Abstract and Introduction
Abstract
Background Nonadherence to cardiovascular medications is a significant public health problem. This randomized study evaluated the effect on medication adherence of linking hospital and community pharmacists.
Methods Hospitalized patients with coronary artery disease discharged on aspirin, β-blocker, and statin who used a participating pharmacy were randomized to usual care or intervention. The usual care group received discharge counseling and a letter to the community physician; the intervention group received enhanced in-hospital counseling, attention to adherence barriers, communication of discharge medications to community pharmacists and physicians, and ongoing assessment of adherence by community pharmacists. The primary end point was self-reported use of aspirin, β-blocker, and statin at 6 months postdischarge; the secondary end point was a ≥75% proportion of days covered (PDC) for β-blocker and statin through 6 months postdischarge.
Results Of 143 enrolled patients, 108 (76%) completed 6-month follow-up, and 115 (80%) had 6-month refill records. There was no difference between intervention and control groups in self-reported adherence (91% vs 94%, respectively, P = .50). Using the PDC to determine adherence to β-blockers and statins, there was better adherence in the intervention versus control arm, but the difference was not statistically significant (53% vs 38%, respectively, P = .11). Adherence to β-blockers was statistically significantly better in intervention versus control (71% vs 49%, respectively, P = .03). Of 85 patients who self-reported adherence and had refill records, only 42 (49%) were also adherent by PDC.
Conclusions The trend toward better adherence by refill records with the intervention should encourage further investigation of engaging pharmacists to improve continuity of care.
Introduction
Medications such as aspirin, β-blockers, and statins have been shown to reduce morbidity and mortality in patients with acute coronary syndrome. Several national quality improvement initiatives have focused on improving prescribing of these medications at hospital discharge in patients with acute coronary syndrome. Although critical to achieving long-term benefit, adherence to these medications after hospital discharge has received less attention. Research at Duke University Medical Center has shown in a population with documented coronary artery disease (CAD) that the percentage of patients who reported consistent, long-term use was 71% for aspirin; 46% for β-blockers; 44% for lipid-lowering therapy; and 21% for triple therapy with aspirin, β-blockers, and lipid-lowering therapy. Other research studies also have shown outpatient adherence to be poor, and nonadherence has been associated with increased mortality.
The most successful interventions to improve patient medication adherence typically address multiple factors associated with nonadherence, including lack of patient knowledge or perceived benefits, perceived harms of medications, poor medication management skills, and inadequate social support. However, even those interventions considered successful have demonstrated only modest improvements in medication adherence. Clearly, there is need for development and testing of new intervention strategies.
The PILOT-EBM study was a prospective, randomized study coordinated through Duke University Medical Center that tested a multifaceted intervention to improve postdischarge adherence to evidence-based medications for CAD. The intervention included patient education, adherence aids, and expanded communication linkages between hospital-based and community pharmacists, physicians, and patients, beyond what usually exists in the US health care system.