or specialized secondary education (75 and 72 patients, respectively), 10% of the patients had incomplete secondary education and 2.5% of the patients -incomplete higher education.More than a half of enrolled patients were married (55.5%), 31 (11.4%)patients were single, one fourth of the patients (n=70; 25.7%) were widowed, 20 (7.4%) were divorced.
Exactly half of the patients (n=136) had never been smoking, about one third of the patients (28.7%) were active smokers and had been smoking about a pack of cigarettes (19.5) per day for more than 30 years.One in five patients (n=58; 21.3%) had stopped smoking: before quitting they had been smoking about 16 cigarettes/day for more than 20 years (23.9±13.4).Majority of the patients had stopped smoking on the average 7.7 years earlier, however 10 of these 58 persons had quitted smoking shortly before the reference hospitalization (from 2 weeks to 1.5 month).
According to questionnaires data alcohol consumption was very little and seldom in more than 60% of the patients, 80 (29.4%) patients reported of 0.5-7 portions of alcohol per week.22 (8%) abused alcohol, taking from 10 to 35 portions of alcohol per week.6 (2%) persons had not filled up this item.Socalled portion of alcohol is used to measure alcohol consumption.Each portion of alcohol is approximately 15-18 ml of pure alcohol according to different standards.1 portion of alcohol matches 1 bottle of beer, glass of wine 150 ml or 50 ml of strong alcoholic beverage (vodka, whiskey, cognac and etc.).
Although 133 patients were permanently followed-up in medical centers, 187 persons answered on the question about regularity of doctors attendance: 75 (40.1%)patients visited their doctor approximately once in 6 months, 21 (11.2%)-less than once in 6 months, 16 (8.6%)-less than once a year, 75 (40.1%)persons visited their doctor irregularly (these included patients who reported absence of permanent medical follow-up, perhaps, they meant single visits in cases of any acute health problems).
More than a half of respondents (n=149; 54.8%) were informed about their disease, its treatment and prognosis by their primary care physician.15 (5.5%) -used information presented in television commercials and popular literature, 9 (3.3%) -usually consulted their relatives about treatment of the disease.Only 7 (2.6%) patients read popular science medical publications, 32 (11.8%) persons confessed they know nothing about their illness.Only 2 patients attended school for patients.Others did not point out their source of information about their disease.
Majority of patients (n=197; 72.4%) knew their mean blood pressure level and 156 (79.2%) of them were correctly orientated in their blood pressure level in reference to the normal value.121 (44.5%) patients knew their mean glucose level, 93 (76.9%) of them correctly appraised it.A parameter, the patients were worst informed about, was cholesterol level: only 49 (18%) patients knew it, majority of them -41 (83.7%) -correctly appraised their cholesterol level with respect to the normal values (Fig. 1).

Factors that form patient's attitude to treatment / Факторы, формирующие отношение пациента к лечению
In accordance with the valid Morisky-Green test results 120 (44.1%) of 272 persons adhered to the treatment, adherence was considered as unsatisfactory in 141 (51.8%) patients, 11 (4.1%) persons did not answer the test questions.At that 191 (70.2%) patients positively answered on the question "Do you take drugs in accordance with your doctors' recommendations?", 81 (29.8%) patients infringed recommendations due to different reasons (forgetfulness, self BAA intake, intake of not prescribed preparations, self change of drugs intake regimen).
The most common reasons for not following doctor's recommendations concerning drugs intake were the following: forgetfulness (this answer was chosen by 44 of 272 patients), fear of side effects and harm of drugs intake (n=19), large amount of daily prescribed drugs (n=16).High cost of medical preparations as a reason for poor adherence was only reported by 8 patients, 9 patients in no circumstances большинство этих пациентов -41 (83,7%) верно оценивают свой уровень холестерина по отношению к норме (рис.1).
Согласно результатам валидированного теста Мориски-Грина 120 (44,1%) пациентов из 272 человек были приверженными лечению, у 141 (51,8%) пациента приверженность расценивалась как неудовлетворительная, 11 ( wanted to intake drugs for a long period.Complicacy of prescribed drugs intake scheme and doubts in accuracy of recommended therapy was noted by 3 patients in each case.4 patients considered absence of tangible effect of the treatment as the main reason for poor adherence.Different combinations of the answers were mentioned 1-2 times and repeated above listed reasons. Despite poor adherence in a large amount of patients, 181 (67%) patients were ready to intake preparations throughout life if this would improve their life and health prognosis, 47 (17.3%) patients did not mind prolonged treatment as long as their health would improve at drugs intake, 6 persons considered important the both conditions.Other patients in no circumstances were ready to intake drugs for very long period.
Among the most effective measures, which could increase treatment adherence, detailed information about their disease and methods of its treatment provided by a doctor in charge was indicated by 125 (46%) patients, a cut in prices on medical preparations -by 32 (11.8%) patients.11 (4%) patients wanted more close attention to their health from a physician; 4 (1.5%) persons considered that improvement in medical care organization (doctors attendance, drug prescription) would help to enhance treatment adherence.53 (19.5%) patients believed that they were already rather accurately following all the prescribed recommendations.Only 9 persons rejected all possible measures to improve adherence, and did not want to follow any doctor's recommendations.Other patients preferred combinations of the answers: the most popular were combinations of getting detailed information from a doctor and more close attention of a doctor with measures to lowering drug costs (6 and 4 patients, respectively).
Only 173 patients, enrolled into the study, reported of drugs used before the reference hospitalization, at that, 35 persons confirmed that they were not prescribed any drugs before the hospitalization, other patients did not remember or did not know names of received preparations.Data on received treatment are shown in Table 2.
Результаты корреляционного анализа выявили статистически значимую прямую взаимосвязь между возрастом и результатами теста Мориски-Грина: более приверженными оказались молодые пациенты.На приверженность выполнению врачебных рекомендаций положительно влияют (приведены результаты корреляционного анализа, при котором коэффициент корреляции Спирмена достиг уровня значимости p<0,05): Factors that form patient's attitude to treatment / Факторы, формирующие отношение пациента к лечению development, necessary drugs, their intake regimen, levels of parameters testifying to well compensated disease (blood pressure, cholesterol, glucose levels etc.); 3. A place of follow-up -patients, who were regularly followed-up in a local out-patient clinic, departmental medical centers, therapeutic units of medical universities and research medical institutes and centers, were found out to be the most adherent to treatment.Patients of commercial medical centers and those who were not followed-up anywhere demonstrated less treatment adherence; 4. A source of information: patients, received information from their doctor and from special medical publications (brochures, magazines for patients) were more adherent, those who received information about treatment of their disease from friends and relatives or those who knew nothing about their disease revealed poorer adherence.

Discussion
Taking into consideration that some patients were prescribed no treatment before the reference hospitalization, questionnaire results only allowed to evaluate potential willingness) of the patients to follow doctor's recommendations and to reveal factors, formation of patient's attitude to treatment.
About 250 factors that somehow impact on patients' attitude to therapy regimen maintenance have been identified by now [9].A number of studies have demonstrated gender, age and social distinctions in treatment adherence.It was found out that women, elderly people, persons with high education and high income are treated more consistently [13].Our work had not revealed any correlations between adherence and parameters of gender, education, marital status, risk factors presence, however
Poor treatment adherence may often be explained by low motivation to lifestyle modification, negligent behavior towards own health; low awareness of risk factors, mistrust of physician advices [14].According to Benson J. et al. data 66% of patients prefer not to intake preparations permanently because of the fear that treatment may do harm to their health [15].According to our research data only 19 (7%) participants of the study indicated fear of probable drugs side effects as a possible reason for noncompliance with medical advice.
Inquiry of hypertensive patients, conducted in Almazov Federal Heart, Blood and Endocrinology Center, showed that less than 30% of the patients with diagnosed hypertension were ready for permanent treatment [16].According to our results a total of 234 patients (86% of participants of the study) were ready to intake drugs for a long time on condition of their positive influence on a disease prognosis and quality of life.However it must be taken into account that our register included patients admitted due to severe IHD complication -acute coronary syndrome that might have impacted answers concerning treatment.
Trust in a doctor and his (her) competency is very important for patients [17,18].On the basis of our analysis the main factors influencing treatment adherence were those that reflected the physician-patient relationship, such as: regular follow-up for chronic diseases, receipt of information about a disease and methods of its treatment from a doctor in chargeall these factors have the major impact on patients adherence to given recommendation.
So, main effort should be aimed at creation of stable and high-quality physician-patient relations; a provision of detailed information about a disease and its complications to motivate a patient to carry out strictly and regularly preventive measures and to follow prescribed drugs intake [19].Our research also confirmed that the major line in enhancement of treatment adherence is improvement of the physicianpatient interaction, focused on full informing of a patient about his disease and methods of its treatment, implication of a patient in treatment process with his involvement in active self-control of health indices, healthy lifestyle forming, creation of proper motivation for following doctor's recommendations and increase in adherence to prescribed treatment.

Conclusion
The specifically developed questionnaire let determine the most significant factors that formed patients' attitude to the treatment preceding the reference hospitalization and factors of adherence to the therapy prescribed before the hospitalization.All the significant factors were associated with the physician-patient relationships, what testifies to important role of both doctor and patient in enhancement of treatment adherence.
-PhD, MD, Senior Researcher, Department of Preventive Pharmacotherapy, State Research Centre for Preventive Medicine (SRCPM) Factors that form patient's attitude to treatment / Факторы, формирующие отношение пациента к лечению plaints (the answer was chosen by 22 patients -53.7%), 7 (17.1%)persons claimed about poor medical care organization and difficulties in making doctor's appointment, and 11 (26.8%)patients reported about fear of attending medical centers and of learning the truth about their health.Only 1 (2.4%) patient distrusted health professionals.