Multifaceted Intervention Leads to Improved Cardioprotective Medication Adherence

The use of a multifaceted intervention led to improved adherence to cardioprotective medications after hospital discharge for acute coronary syndrome (ACS) by approximately 15%, according to results of a recent study [JAMA Intern Med. DOI:10.1001/jamainternmed.2013.12944]. Mean adherence to a combination of 4 cardioprotective medications improved by about 7%. An improvement in blood pressure and low-density lipoprotein cholesterol (LDL-C) levels, however, were not observed.

P. Michael Ho, MD, PhD, Denver VA Medical Center, and his colleagues conducted a patient-level, prospective, randomized clinical trial at 4 Veterans Affairs medical centers. The purpose of the trial was to examine the effect of a multifaceted, patient-centered intervention to improve adherence to cardioprotective medication regimens compared with usual care for veterans after being hospitalized for ACS.

The study included 253 patients: 129 in the intervention group and 124 in the usual care group. Most patients were men with a mean age of about 64 years. The intervention consisted of 4 components (See Table below).

Both treatment groups received standard ACS discharge instructions (eg, follow-up appointments, diet/exercise advice). Participants randomized to the intervention group also made an appointment with a pharmacist within 7 to 10 days after discharge. Both groups were scheduled for a 12-month clinic visit.

The primary outcome of the study was the proportion of patients who were adherent to cardioprotective medication regimens (beta blockers, statins, clopidogrel, and ACE/ARB) in the year after discharge for ACS. Secondary outcomes included the proportion of patients reaching blood pressure goals and LDL-C goals (<140/90 mmHg and <100 mg/dL, respectively). 

Results for the primary outcome showed a greater proportion of patients in the intervention group were adherent compared with the usual care group (89.3% vs 73.9%; P=.003). The mean proportion of days covered for the 4 medications combined was also greater for the intervention group (0.94 vs 0.87; P<.001).

There was a statistically significant greater proportion of patients in the intervention group were adherent to statins (93.2% vs 71.3%; P<.001), ACE/ARB (93.1% vs 81.7%; P=.03), and clopidogrel (86.8% vs 70.7%; P=.03). Adherence to beta-blockers was comparable for both groups (88.1% vs 84.8%; P=.59).

Results for secondary outcomes showed no statistically significant differences in the proportion of patients achieving blood pressure (P=.23) or LDL-C (P=.14) target goals. No statistically significant differences were seen for the tertiary outcomes of rehospitalization. Cost differences between the 2 groups were also not statistically different; including direct costs of the intervention and annual costs for both interventions and usual care groups.

The majority of participants were men, and consequently the results may not be generalizable to other patient populations. Pharmacy refill data, although a valid measurement tool, were used to assess adherence, and does not necessarily mean that patients actually ingested the medication. Furthermore, all consenting patients were permitted to participate regardless of their prior adherence history.

In summary, Dr. Ho said, “Our results suggest that continuing to engage patients after hospital discharge through interactive voice response and/or pharmacist interaction can improve adherence to important cardiovascular medications.”