ACS Medication Adherence Following Hospital Discharge

Dallas—After acute coronary syndrome (ACS) hospital discharge, patient adherence to medications is poor. By 1 month post-discharge, one-third of patients stop taking at least 1 medication prescribed, and by 1 year post-discharge, only approximately 60% of individuals are taking statins. This poor adherence is in turn associated with adverse outcomes.

Michael Ho, VA Eastern Colorado Health Care System, Denver, Colorado, discussed a study of the impact multifaceted intervention in the year following an ACS hospitalization had on adherence to cardiac medications. This study was discussed at the AHA Scientific Sessions in a presentation titled Prevention from Schools to Countries.

This was a randomized, controlled study at 4 Veterans Affairs (VA) sites in Denver, Colorado; Little Rock, Arkansas; Seattle, Washington, and Durham, North Carolina. Patients were included if they were admitted with ACS and used the VA for usual medical care. Patients were excluded if they were admitted with a primary noncardiac condition; if planned discharge was to a nursing home; limited life expectancy; lack of phone; used a non-VA pharmacy; or did not use the VA as a source of primary care. A total of 253 patients met the inclusion criteria; however, only 241 completed the study. The 241 participants were randomized into 1 of 2 study cohorts: intervention group (n=122) or usual care group (n=119) prior to hospital discharge. See Table (below) for baseline characteristics for each group.

The intervention had 4 components:

• Pharmacist-led medication reconciliation and tailoring

• Patient education

• Collaborative care between pharmacist and primary care provider/cardiologist

• Voice messaging (educational and medication refill reminder calls)

The primary outcome was the proportion of patients adherent to medications based on mean proportion of days covered (PDC) >.8 in the year following hospital discharge using pharmacy refill data for clopidogrel, beta-blockers, HMG CoA reductase inhibitors (statins), and angiotensin-converting enzyme inhibitor (ACE)/angiotensin receptor blocker (ARB). Secondary study outcomes included achievement of blood pressure (BP) and low-density lipoprotein (LDL) cholesterol targets.

In the intervention group, 89.3% of patients were adherent, while 73.9% of the usual care group were adherent (P=.003). The mean PDC was higher in the intervention (.94) compared with the usual care group (.87; P=.001).

The intervention cohort was more adherent to clopidogrel (87% vs 71%; P=.03), statins (93% vs 82%; P<.001), ACE/ARB (93% vs 82%; P=.03), and beta-blockers (88% vs 85%; P=.59). The difference in adherence between groups was not significant for beta-blockers.

There was also no significant difference in BP between the 2 cohorts; however, there was a trend toward better BP control in the intervention group—59% of the intervention group achieved BP goal, while 49% of the usual care group achieved BP goal (P=.23). No significant differences were recorded with LDL between the 2 cohorts—72% of the intervention group had LDL <100 mg/dL and 83% of the usual care group had LDL <100 mg/dL (P=.14).

This intervention model improved adherence with modest costs over the 1-year intervention period, providing a framework for future investigations.