To describe the persistent use of evidence-based cardiovascular medications (EBCMs) 3 months after discharge from an acute coronary syndrome (ACS) event and patient-reported reasons for nonpersistence across age groups.
Medication Applied and Sustained Over Time (MAINTAIN) is a longitudinal follow-up cohort study of the Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation quality improvement initiative and Acute Coronary Treatment and Intervention Outcomes Network registry.
Forty-one acute care hospitals in the United States from January 2006 to September 2007.
One thousand fifty-four patients with a median age of 60 (interquartile range 52-71), including 27% aged 70 and older, admitted with an ACS.
Three-month posthospital discharge telephone follow-up with EBCMs reviewed and reconciled. Patients who reported nonpersistence were surveyed regarding reasons for EBCM discontinuation.
At 3-month follow-up, overall persistence was 71.2%. There was a significant trend toward lower overall persistence with prescribed EBCMs in older adults than in the other age groups (74.9% for <60, 71.0% for 60-69, 64.5% for > or =70; P=.02). Overall, 112 (10.6%) patients discontinued EBCMs with provider advice, and 178 (16.9%) self-discontinued. Provider discontinuation increased across age groups (9.1%, 10.4%, and 13.6%, respectively). A similar trend was observed for EBCM self-discontinuation (15.2%, 17.0%, and 19.9%, respectively). Reasons for self-discontinuation included adverse effects, cost, and perception that the medication was not needed.
Older patients are less likely to be persistent with EBCMs after an ACS event at 3-month follow-up. Understanding patient-reported reasons for discontinuation can influence intervention strategies to improve long-term adherence to EBCMs.
"For example, the IHMRS requires the recording of smoking status into several cutoffs depending on the number of cigarettes smoked per day, which correlates independently to heart attack risk, as opposed to simply recording cigarette smoking status in an arbitrary fashion, which is of lesser value with regard to risk comparisons. The final baseline data collection point of six weeks post-discharge for questionnaire mail-out reflects our intention to gauge each patient's status on each of the questionnaires in the time directly before the HMR and not while in hospital, as factors, such as adherence behavior, may be very high in hospital but may significantly decline over time following discharge [2,3,14,65,66]. Patients in the intervention group will be asked to ensure that they complete their questionnaire before their pharmacist visit and pharmacists will record whether or not this has happened as reported by the patient. Patients in the control group will be given a reminder telephone call if their questionnaires have not been returned by three weeks from the mail-out date. "
[Show abstract][Hide abstract] ABSTRACT: Despite continual improvements in the management of acute coronary syndromes, adherence to guideline-based medications remains suboptimal. We aim to improve adherence with guideline-based therapy following acute coronary syndrome using an existing service that is provided by specifically trained pharmacists, called a Home Medicines Review. We have made two minor adjustments to target the focus of the existing service including an acute coronary syndrome specific referral letter and a training package for the pharmacists providing the service.
We will be conducting a randomized controlled trial to compare the directed home medicines review service to usual care following acute coronary syndromes. All patients aged 18 to 80 years and with a working diagnosis of acute coronary syndrome, who are admitted to two public, acute care hospitals, will be screened for enrolment into the trial. Exclusion criteria will include: not being discharged home, documented cognitive decline, non-Medicare eligibility, and presence of a terminal malignancy. Randomization concealment and sequence generation will occur through a centrally-monitored computer program. Patients randomized to the control group will receive usual post-discharge care. Patients randomized to receive the intervention will be offered usual post-discharge care and a directed home medicines review at two months post-discharge. The study endpoints will be six and twelve months post-discharge. The primary outcome will be the proportion of patients who are adherent to a complete, guideline-based medication regimen. Secondary outcomes will include hospital readmission rates, length of hospital stays, changes in quality of life, smoking cessation rates, cardiac rehabilitation completion rates, and mortality.
As the trial is closely based on an existing service, any improvements observed should be highly translatable into regular practice. Possible limitations to the success of the trial intervention include general practitioner approval of the intervention, general practitioner acceptance of pharmacists' recommendations, and pharmacists' ability to make appropriate recommendations. A detailed monitoring process will detect any barriers to the success of the trial. Given that poor medication persistence following acute coronary syndrome is a worldwide problem, the findings of our study may have international implications for the care of this patient group.
Australian New Zealand Clinical Trials Registry ACTRN12611000452998.
[Show abstract][Hide abstract] ABSTRACT: Evidence-based therapies (EBTs) for the prevention of cardiovascular disease (CVD) are reportedly underutilized in older people. The primary purpose of this study was to evaluate the use of EBTs for the prevention of CVD events in older people and secondarily whether a Home Medicines Review (HMR) service by pharmacists' predicts the use of these medicines. A retrospective cross-sectional audit of HMR reports pertaining to 608 community-dwelling older people (>or=65 years) was conducted. EBTs considered for this audit included four guideline-recommended therapies for CVD: antithrombotic therapy (warfarin +/- antiplatelet therapy), beta-blockers, statins, and angiotensin agents (angiotensin-converting enzyme inhibitors [ACEI] +/- angiotensin II receptor blockers [ARBs]). The prevalence of EBT use among the older people, mean age (SD) 75.6 (7.5) years, was: 73% for antithrombotic therapy, 75% for statins, 74% for angiotensin therapy, and 35% for beta-blockers. CVD risk factors warranting treatment with these EBTs were frequently associated with use of EBTs. EBTs were least likely to be used in those with coronary interventions like coronary artery bypass grafting (CABG)/stent insertion (all EBTs except angiotensin agents) and angiotensin agents in those with a history of myocardial infarction or chronic heart failure. A pharmacist-led HMR service was significantly associated with the prescribing of all 4 EBTs. The results from this study show good adherence to evidence-based guidelines in general, although there is still room for improvement to further optimize clinical outcomes in these complex patients. The study also adds to the available literature on the effectiveness of pharmacists' collaborative contribution to the care of these high-risk patients.
Evaluation & the Health Professions 09/2010; 33(3):276-301. DOI:10.1177/0163278710374854 · 1.91 Impact Factor
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