Multifaceted Intervention to Improve Medication Adherence and Secondary Prevention Measures After Acute Coronary Syndrome Hospital Discharge: A Randomized Clinical Trial | Acute Coronary Syndromes | JAMA Internal Medicine | JAMA Network
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Original Investigation
February 2014

Multifaceted Intervention to Improve Medication Adherence and Secondary Prevention Measures After Acute Coronary Syndrome Hospital Discharge: A Randomized Clinical Trial

Author Affiliations
  • 1VA Eastern Colorado Health Care System, Denver
  • 2Department of Medicine, University of Colorado, Denver
  • 3Colorado Cardiovascular Outcomes Research Group, Denver
  • 4Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus, Aurora
  • 5John L. McClellan Memorial Veterans Hospital, Little Rock, Arkansas
  • 6VA Puget Sound Health Care System, Seattle, Washington
  • 7Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina
  • 8School of Nursing, Duke University, Durham, North Carolina
  • 9Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina
  • 10Department of Psychiatry and Behavioral Sciences, Duke University, Durham, North Carolina
  • 11Department of Health Policy and Management, Texas A&M School of Rural Public Health, College Station
JAMA Intern Med. 2014;174(2):186-193. doi:10.1001/jamainternmed.2013.12944
Abstract

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, β-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 β-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

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