A multifaceted intervention was effective for improving postdischarge medication adherence among patients hospitalized for acute coronary syndrome but had no effect on achievement of blood pressure and cholesterol level goals, in a prospective randomized clinical trial.
The intervention, which involved pharmacist-led medication reconciliation and tailoring, patient education, collaboration between pharmacists and physicians, and voice messaging reminders, was associated with an 89.3% medication adherence rate among 122 patients randomized to the intervention groups, compared with a 73.9% adherence rate among 119 patients randomized to receive usual care, Dr. P. Michael Ho of the Denver Veterans Administration Medical Center, reported on Nov. 17 at the American Heart Association scientific sessions.
The mean proportion of days covered was significantly higher in the intervention group than in the usual care group (0.94 vs. 0.87 days), and a greater proportion of patients in the intervention group were adherent to clopidogrel (86.8% vs. 70.7%), statins (93.2% vs. 71.3%), and ACE inhibitors and angiotensin receptor blockers (93.1% vs. 81.7%). No significant difference was seen between the groups with respect to use of beta-blockers (88.1% vs. 84.8%), Dr. Ho reported. The findings were published simultaneously with the presentation (JAMA Intern Med Nov.18 [doi:10.1001/jamainternmed.2013.12944]).
Despite the improved adherence to treatment, no differences were seen in the percentage of patients achieving blood pressure goals or LDL cholesterol goals, although there was a trend toward greater blood pressure control (58.6% vs. 48.9%), decline in systolic blood pressure (–12 vs. –4 mm Hg), and decline in diastolic blood pressure (–5 vs. –3 mm Hg) for intervention vs. usual care patients, respectively, he said.
Also, adherent patient were more likely to get follow-up LDL cholesterol laboratory evaluations, and "accordingly we saw declines in LDL-C levels in both intervention and usual care patients, which may have attenuated the intervention effect on LDL-C levels," he wrote in the JAMA article, noting that additional studies in larger patient samples are needed to assess the association between adherence and these clinical outcomes.
The cost of the intervention, based on the pharmacist time spent, cardiologist time spent, and pill box cost, was about $360/patient. Medication cost differences did not differ significantly between the intervention and usual care groups.
Patients in the study had been hospitalized for acute coronary syndrome at Department of Veterans Affairs Medical Centers in Denver, Seattle, Durham, N.C., or Little Rock, Ark., and were discharged during 2010 or 2011. They were randomized to the intervention or usual care group prior to discharge.
The intervention, which lasted 1 year following discharge, involved:
• Medication reconciliation and tailoring by a pharmacist who met with patients via an in-person clinic visit or by telephone. The pharmacist addressed medication problems or adverse effects, reconciled differences in medications, provided a pill box and instructions for use if needed, and called a month later to follow up, synchronize refill dates, answer questions, and encourage adherence.
• Patient education at the point of discharge, and afterward by the pharmacist at 1-week and 1-month visits. Thereafter, educational messages were provided via automated voice messages and pharmacist phone calls.
• Collaborative care involving pharmacist and primary care clinician or cardiologist communications.
• Voice messaging at regularly scheduled intervals to remind patients about medications and refills.
Studies show that postdischarge adherence to cardioprotective drug regimens is often poor among patients hospitalized for acute coronary syndrome. For example, several studies have shown that a third of those who were taking their cardiac medications at discharge discontinued at least one medication by 1 month, and only about 60% were still taking statin medications at 1 year. Cohort and population-based studies show that lower adherence to cardioprotective drug regimens after acute MI are associated with a higher 1-year and long-term mortality, Dr. Ho noted.
In the current study, the intervention improved the proportion of adherent patients by about 15% and the mean adherence to the four medications combined by about 7%, Dr. Ho said, noting that the findings, along with those from prior intervention studies, "provide an increasing evidence base of interventions to improve adherence to cardiac medication regimens after ACS discharge."
"It will be important for us to continue to follow up patients longer to assess whether the higher adherence in the intervention group translates into improved clinical outcomes," he wrote, noting that he and his colleagues plan to follow the patients beyond the initial 12 months to assess for differences in outcomes and costs in the longer term.
This study is limited by a number of factors, including the largely male patient population at the VA medical centers where it was conducted, and the use of pharmacy refill data rather than pill counts to assess adherence.