Clinical question
Does an intervention consisting of increased pharmacist involvement and education increase long-term medication adherence in patients after hospitalization for acute coronary syndrome?
Bottom line
Following hospitalization for acute coronary syndrome (ACS), an intervention that emphasizes medication reconciliation, pharmacist-led education, collaboration between pharmacists and physicians, and automated reminders increases patients’ adherence to cardiac medications. However, there was no significant effect seen on clinical outcomes after 1 year. (LOE = 1b)
Reference
Ho PM, Lambert-Kerzner A, Carey EP, et al. Multifaceted intervention to improve medication adherence and secondary prevention measures after acute coronary syndrome hospital discharge: A randomized clinical trial. JAMA Intern Med 2014;174(2):186-193.
Study design
Randomized controlled trial (nonblinded)
Funding source
Government
Allocation
Concealed
Setting
Inpatient (any location) with outpatient follow-up
Synopsis
In this study performed at 4 Veteran Affairs (VA) medical centers, investigators enrolled 253 patients who were hospitalized with a primary diagnosis of ACS, had an anticipated discharge to home, and used the VA as their primary source of medical and pharmaceutical care. Using concealed allocation, patients were randomized to receive usual care or the intervention. Both groups received standard discharge instructions, discharge medication lists, and education on cardiac medications prior to discharge. The intervention group also received the following: (1) two sessions of medication reconciliation and education by a pharmacist within one month of discharge; (2) automated educational voice messages about medications, as well as access to pharmacists upon request throughout the study; (3) collaboration between the patient’s primary care physician and/or cardiologist; and (4) regular voice messages with reminders to take medications and refill medications for the remainder of the year. All patients were scheduled for a 12-month clinic visit. Baseline characteristics of the 2 groups were similar (mean age = 64 years; all but 5 of the patients were men). Patients in the intervention group received an average of 4 hours of additional pharmacist time. For the primary outcome of adherence to 4 classes of cardioprotective medications (beta-blockers, statins, clopidogrel, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers), more patients in the intervention group were adherent compared with the usual care group (89% vs 74%; P = .003). The high adherence in the usual care group reflects a self-selection bias since enrolled patients were those who had volunteered for the study. Despite greater medication adherence in the intervention group, there were no significant differences in the proportion of patients reaching blood pressure and LDL cholesterol goals between the 2 groups. Additionally, tertiary outcomes — including rehospitalization for myocardial infarction, revascularization, and mortality — were similar in the 2 groups. The estimated cost for the intervention was approximately $360 per patient, mainly because of additional pharmacist and cardiologist time. No significant differences in costs due to medication prescriptions were noted in the study.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.