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Original Investigation |

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

P. Michael Ho, MD, PhD1,2,3; Anne Lambert-Kerzner, PhD, MSPH1; Evan P. Carey, MS1,4; Ibrahim E. Fahdi, MD5; Chris L. Bryson, MD, MS6; S. Dee Melnyk, PharmD, MHS7; Hayden B. Bosworth, PhD7,8,9,10; Tiffany Radcliff, PhD11; Ryan Davis, PharmD1; Howard Mun, PharmD6; Jennifer Weaver, PharmD5; Casey Barnett, PharmD5; Anna Barón, PhD1,4; Eric J. Del Giacco, MD5
[+] 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.
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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, 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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ACS indicates acute coronary syndrome; VA, Department of Veterans Affairs.

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