title: Health system barriers and facilitators to medication adherence for the secondary prevention of cardiovascular disease: a systematic review.
abstract: Secondary prevention is cost-effective for cardiovascular disease (CVD), but uptake is suboptimal. Understanding barriers and facilitators to adherence to secondary prevention for CVD at multiple health system levels may inform policy.
  
  
  
  To conduct a systematic review of barriers and facilitators to adherence/persistence to secondary CVD prevention medications at health system level.
  
  
  
  Included studies reported effects of health system level factors on adherence/persistence to secondary prevention medications for CVD (coronary artery or cerebrovascular disease). Studies considered at least one of β blockers, statins, angiotensin-renin system blockers and aspirin. Relevant databases were searched from 1 January 1966 until 1 October 2015. Full texts were screened for inclusion by 2 independent reviewers.
  
  
  
  Of 2246 screened articles, 25 studies were included (12 trials, 11 cohort studies, 1 cross-sectional study and 1 case-control study) with 132 140 individuals overall (smallest n=30, largest n=63 301). 3 studies included upper middle-income countries, 1 included a low middle-income country and 21 (84%) included high-income countries (9 in the USA). Studies concerned established CVD (n=4), cerebrovascular disease (n=7) and coronary heart disease (n=14). Three studies considered persistence and adherence. Quantity and quality of evidence was limited for adherence, persistence and across drug classes. Studies were concerned with governance and delivery (n=19, including 4 trials of fixed-dose combination therapy, FDC), intellectual resources (n=1), human resources (n=1) and health system financing (n=4). Full prescription coverage, reduced copayments, FDC and counselling were facilitators associated with higher adherence.
  
  
  
  High-quality evidence on health system barriers and facilitators to adherence to secondary prevention medications for CVD is lacking, especially for low-income settings. Full prescription coverage, reduced copayments, FDC and counselling may be effective in improving adherence and are priorities for further research.
authors.affiliation: Farr Institute of Health Informatics Research, University College London , London , UK.
authors.forename: Amitava
authors.initials: A
authors.lastname: Banerjee
authors.affiliation: Public Health Foundation of India , New Delhi , India.
authors.forename: Shweta
authors.initials: S
authors.lastname: Khandelwal
authors.affiliation: Public Health Foundation of India , New Delhi , India.
authors.forename: Lavanya
authors.initials: L
authors.lastname: Nambiar
authors.affiliation: Public Health Foundation of India , New Delhi , India.
authors.forename: Malvika
authors.initials: M
authors.lastname: Saxena
authors.affiliation: Population Health Research Institute, McMaster University , Hamilton, Ontario , Canada.
authors.forename: Victoria
authors.initials: V
authors.lastname: Peck
authors.affiliation: WHO Bangladesh, Dhaka , Bangladesh.
authors.forename: Mohammed
authors.initials: M
authors.lastname: Moniruzzaman
authors.affiliation: Pontifícia Universidade Católica do Paraná (PUCPR) , Curitiba , Brazil.
authors.forename: Jose Rocha
authors.initials: JR
authors.lastname: Faria Neto
authors.affiliation: Instituto de Nutrición y Tecnología de los Alimentos, Asociación Kausasunchis-ADEK Perú, Lima , Peru.
authors.forename: Katherine Curi
authors.initials: KC
authors.lastname: Quinto
authors.affiliation: Population Health Research Institute, McMaster University , Hamilton, Ontario , Canada.
authors.forename: Andrew
authors.initials: A
authors.lastname: Smyth
authors.affiliation: Population Health Research Institute, McMaster University , Hamilton, Ontario , Canada.
authors.forename: Darryl
authors.initials: D
authors.lastname: Leong
authors.affiliation: Centro Cardiologico Monzino, IRCCS , Milan , Italy.
authors.forename: José Pablo
authors.initials: JP
authors.lastname: Werba