Pharmacist Monitoring Increases Veteran Adherence to ACS Therapy

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By Annette M. Boyle

P. Michael Ho, MD, PhD

P. Michael Ho, MD, PhD

DENVER — Personalized attention from a pharmacist increases medication adherence in patients to nearly 90% in the year following hospitalization for acute coronary syndrome (ACS), according to a recent study.

Researchers noted that a third of ACS patients typically discontinue at least one oral medication by the end of the first month after hospitalization.

For the study published recently in JAMA Internal Medicine, P. Michael Ho, MD, PhD, staff cardiologist at the VA Eastern Colorado Health Care System in Denver, and colleagues randomly assigned 253 patients admitted with a primary diagnosis of ACS to the VA medical centers in Denver, Seattle, Durham, NC, and Little Rock, AR, to usual care or a pharmacist-led intervention for a year. Centers began the study between July 1, 2010, and July 1, 2011. 1

The study excluded patients who did not expect to receive their primary care at a VA facility or did not fill their prescriptions at a VA pharmacy, as well as those who lacked a telephone, were pregnant, had irreversible disease likely to affect their six-month survival or ability to follow the study protocol, or were being discharged to nursing homes. Twelve patients did not complete the study, leaving 122 in the intervention arm and 119 in usual care.

The multifaceted intervention included an in-person meeting or phone contact with the patient a week to 10 days after discharge, during which the pharmacist would review and reconcile patient medications. A month later, the pharmacist would call again to inquire whether the patient had started on any new medications or had any issues with the medications prescribed for ACS.

The pharmacist also would coordinate the patients’ medications with their primary care provider or cardiologist. Physicians were asked to co-sign the pharmacist’s enrollment note in the patient medical record and were given the pharmacist’s contact information to encourage follow-up.

The study participants received education about the medications and healthy behaviors prior to discharge and at the one-week and one-month calls or at visits with the pharmacist. Automated messages continued to provide educational information to study participants, and patients could request additional educational phone calls from the pharmacist.

Personalized attention from a pharmacist, such as the one shown in this photo, increases medication adherence in patients to nearly 90% in the year following hospitalization for acute coronary syndrome. Photo courtesy of the VA

Personalized attention from a pharmacist, such as the one shown in this photo, increases medication adherence in patients to nearly 90% in the year following hospitalization for acute coronary syndrome. Photo courtesy of the VA

Voice messages also reminded participants to take and refill prescriptions. The reminder calls started two weeks before the refill date, then repeated at seven days prior and the day before the refill should have been scheduled. Patients were told that they could call in to the pharmacy refill line for their convenience. Participants also received monthly medication reminder calls during months two through six.

If the patient did not request a refill, the pharmacist would call the patient.

“We would ask about side effects, whether there were problems getting or taking the medication or if the patient simply forgot,” Ho told U.S. Medicine.

Researchers measured adherence based on refill rates. Secondary endpoints included achieving blood pressure and low-density lipoprotein cholesterol (LDL-C) goals.

Based on refill data, patients in the pharmacist-intervention arm had an 89.3% medication adherence rate, compared with 73.9% for those in the usual-care arm. Intervention increased compliance across nearly all drug types:

  • Adherence rates for clopidogrel were 86.8% for those in the intervention compared with 70.7% for usual care;
  • For statins 93.2% compared with 71.3%; and
  • For angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers (ACEI/ARBs) 93.1% vs. 81.7%.

Rates on adherence for beta blockers, however, were roughly the same between the two groups, at 88.1% for those receiving the intervention and 84.8% for the others.

The researchers found no significant differences in the rates of study participants who reached a blood pressure goal of less than 140/90 mm Hg (or less than 130/80 mm Hg for those with chronic kidney disease or diabetes) and an LDL-C target of less than 100 mg/dL by the end of the study period. The researchers noted a trend toward improved blood pressure control and lower systolic and diastolic blood pressure, however.

“It wasn’t mandated that patients come in for end-of-study blood draws or blood pressure measurements,” Ho noted. Follow-up laboratory evaluation for cholesterol levels was unavailable for 40% of those receiving usual care and 34% of those in the intervention group. Researchers found that those who did come in for evaluation were more adherent to statins: 96% vs. 74%.

Researchers found no statistically significant differences between patients receiving usual care and the intervention in terms of subsequent hospitalizations for myocardial infarction or revascularization or death.

At 74%, the rate of medication adherence by patients receiving usual care in the study was far higher than seen in other studies or clinical practice.

“One potential reason for the high rate seen in the usual-care group was that we had to get consent from all the patients. Patients who were likely to be nonadherent didn’t want to participate, so we likely had the most adherent subgroup of patients in the study,” Ho said.

The 15% increase in adherence rates may have longer term clinical impact. Ho and his colleagues noted that in previous studies, clinical outcomes between usual care and full prescription coverage began to diverge after a year.

With the information available, however, the effect of the increase in adherence on morbidity and mortality cannot be determined. JAMA Internal Medicine editor Rita F. Redberg, MD, M.Sc., noted that “the relatively modest increases in already high rates of medication regimen adherence in the patients studied might not translate into improved outcomes even if maintained for three to five years or longer. … Before recommending investment in this strategy, it would be prudent to know that patient outcomes will actually improve.”

Given the modest investment, about $360 per participant in the program, and the 15% increase in adherence, Ho said he believes additional research that “continues to efficiently engage patients in their own care after discharge” should be explored. He and his colleagues plan to expand the intervention to five to 10 additional VA sites and to continue follow up with study participants to determine whether additional differences in outcomes occur over time.

1 Ho PM, Lamber-Kerzner A, Carey EP, Fahdi IE, Bryson CL, et al. Multifaceted Intervention to Improve Medication Adherence and Secondary Prevention Measures After Acute Coronary Syndrome Hospital Discharge. JAMA Intern Med. Published online Nov. 18, 2013.

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