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1641JACC Vol. 58, No. 15, 2011 CorrespondenceOctober 4, 2011:1640–2

adiposity measurements and the varied mechanisms underlying thesubstrates supporting atrial fibrillation (4,5).

Christopher X. Wong, MBBSHany S. Abed, MBBS, BPharmPayman Molaee, MBBS*Prashanthan Sanders, MBBS, PhD

*Centre for Heart Rhythm DisordersCardiovascular Investigational UnitRoyal Adelaide HospitalAdelaide, South Australia 5000AustraliaE-mail: prash.sanders@adelaide.edu.au

doi:10.1016/j.jacc.2011.06.045

EFERENCES

1. Wong CX, Abed HS, Molaee P, et al. Pericardial fat is associated withatrial fibrillation severity and ablation outcome. J Am Coll Cardiol2011;57:1745–51.

2. Nelson AJ, Worthley MI, Psaltis PJ, et al. Validation of cardiovascularmagnetic resonance assessment of pericardial adipose tissue volume.J Cardiovasc Magn Reson 2009;11:15.

3. Iacobellis G, Willens HJ. Echocardiographic epicardial fat: a review ofresearch and clinical applications. J Am Soc Echocardiogr 2009;22:1311–9, quiz 1417–8.

4. Wong CX, Stiles MK, John B, et al. Direction-dependent conductionin lone atrial fibrillation. Heart Rhythm 2010;7:1192–9.

5. Stiles MK, John B, Wong CX, et al. Paroxysmal lone atrial fibrillationis associated with an abnormal atrial substrate: characterizing the“second factor.” J Am Coll Cardiol 2009;53:1182–91.

Medication AdherenceIs Not Our Problem?I would respectfully disagree with the decision to exclude medica-tion adherence from the position statement on performancemeasures for adults with coronary artery disease and hypertension(1). After reviewing the reasons outlined by the writing committee,I am concerned that this decision may have been made without adetailed review of the best available evidence. I believe thatmedication adherence should be considered an important outcomeof care rather than an inevitable destiny for one-half the patientswho receive prescription medicines.

Three reasons were provided for excluding nonadherence as aperformance measure for physicians. First, “adherence is largely not inthe individual physician’s locus of control” (1). On the contrary, asignificant body of research suggests that physicians have powerfulinfluence over medication adherence. Although factors underlying thepositive elements of this association have not been clearly defined,evidence suggests that patient–physician relationships (2), follow-upvisits (3), communication (4), and medical management skills (5) areimportant determinants. Therefore, it would appear that physiciansare not just innocent bystanders in this public health epidemic.

Second, “because patient autonomy is the overriding ethical andpragmatic principle governing the patient–physician relationship, thepatient is free to decide whether to take medications as prescribed” (1).

ew would argue that patients have the final say in the matter of

dherence. However, upholding the principle of patient autonomy

oes not preclude physicians from helping patients make goodecisions. If physicians (or other health care professionals) opt out ofhe decision-making process, patients are left to navigate the Internetr newspapers to help inform their choice of whether to takeedications regularly. At a minimum, engagement in the decision-aking process will ensure that physicians are aware of the final

ecision. Perhaps acknowledging that a final patient decision aboutdherence is understandable might even improve compliance with thethical principle of patient autonomy.

The final reason provided was phrased as follows: “a measure ofatient adherence could cause physicians to avoid caring foratients with a history of nonadherence or a perceived likelihood ofeing nonadherent” (1). In contrast, I believe that a measure ofdherence could begin to promote the idea that good adherence isn outcome of external factors. I would hope the anecdotal risk forefusing care to patients would be speculative at best, whereas thealue of mobilizing a highly skilled profession toward an “age-old”roblem would be priceless.

Medication adherence is a complex phenomenon with a mul-itude of causes that are probably slightly different for every patient.onetheless, a physician’s influence is likely an important factor,

ven under conditions of high copayments or poor employerenefit plans (2). Ultimately, I am concerned that the messagesontained in the medication adherence section of the document (1)ill reinforce a longstanding myth that physicians have no role tolay in addressing this public health problem.

David Blackburn, PharmD

University of Saskatchewanollege of Pharmacy & Nutrition10 Science Placeaskatoon, Saskatchewan S7N 5C9anada-mail: d.blackburn@usask.ca

doi:10.1016/j.jacc.2011.07.009

lease note: Dr. Blackburn is the Chair in Patient Adherence to Drug Therapy in theollege of Pharmacy and Nutrition at the University of Saskatchewan. This positionas created through educational financial support from AstraZeneca Canada, Merckrosst Schering, Pfizer Canada, and the Province of Saskatchewan Ministry ofealth. None of these sponsors were involved in drafting this letter.

EFERENCES

1. Drozda J, Messer JV, Spertus J, et al. ACCF/AHA/AMA–PCPI 2011performance measures for adults with coronary artery disease andhypertension: a report of the American College of Cardiology Foun-dation/American Heart Association Task Force on Performance Mea-sures and the American Medical Association–Physician Consortium forPerformance Improvement. J Am Coll Cardiol 2011;58:316–36.

2. Piette JD, Heisler M, Krein S, Kerr EA. The role of patient-physiciantrust in moderating medication nonadherence due to cost pressures.Arch Intern Med 2005;165:1749–55.

3. Brookhart MA, Patrick AR, Schneeweiss S, et al. Physician follow-upand provider continuity are associated with long-term medicationadherence a study of the dynamics of statin use. Arch Intern Med2007;167:847–52.

4. Zolnierek KBH, DiMatteo MR. Physician communication and patientadherence to treatment: a meta-analysis. Med Care 2009;47:826–34.

5. Tamblyn R, Abrahamowicz M, Dauphinee D, et al. Influence ofphysicians’ management and communication ability on patients’ persis-tence with antihypertensive medication. Arch Intern Med

2010;170:1064–72.