title: Multifaceted intervention to improve medication adherence and secondary prevention measures after acute coronary syndrome hospital discharge: a randomized clinical trial.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  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).
  
  
  METHODS
  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
  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.
  
  
  BACKGROUND
  clinicaltrials.gov Identifier: NCT00903032.
authors.affiliation: VA Eastern Colorado Health Care System, Denver2Department of Medicine, University of Colorado, Denver3Colorado Cardiovascular Outcomes Research Group, Denver.
authors.forename: P Michael
authors.initials: PM
authors.lastname: Ho
authors.affiliation: VA Eastern Colorado Health Care System, Denver.
authors.forename: Anne
authors.initials: A
authors.lastname: Lambert-Kerzner
authors.affiliation: VA Eastern Colorado Health Care System, Denver4Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus, Aurora.
authors.forename: Evan P
authors.initials: EP
authors.lastname: Carey
authors.affiliation: John L. McClellan Memorial Veterans Hospital, Little Rock, Arkansas.
authors.forename: Ibrahim E
authors.initials: IE
authors.lastname: Fahdi
authors.affiliation: VA Puget Sound Health Care System, Seattle, Washington.
authors.forename: Chris L
authors.initials: CL
authors.lastname: Bryson
authors.affiliation: Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina.
authors.forename: S Dee
authors.initials: SD
authors.lastname: Melnyk
authors.affiliation: Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina8School of Nursing, Duke University, Durham, North Carolina9Division of General Internal Medicine, Department of Medicine, Duke University.
authors.forename: Hayden B
authors.initials: HB
authors.lastname: Bosworth
authors.affiliation: Department of Health Policy and Management, Texas A&M School of Rural Public Health, College Station.
authors.forename: Tiffany
authors.initials: T
authors.lastname: Radcliff
authors.affiliation: VA Eastern Colorado Health Care System, Denver.
authors.forename: Ryan
authors.initials: R
authors.lastname: Davis
authors.affiliation: VA Puget Sound Health Care System, Seattle, Washington.
authors.forename: Howard
authors.initials: H
authors.lastname: Mun
authors.affiliation: John L. McClellan Memorial Veterans Hospital, Little Rock, Arkansas.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Weaver
authors.affiliation: John L. McClellan Memorial Veterans Hospital, Little Rock, Arkansas.
authors.forename: Casey
authors.initials: C
authors.lastname: Barnett
authors.affiliation: VA Eastern Colorado Health Care System, Denver4Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus, Aurora.
authors.forename: Anna
authors.initials: A
authors.lastname: Barón
authors.affiliation: John L. McClellan Memorial Veterans Hospital, Little Rock, Arkansas.
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Del Giacco
mesh_terms: D054058:Acute Coronary Syndrome / Q000188:drug therapy*; D002316:Cardiotonic Agents / Q000627:therapeutic use*; D005500:Follow-Up Studies; D007400:Interprofessional Relations; D055118:Medication Adherence; D010351:Patient Discharge; D010353:Patient Education as Topic / Q000379:methods*; D010817:Physician-Patient Relations; D011379:Prognosis; D012189:Retrospective Studies; D055502:Secondary Prevention / Q000379:methods*; D013997:Time Factors
chemical_list: D002316:Cardiotonic Agents