The impact of cardiovascular medication use on patients’ daily lives: a cross-sectional study
The impact of cardiovascular medication use on patients' daily lives: a cross‑sectional study
Danielle M. van der Laan 0 1
Petra J. M. Elders 0 1
Christel C. L. M. Boons 0 1
Giel Nijpels 0 1
Janet Krska 0 1
Jacqueline G. Hugtenburg 0 1
0 Medway School of Pharmacy, Universities of Greenwich and Kent , Chatham Maritime, Kent , UK
1 Department of General Practice and Elderly Care Medicine and the Amsterdam Public Health Research Institute, VU University Medical Center , Amsterdam , The Netherlands
2 Danielle M. van der Laan
Background The management of multiple long-term medicines of patients with chronic diseases creates a burden for patients. However, limited research is performed on its impact on patients' daily lives. Objective The aim of this study was to explore the impact of cardiovascular medication on different daily life aspects and to examine differences of these aspects between adherent and non-adherent patients. Setting Two community pharmacies in the Netherlands. Method In this cross-sectional study patients (≥ 45 years) using cardiovascular medication participated. Two equally group sized samples of patients non-adherent as assessed with pharmacy refill data, and patients adherent were selected. Main outcome measure Data were collected by means of the Living with Medicines Questionnaire measuring the impact of medicines use on patients' daily lives. Results In total, 196 patients participated, including 96 non-adherent patients. Substantial proportions of patients experienced medication-related burden on different daily life aspects. This burden was mainly related to the acceptance of long-term medicine use, medication-related concerns or dissatisfaction, the interference of medicines with social and daily lives, and the interaction and communication with health care providers. No statistically significant results were found when comparing the impact on patients' daily lives between adherent and nonadherent patients. Conclusion Health care providers should acknowledge the impact of multiple long-term medicines on patient's daily lives and should make an effort to diminish patients' medication-related burden by improving patient-provider relationships and by providing adequate treatment information incorporating patients' individual circumstances. This may facilitate the integration of long-term medicine use in patients' daily lives.
Cardiovascular medication; Medication-related burden; Medication non-adherence; Patients' daily lives; The Netherlands
Department of Clinical Pharmacology and Pharmacy
and the Amsterdam Public Health Research Institute,
VU University Medical Center, De Boelelaan 1117,
Amsterdam 1081 HV, The Netherlands
Patients with chronic diseases are confronted with
developing an understanding of the disease and treatment, should
attend regular appointments, take several chronic medicines
and enact lifestyle changes [1–5]. The management of chronic
diseases therefore requires substantial personal investment
from patients. Treatment regimens are complex and
longterm medicine use creates burden for patients . A systematic
review identified five dimensions of medication-related
burden: burden related to medication routines, medication
characteristics, adverse effects, health care system and social aspects
. Excessive medication-related burden may increase the
negative impact on patients’ daily lives and negatively affects
the health-related quality of life [7, 8]. This is especially the
case in patients with cardiovascular disease for whom mostly
multiple medicines are prescribed and for whom most
medicines prescribed must be used until the end of their life [1,
2]. Patients who experience excessive medication-related
burden may encounter problems with adhering to the prescribed
regimen [3, 6, 9, 10]. As a consequence, patients become
non-adherent to their medication which in its turn leads to
increased morbidity and mortality, more hospital admissions
and higher health care costs [11, 12]. Limited data on patients’
experienced burden of long-term medicine use and its impact
on patients’ daily lives especially in cardiovascular disease
Aim of the study
The aim of the present study was to explore the impact of
chronic cardiovascular medication use on different aspects of
patients’ daily lives and to examine the differences of these
aspects between adherent and non-adherent patients.
All procedures performed in studies involving human
participants were in accordance with the ethical standards of the
institutional and/or national research committee and with the
1964 Helsinki declaration and its later amendments or
comparable ethical standards. The Medical Ethics Committee of
the VU University Medical Center Amsterdam approved this
study. Informed consent was obtained from all individual
participants included in this study.
A cross-sectional study was performed in an urban area of
the Netherlands. We intended to include two equally
groupsized samples of patients adherent and non-adherent to their
prescribed cardiovascular medication. Two community
pharmacies participated. Data were collected by means of the
Living with Medicines Questionnaire (LMQ-2) . This
is an easy-to-use and well-designed instrument to measure
the impact of medicine use on patients’ daily lives. The
questionnaire has originally been developed in the United
Kingdom (UK) based on in-depth interview with patients
prescribed four or more regular medicines to explore the
issues associated with long-term medicine use [8, 13]. The
questionnaire was sent by post to the home addresses of
Patients were eligible if they were 45 years or older and
were prescribed cardiovascular medication including
antihypertensives, antihyperlipidemics and anticoagulants for
more than 1 year. Exclusion criteria were patients who were
unable to fill out a questionnaire, had insufficient Dutch
language skills or used repeat dispensing which is an
additionally offered service by the pharmacy.
The selection method of the Dutch Foundation for
Pharmaceutical Statistics (SFK) was used in order to identify
non-adherent patients . SFK has been developed by
the Royal Dutch Pharmacists Association and collects
information on dispensed drugs from the majority of the
pharmacies in the Netherlands. Using this software, the
Proportion of Days Covered (PDC) was calculated and a
list of non-adherent patients (PDC < 80%) was assembled.
In each pharmacy a random sample was taken from this
list using a randomisation table. A limitation of the SFK
method for the selection of non-adherent patients is that
data concerning medication refill or medication regimen
changes may sometimes be missing. As a result, patients
can be falsely classified as non-adherent. Therefore, each
patient in the sample was contacted by telephone in order
to verify whether the low PDC could be explained by the
following factors: (
) visits to another pharmacy to refill
) hospital admissions, (
) a health care
provider initiated discontinuation or (
) changes to the
prescribed regimen. Patients able to explain their refill
non-adherence with one of the above described aspects in
the previous period, were reclassified to the adherent
sample. Patients that denied these explanations, were included
in the final non-adherent sample.
The pharmacy information and administration system was
used to identify adherent patients by making a list of all
patients in the pharmacy that met the inclusion criteria.
Again a sample of these patients was taken using a
randomisation table. In order to only include adherent patients
(PDC ≥ 80%), patients that were present on the SFK list as
described above were subsequently excluded. The
remaining patients in the sample were contacted by telephone and
asked for participation.
LMQ-2 measures the impact of medicine use on patients’
daily lives and consists of 42 items divided over eight
) patient–doctor relationships and
communication about medicines, (
) interferences with daily life, (
) effectiveness, (
communication about medicines, (
) acceptance of medicine use,
) autonomy/control over medicine use and (
about potential harm. Responses are rated on a five-point
Likert scale to measure the extent of agreement with the
42 items, ranging from 1 (strongly disagree) to 5 (strongly
agree) . The LMQ-2 has been shown to be a valid and
reliable multidimensional measure of prescription medicine
use experiences and was robust against potential
obsequiousness bias .
In order to use the LMQ-2 in the Netherlands, the
questionnaire was translated using a forward–backward
procedure in which the English version was first translated into
Dutch by the researchers. The Dutch version was
thereafter translated backwards into English by a native speaker
in order to verify the accordance with the original English
version. The accordance with the English version was
verified and approved by the developer of the questionnaire (JK).
After the translation process, the feasibility and readability
of the Dutch version of the questionnaire was tested in a
sample (n = 10) of patients using chronic cardiovascular
medication using the ‘think-aloud’ method. This method
enables to identify difficult or unclear sentences, because
patients read aloud every word in each question . The
questionnaire was not further adapted based upon the test
Patient characteristics including age, gender, origin,
education level, employment status, living situation, assistance
with medication use from others and number of prescribed
medicines were obtained. Means and standard deviations for
continuous variables and frequencies and percentages for
categorical variables were calculated. The 42 items were both
positively and negatively phrased. Reverse scoring enabled
uniformity in the direction of responses, with a higher score
indicating more impact of medicines use on patients’ daily
lives. The LMQ-2 sum score was obtained by summing the
scores for each item and was presented as means and standard
deviations. The sum score ranges from 42 to 210. In
addition, a theme sum score was calculated for each of the eight
themes. Independent samples t tests were used to compare
sum and theme scores between the adherent and non-adherent
sample. When examining the LMQ-2 scores on item level,
the scale was dichotomised into 1 (strongly agree, agree with
item) and 0 (strongly disagree, disagree, neutral with item)
. Proportions of patients agreeing with the LMQ-2 items
were presented as frequencies and percentages for the total
study population. Furthermore, logistic regression analyses
were used in order to examine the differences in LMQ-2 item
scores between adherent and non-adherent patients. Odds
ratios (OR) with 95% confidence intervals (CI) and p values
were presented. A p value of ≤ 0.01 was considered
statistically significant. Statistical analyses were performed using
SPSS version 22.0 (IBM Corp, Armonk, NY, USA).
A total of 394 patients were invited to participate (Fig. 1).
Of patients willing to participate (n = 295), 94 patients
did not respond to the questionnaire and five
individuals were excluded due to missing questionnaire data. The
final sample consisted of 196 patients, including 100 and
96 patients in the adherent and non-adherent sample,
In Table 1 the patient characteristics are listed. In the total
study population the mean age was 71.0 years and 51.0%
was male. Patients were predominantly from Dutch origin
(89.8%), retired (65.8%) and lived with others (74.0%).
About two-thirds of patients was prescribed at least four
medicines. No significant differences in patient
characteristics between the adherent and non-adherent sample were
found, except for number of prescribed medicines.
Significantly more non-adherent patients used more than four
prescribed medicines (p = 0.004) than adherent patients.
Impact of medicines use on daily life
In Table 2 the results of the LMQ-2 sum scores and themes
scores are presented. In the total study population the mean
sum score was 93.1 (SD 13.6). For the adherent and
nonadherent patients, the sum score was 93.2 (SD 13.3) and 93.0
(SD 14.0), respectively. No statistically significant
differences between the adherent and non-adherent patients were
found for neither the LMQ-2 sum score nor LMQ-2 theme
In Table 3 the results of the LMQ-2 scores on item level
are presented. A selection of notable results on the
proportions of patients agreeing with the items are described below.
In both the adherent and non-adherent sample almost a
quarter of patients indicated not to trust the doctor in choosing
their medicines (24.0%) and almost half of the patients
indicated that their doctor does not always take their concerns of
side effects seriously (42.3%). About 40% of patients
indicated they were concerned about experiencing side effects or
Sum score (range 42–210)
1 Patient–doctor relationships and communication about
2 Interferences with daily life (
3 Practicalities (
4 Effectiveness (
5 Patient–pharmacist communication about medicines (
6 Acceptance of medicine use (
7 Autonomy/control over medicine use (
8 Concerns about potential harm (
LMQ Living with Medicines Questionnaire, SD standard deviation
aIndependent samples t tests
were concerned about long-term effects of taking medicines.
For up to 35% of patients medicines adversely affected their
social and daily lives, including not living their life as they
want to (34.7%) and experiencing interference with their
social life (23.0%). A majority of the patients indicated not
to be able to adapt their medicine-taking to their lifestyles
(57.7%). One out of four patients indicated they did not
accept that they have to take medicines long term (23.0%).
Over one-third of patients (35.2%) indicated not being
confident about speaking with the pharmacist about medicines.
When comparing the adherent and non-adherent patients,
no statistically significant differences between groups were
found on LMQ-2 item level. For one item, ‘I find using my
medicines difficult’ (p = 0.012), the proportion of
nonadherent patients was marginally significantly higher than
adherent patients. Other trends were that a lower proportion
of non-adherent patients agreed with the statement: ‘My
medicines allow me to live my life as I want to’ (p = 0.046),
and a higher proportion with the statement: ‘I can change the
times I take my medicines if I want to’ (p = 0.032).
This study demonstrated that the experienced burden of
cardiovascular medication use on patients’ daily lives was
mainly related to the acceptance of long-term medicine use,
medication-related concerns or dissatisfaction, the
interference of medicines with social and daily lives, and the
interaction and communication with health care providers.
There were no significant differences in experienced burden
between the adherent and non-adherent sample.
In this study, substantial proportions of patients
experienced medication-related burden. The majority of these
findings resonate with the results of two other studies
administrating the LMQ [17, 18]. These studies concluded that
long-term use of medicines was burdensome and may
negatively affect patients’ quality of life. The finding of our study
that the experienced medication-related burden was related
to different daily life aspects, corresponds with other
literature. In a review of Sav et al.  different dimensions of
treatment burden were identified in multiple studies
including side effects of treatment, the economic burden imposed
by treatment, time required to obtain, administer and manage
treatment, and the psychosocial aspects of burden
including the impact on social and daily lives. In contrast to this
review, no conclusions can be drawn about the experienced
economic burden in our study population since no costs
related aspects were assessed in the questionnaire. In a
review of Rosbach and Andersen  it was also concluded
that the burden of treatment is a complex concept
consisting of many different components and factors interacting
with each other. They also found that patients seem to use
strategies to diminish the burden and try to routinize and
integrate complex treatment into their daily lives. Since, the
experienced medication-related burden is also related to the
interaction with health care providers, a structural change in
health care delivery is required to diminish patients’ burden
. Therefore, it is important for health care providers to
recognise that poor patient–provider relationships may lead
to increased burden and that they should make an effort to
improve communication about patients’ attitudes and
concerns, involve patients in treatment decisions and
incorporating individual’s circumstances and preferences [1, 4, 7].
This may increase the chance to better integrate long-term
My medicines prevent my 126 (64.3)
condition getting worse
Theme 5 Patient–pharmacist communication about medicines
The information my
pharmacist gives me about
my medicines is useful
I am confident speaking to 127 (64.8)
my pharmacist about my
I understand what my
pharmacist tells me
about my medicines
Theme 6 Acceptance of medicine use
I can choose whether or 67 (34.2)
not to take my medicines
I can adapt my medicine- 83 (42.3)
taking to my lifestyle
Theme 8 Concerns about potential harm
I am concerned about
experiencing side effects
I am concerned about
longterm effects of taking
I worry that my medicines
may interact with each
CI confidence interval, LMQ Living with Medicines Questionnaire
aLogistic regression analyses *p ≤ 0.05; **p ≤ 0.01 (= statistical significant)
treatment in patients’ daily lives. This finding was also
confirmed by a review of Mohammed et al., which indicated
a need for health care providers to have more insight into
patients’ medication-related burden since it plays a central
role in influencing beliefs and behaviour towards medicines.
By understanding patients’ experienced burden, health care
providers can provide individualised care and assist patients
in improving medication therapy and health outcomes .
No statistically significant results were found when
comparing the burden on patients’ daily lives between the
adherent and non-adherent sample. The findings did not support
our original hypothesis that non-adherent patients might
perceive more medication-related burden than adherent patients.
The similar level of burden found between these two groups
is therefore interesting and requires further exploration.
The fact that the questionnaire was not able to distinguish
between adherent and non-adherent patients can have several
explanations. First, the perceived burden of chronic
medication in adherent and non-adherent patients might be
similar. Second, adherent and non-adherent patients may cope
in a differential manner with this burden. A questionnaire
that is specifically designed to measure burden and not the
coping mechanisms to manage this burden is not suitable
to identify these differences. In addition, rather than in the
experienced burden, the beliefs about medicines might
influence medication intake behaviour [22, 23]. The marginal
differences between adherent and non-adherent patients in
a few LMQ-2 items, including finding medicines use
difficult, feeling in control of changing times of medicine intake,
and feeling that medicines allow living life as wanted, could
be explained to support in this direction. However, these
differences should be viewed with caution due to multiple
testing. It might be interesting to elaborate on the possible
relationship of these items with non-adherence in further
Some limitations need to be discussed. First, the accuracy
of the selection method of SFK to identify non-adherent
patients is limited. It may occur that certain data in SFK is
missing whereupon it is possible to falsely classify patients
as non-adherent. However, to minimise bias missing SFK
data was verified with each patient and when needed a
patient was reclassified. Another limitation was that the
sample size was maybe not large enough to find differences
between adherent and non-adherent patients. A final
limitation was that the adherent and non-adherent samples were
slightly different on patient characteristics. The samples
differed on the number of prescribed medicines. In the UK,
LMQ-2 scores have been shown to be related to the number
of prescribed medicines . However, in our sample no
significant correlation was found (data not shown), but again
this may be due to insufficient sample size.
This study demonstrated that substantial proportions of
patients using chronic cardiovascular medication
experienced medication-related burden on different daily life
aspects. Health care providers must acknowledge the impact
of multiple long-term medicine use on patients’ daily lives
and should make an effort to diminish patients’
medicationrelated burden. Therefore, patient–provider relationships
and their communication need to be improved,
incorporating patients’ individual circumstances and preferences in
order to facilitate the integration of long-term medicine use
in patients’ daily lives. We did not find differences in
experienced burden between adherent and non-adherent patients.
It shows that we might underestimate the burden in adherent
patients, which is an interesting finding. Further research
could explore this and the potential effects of intervention
strategies aimed at coping mechanisms for
medicationrelated burden on patients’ medication adherence.
Acknowledgements The authors thank the Royal Dutch Pharmacists
Association for funding this research. The authors thank the
developers of the LMQ-2 for developing an easy-to-use and well-designed
Funding This study is funded by the Royal Dutch Pharmacists
Conflicts of interest All authors declare that they have no conflicts of
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1. Gallacher K , May CR , Montori VM , Mair FS . Understanding patients' experiences of treatment burden in chronic heart failure using normalization process theory . Ann Fam Med . 2011 ; 9 ( 3 ): 235 - 43 .
2. Granger BB , Sandelowski M , Tahshjain H , Swedberg K , Ekman I. A qualitative descriptive study of the work of adherence to a chronic heart failure regimen. Patient and physician perspectives . J Cardiovasc Nurs . 2009 ; 24 ( 4 ): 308 - 15 .
3. Vijan S , Hayward RA , Ronis DL , Hofer TP . Brief report: the burden of diabetes therapy . J Gen Intern Med . 2005 ; 20 : 479 - 82 .
4. Gallacher K , Morrison D , Jani B , Macdonald S , May CR , Montori VM , et al. Uncovering treatment burden as a key concept for stroke care: a systematic review of qualitative research . PLoS Med . 2013 ; 10 ( 6 ): e1001473 .
5. Tran VT , Barnes C , Montori VM , Falissard B , Ravaud P . Taxonomy of the burden of treatment: a multi-country web-based qualitative study of patients with chronic conditions . BMC Med . 2015 ; 13 : 115 .
6. Mohammed MA , Moles RJ , Chen TF . Medication-related burden and patients' lived experience with medicine: a systematic review and metasynthesis of qualitative studies . BMJ Open . 2016 ; 6 ( 2 ): e010035 .
7. Eton DT , Ramalho de Oliveira D , Egginton JS , Ridgeway JL , Odell L , May CR , et al. Building a measurement framework of burden of treatment in complex patients with chronic conditions: a qualitative study . Patient Relat Outcome Meas . 2012 ; 3 : 39 - 49 .
8. Krska J , Morecroft CW , Poole H , Rowe PH . Issues potentially affecting quality of life arising from long-term medicines use: a qualitative study . Int J Clin Pharm . 2013 ; 35 ( 6 ): 1161 - 9 .
9. Ingersoll KS , Cohen J . The impact of medication regimen factors on adherence to chronic treatment: a review of literature . J Behav Med . 2008 ; 31 ( 3 ): 213 - 24 .
10. Demain S , Goncalves AC , Areia C , Oliveira R , Marcos AJ , Marques A , et al. Living with, managing and minimising treatment burden in long term conditions: a systematic review of qualitative research . PLoS ONE . 2015 ; 10 ( 5 ): e0125457 .
11. Kim S , Shin DW , Yun JM , Hwang Y , Park SK , Ko YJ , et al. Medication adherence and the risk of cardiovascular mortality and hospitalization among patients with newly prescribed antihypertensive medications . Hypertension . 2016 ; 67 ( 3 ): 506 - 12 .
12. Chowdhury R , Khan H , Heydon E , Shroufi A , Fahimi S , Moore C , et al. Adherence to cardiovascular therapy: a metaanalysis of prevalence and clinical consequences . Eur Heart J . 2013 ; 34 ( 38 ): 2940 - 8 .
13. Krska J , Morecroft CW , Rowe PH , Poole H. Measuring the impact of long-term medicines use from the patient perspective . Int J Clin Pharm . 2014 ; 36 ( 4 ): 675 - 8 .
14. Royal Dutch Pharmacists Association (KNMP) . Foundation for Pharmaceutical Statistics (SFK) . https://www.sfk. nl/ Accessed 21 June 2017 .
15. Krska J , Katusiime B , Corlett S. Validation of an instrument to measure patients' experiences of medicine use: the Living with Medicines Questionnaire . Patient Prefer Adherence . 2017 ; 11 : 671 - 9 .
16. Charters E. The use of think-aloud methods in qualitative research. An introduction to think-aloud methods . Brock Educ . 1003 ; 12 ( 2 ): 68 - 82 .
17. Krska J , Morecroft CW , Poole H , Rowe PH . A novel instrument to measure medicines-related quality of life . Int J Clin Pharm . 2013 ; 35 : 488 .
18. Katusiime B , O'Grady M , Vaghji C , Rubasayone R , Ojikutu T , Corlett SA , et al. Patients' experiences of using regular medicines-a quantitative survey . Pharmacoepidemiol Drug Saf . 2014 . https://doi.org/10.1002/pds.3682.
19. Sav A , King MA , Whitty JA , Kendall E , McMillan SS , Kelly F , et al. Burden of treatment for chronic illness: a concept analysis and review of the literature . Health Expect . 2015 ; 18 ( 3 ): 312 - 24 .
20. Rosbach M , Andersen JS . Patient-experienced burden of treatment in patients with multimorbidity-a systematic review of qualitative data . PLoS ONE . 2017 ; 12 ( 6 ): e0179916 .
21. May C , Montori VM , Mair FS . We need minimally disruptive medicine . BMJ . 2009 ; 339 : b2803 .
22. Horne R , Weinman J , Hankins M. The beliefs about medicines questionnaire: the development and evaluation of a new method for assessing the cognitive representation of medication . Psychol Health . 1999 ; 14 : 1 - 24 .
23. Mahler C , Hermann K , Horne R , Jank S , Haefeli WE , Szecsenyi J . Patients' beliefs about medicines in a primary care setting in Germany . J Eval Clin Pract . 2012 ; 18 ( 2 ): 409 - 13 .