Multifaceted intervention to improve medication adherence and secondary prevention measures after acute coronary syndrome hospital discharge: a randomized clinical trial.
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IMPORTANCE: Adherence to cardioprotective medication regimens in the year after hospitalization for acute coronary syndrome (ACS) is poor. OBJECTIVE: To test a multifaceted intervention to improve adherence to cardiac medications. DESIGN, SETTING, AND PARTICIPANTS: In this randomized clinical trial, 253 patients from 4 Department of Veterans Affairs medical centers located in Denver (Colorado), Seattle (Washington); Durham (North Carolina), and Little Rock (Arkansas) admitted with ACS were randomized to the multifaceted intervention (INT) or usual care (UC) prior to discharge. INTERVENTIONS: The INT lasted for 1 year following discharge and comprised (1) pharmacist-led medication reconciliation and tailoring; (2) patient education; (3) collaborative care between pharmacist and a patient's primary care clinician and/or cardiologist; and (4) 2 types of voice messaging (educational and medication refill reminder calls). MAIN OUTCOMES AND MEASURES: The primary outcome of interest was proportion of patients adherent to medication regimens based on a mean proportion of days covered (PDC) greater than 0.80 in the year after hospital discharge using pharmacy refill data for 4 cardioprotective medications (clopidogrel, -blockers, 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors [statins], and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers [ACEI/ARB]). Secondary outcomes included achievement of blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) level targets. RESULTS Of 253 patients, 241 (95.3%) completed the study (122 in INT and 119 in UC). In the INT group, 89.3% of patients were adherent compared with 73.9% in the UC group (P =.003). Mean PDC was higher in the INT group (0.94 vs 0.87; P<.001). A greater proportion of intervention patients were adherent to clopidogrel (86.8% vs 70.7%; P =.03), statins (93.2% vs 71.3%; P <.001), and ACEI/ARB (93.1% vs 81.7%; P =.03) but not -blockers (88.1% vs 84.8%; P =.59). There were no statistically significant differences in the proportion of patients who achieved BP and LDL-C level goals. CONCLUSIONS AND RELEVANCE: A multifaceted intervention comprising pharmacist-led medication reconciliation and tailoring, patient education, collaborative care between pharmacist and patients' primary care clinician and/or cardiologist, and voice messaging increased adherence to medication regimens in the year after ACS hospital discharge without improving BP and LDL-C levels. Understanding the impact of such improvement in adherence on clinical outcomes is needed prior to broader dissemination of the program. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00903032.
author list (cited authors)
Ho, P. M., Lambert-Kerzner, A., Carey, E. P., Fahdi, I. E., Bryson, C. L., Melnyk, S. D., ... Del Giacco, E. J.
complete list of authors
Ho, P Michael||Lambert-Kerzner, Anne||Carey, Evan P||Fahdi, Ibrahim E||Bryson, Chris L||Melnyk, S Dee||Bosworth, Hayden B||Radcliff, Tiffany||Davis, Ryan||Mun, Howard||Weaver, Jennifer||Barnett, Casey||Barón, Anna||Del Giacco, Eric J