Recent Approaches to Improve Medication Adherence in Patients with Coronary Heart Disease: Progress Towards a Learning Healthcare System

Use of Optimal Medical Therapy in Patients With Cardiovascular Disease Undergoing Cardiac Rehabilitation

Optimal medical therapy (OMT) in patients with coronary artery disease (CAD) and/or heart failure (HF) is underused despite the established benefits of these medications. Cardiac rehabilitation (CR) may be one place where OMT could be promoted. We sought to describe the prevalence and characteristics of OMT use in patients with CAD or HF undergoing CR. We included patients with CAD (myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting, angina) and HF enrolled in our CR program. For patients with CAD, we defined OMT to consist of aspirin or other antiplatelets, statins, and beta-blockers (BB). For patients with HF or EF ≤ 40%, OMT included BB, spironolactone, and either Angiotensin Converting Enzyme inhibitors (ACEi)/angiotensin receptor blockers or angiotensin receptor neprilysin inhibitor (ARNI). For CAD patients with normal EF, OMT also included ACEi/ARB/ARNI if they also had diabetes type 2. From January 2015 to December 2019, 828 patients were referred to CR and 743 attended. Among 612 patients (mean age: 65, 23% female) with CAD, 483 (79%) patients were on OMT. Of the 131 HF patients (mean age: 64, 21% female) enrolled in CR, only 23 (18%) met all 3 OMT criteria, whereas most patients were on only 1 (93 %) or 2 (76%) HF specific medications. Spironolactone was the least prescribed (22%) medication. Over the study period, we observed a steady increase in the use of ARNI (2015: 0% vs 2019: 27%, p < 0.01). Among the individuals, 69 patients experienced both CAD and HF, while only 7 patients were under OMT for both CAD and HF. Most patients attending CR with CAD are receiving OMT, but most patients with HF are not. Although OMT has improved over time, there remains room for improvement, particularly among patients with HF.

Compliance and satisfaction with treatment as a success of therapy effectiveness in the group of patients with ischemic heart disease: a cross-sectional study

OBJECTIVES

Non-adherence and non-compliance to pharmaceutical treatment is one of the most common causes of not effective management of patients suffering from ischemic heart disease (IHD). It is crucial to understand the reasons behind it but studies on this subject performed in the Polish population are still lacking.

MATERIAL AND METHODS

The 329 patients (160 male and 169 female) diagnosed with IHD who reported for follow-up appointments are examined. The following standardized questionnaires were used: Treatment Satisfaction with Medicines Questionnaire (SATMED-Q) and Adherence to Refills and Medication Scale (ARMS), which evaluates the patient's compliance and adherence level, respectively.

RESULTS

Patients with IHD showed moderate compliance with pharmacological recommendations and average satisfaction with treatment. Anemia, drugs side effects, and SATMED-Q total score were significant predictors of the overall ARMS score in the univariate analysis, whereas the male gender and satisfaction with treatment improves this results. In multivariate analysis, significant predictors of lower adherence included family history of IHD, anemia and drugs side effects, while higher education and SATMED-Q overall score increased adherence.

CONCLUSIONS

Treatment satisfaction is a significant predictor of increased overall treatment adherence as well as adherence in terms of drug intake and drug and prescription refills. Raising patient awareness should be an important goal of future educational activities. Int J Occup Med Environ Health. 2023;36(4):465-76.

Patient Adherence to Secondary Prevention Therapies After an Acute Coronary Syndrome: A Scoping Review

PURPOSE

Adherence to guideline-recommended, long-term secondary preventative therapies among patients with acute coronary syndrome (ACS) is fundamental to improving long-term outcomes. The purpose of this scoping review was to provide a broad synopsis of pertinent studies in a structured and comprehensive way regarding factors that influence patient adherence to medical therapy after ACS.

METHODS

Relevant articles focusing on adherence to medical therapy after ACS were retrieved from the EMBASE and MEDLINE databases (search date, September 7, 2021). Studies were independently screened, and relevant information was extracted.

FINDINGS

A total of 58 studies were identified by using the EMBASE and MEDLINE databases. Adherence to secondary prevention was moderate to low and steadily decreased over time. Nearly 30% of patients discontinued one or more medications within 90 days of their primary ACS, and adherence decreased to 50% to 60% at 1 year postdischarge. There were no major differences in adherence between drug classes. Factors influencing patient adherence can be broadly divided into 3 categories: patient related, health care system related, and disease related. Patients managed with percutaneous coronary interventions were more adherent to follow-up treatment than medically managed patients. Depression was reported as a major psychological factor that negatively affected adherence. Improved adherence was observed when higher levels of patient education and provider engagement were delivered during postdischarge follow-up, particularly when scheduled early. Notably, the incidence of major adverse cardiovascular events was lower in hospitals with high 90-day medication adherence than those with moderate or low adherence.

IMPLICATIONS

Patient nonadherence to guideline-recommended long-term pharmacologic secondary preventative therapies after ACS is multifactorial. A comprehensive multifaceted approach should be implemented to improve adherence and clinical outcomes. This approach should include key interventions such as early follow-up visits, high medication adherence at 90 days, patient engagement and education, and development of novel interventions that support the 3 broad categories influencing patient adherence as discussed in this review.

Randomized phase III trial evaluating motivational interviewing and text interventions to optimize adherence to breast cancer endocrine therapy (Alliance A191901): the GETSET protocol

BACKGROUND

Hormone receptor-positive (HR +) breast cancer is the most common type of breast cancer in the USA but has excellent long-term outcomes in recent decades, in part due to effective oral endocrine therapy (ET). ET medications are typically prescribed for 5 to 10 years, depending on the risk of recurrence, and must be taken daily. One limiting factor to ET efficacy is nonadherence, with high-risk groups for nonadherence including younger women and Black women.

METHODS

The Alliance for Clinical Trials in Oncology (Alliance) trial A191901 is an ongoing, four-arm (text message reminder (TMR), motivational interviewing (MI), TMR plus MI, or enhanced usual care) randomized clinical trial that tests the efficacy and effect of two interventions (TMR and/or MI) on improved ET adherence, patient-reported outcomes (PROs), and resource use requirements among HR + breast cancer survivors. Participants are randomized in a 1:1:1:1 ratio to the four arms. With an assumed loss to follow-up of approximately 11%, we plan to recruit 1180 participants. Randomization is stratified based on age and race to ensure balance between the arms, and we oversample younger and Black women, with each group representing 30% of the study population. Participants randomized to an intervention will actively participate in the intervention for 9 months, and all participants will be followed for adherence data and PRO endpoints, through the use of the Pillsy cap medication event monitoring system and Alliance ePRO survey app (i.e., Patient Cloud). The primary analysis will compare Pillsy-measured ET adherence among study arms at 12 months.

DISCUSSION

This multisite study will not only define strategies to improve adherence to breast cancer oral therapies, but it will also potentially support strategies in large cooperative research groups that can increase delivery and tolerability of ET, involve diverse patient populations in clinical research, and engage patients effectively in interventional studies, using remote and cost-effective delivery methods.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04379570 . Registered on 7 May 2020.

Nursing Interventions and Care Strategies for Patients with Coronary Heart Disease: A Comprehensive Review

Cardiovascular diseases are a major cause of death worldwide, and coronary heart disease (CHD) is a prevalent cardiovascular condition and a significant health burden for the population. In this disease, insufficient blood flow to the heart due to plaque accumulation in the coronary arteries causes chest pain, heart attack, and even death. So, it is vital to identify risk factors, prevention, appropriate treatment, and rehabilitation. Nurses play an indispensable role in managing and caring for patients with CHD. Indeed, they possess a deep understanding of the disease and its complexities, enabling them to provide comprehensive care to patients. Nurses monitor vital signs, administer medications, and perform diagnostic tests, ensuring patients receive timely and appropriate interventions. They also educate patients and their families about CHD, emphasizing lifestyle modifications, medication adherence, and self-care practices. Moreover, nurses offer emotional support, guiding patients through the physical and psychological challenges associated with CHD. Their expertise, compassion, and dedication significantly improve patient outcomes and overall quality of life. Nurses are responsible for assessing, diagnosing, and counseling patients on how to manage their disease, making them the front line of defense in preventing and addressing this serious condition. In the current study, we reviewed the literature to consider the best practices and emerging trends in nursing interventions and care strategies for patients with CHD.

Single-pill combination in the management of chronic coronary syndromes: A strategy to improve treatment adherence and patient outcomes?

Chronic coronary syndrome (CCS) represents a major challenge for physicians, particularly in the context of an increasing aging population. Additionally, CCS is often underestimated and under-recognised, particularly in female patients. As patients are frequently affected by several chronic comorbidities requiring polypharmacy, this can have a negative impact on patients' adherence to treatment. To overcome this barrier, single-pill combination (SPC), or fixed-dose combination, therapies are already widely used in the management of conditions such as hypertension, dyslipidaemia, and diabetes mellitus. The use of SPC anti-anginal therapy deserves careful consideration, as it has the potential to substantially improve treatment adherence and clinical outcomes, along with reducing the failure of pharmacological treatment before considering other interventions in patients with CCS.

Impact of Close Surveillance on Dual-Antiplatelet Therapy Compliance in Myocardial Infarction Patients Post-Percutaneous Coronary Intervention

BACKGROUND

Dual-antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor is the mainstay regimen for acute coronary syndrome (ACS) patients after percutaneous coronary intervention (PCI). We aimed to investigate DAPT compliance and switching patterns in ACS patients prescribed ticagrelor and aspirin. Secondly, we evaluated the impact of a pilot strategy of close surveillance telephone calls.

METHODS

The study enrolled 150 consecutive ACS patients who underwent PCI and were prescribed DAPT (aspirin and ticagrelor). This cohort, the "close surveillance arm," then received telephone calls from a healthcare professional to inquire about DAPT for up to one year. These findings, and clinical outcomes, were then compared to a "historical arm" of ACS patients (n = 505) who received PCI and were prescribed DAPT before initiation of the program. Finally, healthcare providers were surveyed about their experience with prescribing DAPT.

RESULTS

The rate of ticagrelor cessation trended lower in the close surveillance arm (22.00 % versus 31.70 %, p = 0.0783). The most common reasons for ticagrelor cessation were adverse medication reaction (dyspnea), bleeding, and financial burden. Nevertheless, the adverse events were few and similar between the two groups during follow-up. Over 96 % of healthcare providers surveyed stated that they worry about their patients' DAPT compliance post-PCI.

CONCLUSION

Noncompliance and switching medications are still common for patients who undergo PCI for ACS. A close surveillance program identified patients at risk for medication cessation or switching and could potentially mitigate this phenomenon and improve quality of care.

Comparison of Sodium-Glucose Cotransporter-2 Inhibitor and Glucagon-Like Peptide-1 Receptor Agonist Prescribing in Patients With Diabetes Mellitus With and Without Cardiovascular Disease

Sodium-glucose cotransporter-2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor agonists (GLP1-RAs) reduce cardiovascular events and mortality in patients with type 2 diabetes mellitus (T2DM). We sought to describe trends in prescribing for SGLT2is and GLP1-RAs in diverse care settings, including (1) the outpatient clinics of a midwestern integrated health system and (2) small- and medium-sized community-based primary care practices and health centers in 3 midwestern states. We included adults with T2DM and ≥1 outpatient clinic visit. The outcomes of interest were annual active prescription rates for SGLT2is and GLP1-RAs (separately). In the integrated health system, 22,672 patients met the case definition of T2DM. From 2013 to 2019, the overall prescription rate for SGLT2is increased from 1% to 15% (absolute difference [AD] 14%, 95% confidence interval [CI] 13% to 15%, p <0.01). The GLP1-RA prescription rate was stable at 10% (AD 0%, 95% CI -1% to 1%, p = 0.9). In community-based primary care practices, 43,340 patients met the case definition of T2DM. From 2013 to 2017, the SGLT2i prescription rate increased from 3% to 7% (AD 4%, 95% CI 3% to 6%, p <0.01), whereas the GLP1-RA prescription rate was stable at 2% to 3% (AD 1%, 95% CI -1 to 1%, p = 0.40). In a fully adjusted regression model, non-Hispanic Black patients had lower odds of SGLT2i or GLP1-RA prescription (odds ratio 0.56, 95% CI 0.34 to 0.89, p = 0.016). In conclusion, the increase in prescription rates was greater for SGLT2is than for GLP1-RAs in patients with T2DM in a large integrated medical center and community primary care practices. Overall, prescription rates for eligible patients were low, and racial disparities were observed.

Patient Pill Organization Strategies and Adherence Measured in a Cross-Sectional Study of Hypertension

BACKGROUND

The strategies patients use to organize medications (eg, pill dispenser) may be reflected in adherence measured at follow-up. We studied whether medication organization strategies patients use at home are associated with adherence measured using pharmacy-fills, self-report, and pill counts.

DESIGN

Secondary analysis of data from a prospective randomized clinical trial.

SETTING

Eleven US safety-net and community primary care clinics.

PATIENTS

Of the 960 enrolled self-identified non-Hispanic Black and White patients prescribed antihypertensive medications, 731 patients reported pill organization strategies and were included.

VARIABLE

Patients were asked if they use any of the following medication organization strategies: finish previous refills first; use a pill dispenser; combine same prescriptions; or combine dissimilar prescriptions.

OUTCOMES

Adherence to antihypertensive medications using pill counts (range, 0.0-1.0% of the days covered), pharmacy-fill (proportion of days covered >90%), and self-report (adherent/non-adherent).

RESULTS

Of the 731 participants, 38.3% were men, 51.7% were age ≥65, 52.9% self-identified as Black or African American. Of the strategies studied, 51.7% finished previous refills first, 46.5% used a pill dispenser, 38.2% combined same prescriptions and 6.0% combined dissimilar prescriptions. Median (IQR) pill count adherence was 0.65 (0.40-0.87), pharmacy-fill adherence was 75.7%, and self-reported adherence was 63.2%. Those who combined same prescriptions had significantly lower measured pill count adherence than those who did not (0.56 (0.26-0.82) vs 0.70 (0.46-0.90), p<0.01) with no significant difference in pharmacy-fill (78.1% vs 74%, p=0.22) or self-reported adherence (63.0% vs 63.3%, p=0.93).

CONCLUSION

Self-reported medication organization strategies were common. Combining same prescriptions was associated with lower adherence as measured using pill counts but not pharmacy-fills or self-report. Clinicians and researchers should identify the pill organization strategies used by their patients to understand how these strategies may influence measures of patient adherence.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03028597; https://clinicaltrials.gov/ct2/show/NCT03028597 (Archived by WebCite at http://www.webcitation.org/72vcZMzAB).

Effect of primary care-level chronic disease management policy on self-management of patients with hypertension and diabetes in Korea

AIMS

This study aimed to evaluate the effect of introducing a regional chronic disease management project on the self-management of patients with hypertension and diabetes.

METHODS

This study included 174,546 patients. The relationship between introducing chronic disease management in a region and the self-awareness of disease status was analyzed using a generalized estimating equation model. Poisson regression analysis was used to evaluate the effect of policy adoption on medication adherence and risk-reduction behavior in patients with hypertension and diabetes. Finally, we used a difference-in-differences model to assess the net effectiveness of policies.

RESULTS

Overall, regions with policies implemented showed more condition awareness and drug adherence than those without; however, this was only significant in regions where patients and physicians were incentivized. Risk-reduction behavior for patients with diabetes was higher in regions with policies implemented than in those without. The policy had a net effect of significantly and non-significantly increasing disease awareness and medication adherence, respectively.

CONCLUSION

Chronic disease management policies at the primary care level that incentivized both patients and physicians improved patient self-management. However, the effects on patients with diabetes and hypertension differed. Future studies should account for additional patient outcomes, including long-term impact assessments and clinical outcomes.

Suboptimal control of cardiovascular risk factors in myocardial infarction survivors in a cardiac rehabilitation program

INTRODUCTION AND OBJECTIVES

As short-term mortality continues to decrease after myocardial infarction (MI), secondary prevention strategies attain increasing relevance. This study aimed at assessing the control of cardiovascular (CV) risk factors, including dyslipidemia, hypertension and diabetes, in a contemporary cohort of MI survivors who completed an exercise-based cardiac rehabilitation (EBCR) program.

METHODS

Observational, retrospective cohort study including patients admitted to a tertiary center with acute MI between November 2012 and April 2017, who completed a phase II EBCR program after discharge. Achievement of low-density lipoprotein (LD) cholesterol, blood pressure and HbA1c guideline recommended targets was assessed. Lipid profile parameters were assessed and compared at three time points (hospitalization, beginning and end of the program).

RESULTS

A total of 379 patients were included. Mean age was 58.8±10.6 years; 81% were male. Considering the European Society of Cardiology's guidelines on contemporary data collection, 61%, 87% and 71% achieved the recommended LDL cholesterol, blood pressure and HbA1c targets, respectively, at the end of the program. Combining all three risk factors, 42% achieved the recommended targets. High-sensitivity C-reactive protein decreased between the beginning and the end of the program [0.14 (0.08-0.29) mg/L to 0.12 (0.06-0.26) mg/L; p<0.001].

CONCLUSION

Despite contemporary management strategies, including enrollment in a structured EBCR program, a substantial number of patients presented suboptimal control of CV risk factors. Considering the dyslipidemia, hypertension and diabetes results, less than half of the enrolled individuals achieved the recommended targets. These findings highlight a pivotal unmet need which could be particularly relevant in improving CV outcomes by enhancing secondary prevention profiles.

Perceptions of injectable therapies with cardiovascular benefit: an ACNAP survey of healthcare professionals to explore facilitators and barriers

AIMS

Injectable medicines are increasingly used to manage risk factors for cardiovascular (CV) events, such as dyslipidaemia and diabetes. These include proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists. Little is known about perceptions of injectable therapies among CV healthcare professionals (HCPs). This study explores their views to identify relevant facilitators and barriers to the use of injectables with CV benefit.

METHODS AND RESULTS

A 22-question survey was distributed internationally via online channels. In total, 192 anonymous responses were received (43.7% physicians, 32.6% nurses, 16.8% pharmacists, 6.8% others). Among respondents with experience of these medicines, 69.1% had used an injectable PCSK9 inhibitor and 67.0% had used an injectable GLP-1 receptor agonist. Commonly raised issues were resource problems (36.5%), lack of knowledge among colleagues (32.3%), paperwork (32.3%), and lack of patient knowledge (28.1%). Key barriers respondents felt made patients decline these treatments were fear of injection (56.6%), lack of awareness or education (26.4%), and administration issues (15.1%); potential reasons for discontinuation included side effects (46.4%), perceived lack of benefit (28.6%), and local reactions (21.4%). The main topics around injectables requiring further support included managing non-adherent patients (16.2%), troubleshooting with patients (16.2%), and educating colleagues about injectables (12.2%). Preferred educational methods to support HCPs were face-to-face training (43.5%) and online learning (26.1%); favoured formats were based on role playing and case studies.

CONCLUSION

Healthcare professionals highlighted various potential barriers to initiation, continuation, and adherence with injectable therapies in CV medicine. Although some require healthcare system changes, many could be addressed through simple measures based primarily on enhanced training and support for patients and HCPs.

GA4GH: International policies and standards for data sharing across genomic research and healthcare

The Global Alliance for Genomics and Health (GA4GH) aims to accelerate biomedical advances by enabling the responsible sharing of clinical and genomic data through both harmonized data aggregation and federated approaches. The decreasing cost of genomic sequencing (along with other genome-wide molecular assays) and increasing evidence of its clinical utility will soon drive the generation of sequence data from tens of millions of humans, with increasing levels of diversity. In this perspective, we present the GA4GH strategies for addressing the major challenges of this data revolution. We describe the GA4GH organization, which is fueled by the development efforts of eight Work Streams and informed by the needs of 24 Driver Projects and other key stakeholders. We present the GA4GH suite of secure, interoperable technical standards and policy frameworks and review the current status of standards, their relevance to key domains of research and clinical care, and future plans of GA4GH. Broad international participation in building, adopting, and deploying GA4GH standards and frameworks will catalyze an unprecedented effort in data sharing that will be critical to advancing genomic medicine and ensuring that all populations can access its benefits.

Factors Affecting Tendency and Adherence to Traditional Persian Medicine: A Qualitative Study

Background: Adherence to medications is crucial for them to be effective. Traditional Persian Medicine (TPM) is an ancient medical discipline originated from old Persia and is currently used along with modern medicine in Iran. Evaluating the factors affecting adherence to TPM can have far-reaching implications for policymakers to make informed decisions. Objectives: This qualitative study investigates the factors affecting tendency and adherence to TPM among Iranians. Methods: We collected data from stakeholders in TPM using a focus group involving 13 participants and by conducting four in-depth interviews. The saturation point was reached at the 4th interview. We recorded all the interviews and then transcribed them verbatim for thematic content analysis. Results: We obtained 297 codes and 29 sub-themes for the factors affecting adherence to TPM, including the factors affecting compliance and tendency. Then we extracted the main themes. People’s beliefs, the inherent characteristics of traditional medicine and its status quo, attempts to bring about positive changes to TPM, and the problems facing the modern health system were the main factors affecting adherence to TPM. Conclusions: Despite many strenuous efforts in Iran to study TPM along with the lines of evidence-based medicine, policymaking, financing, patients’ and healthcare providers’ education, popular beliefs, and administrative transparency are needed to be addressed more adequately to promote adherence to TPM and help build integrative medicine in Iran’s healthcare system.

Nurse-led counseling for coronary artery disease patients: A 1-year follow-up study

Nurse-led counseling and systematic follow-up have been shown to reduce cardiovascular risk factor levels. The study aims were to investigate if cardiovascular risk factor levels could be reduced in patients with coronary artery disease with a nurse-led intervention and to report patients' evaluations of nurse-led counseling. The study design was a real-life longitudinal follow-up counseling intervention. Data were collected from November 2017 to May 2020. The nurse-led intervention and patients' follow-up time was 1 year. Of the 78 patients recruited, 74 completed the study. The most significant findings were in the levels of total cholesterol, low-density lipoprotein cholesterol, and triglycerides at every follow-up visit compared to their baseline levels and that waist circumference decreased during the 1-year follow-up. Patients assessed the quality of nurse-led counseling to be very good, though it decreased slightly during follow-up. The results suggest the integrated care path and specialized and primary care for coronary artery disease patients need further development. More research is needed on how to strengthen patients' self-management and what kind of counseling would best promote it.

Effect of Medication Adherence and Early Follow-Up on Unplanned Readmission Post-Myocardial Infarction: Quality Improvement in a Safety Net Hospital

Medication nonadherence is a strong predictor of adverse events and unplanned 30-day readmissions in post-myocardial infarction (MI) patients. Nonadherence with dual antiplatelet therapy (DAPT) is of particular concern in post-MI patients, given the high rate of percutaneous coronary intervention in this population. Review of post-MI quality measures revealed that compared to national benchmarks, our safety net hospital had lower DAPT adherence rates and higher unplanned 30-day readmission rates. The aim was to improve these important quality measures by creating a transition of care pathway primarily focused on medication accessibility and affordability of DAPT and early follow-up. A multidisciplinary task force created a transition of care pathway that included bedside medication delivery, patient assistance program enrollment for medications, and follow-up within 10 days of discharge in a dedicated post-MI clinic. Resources for the pathway (personnel and hospital) were already available and repurposed. We compared quality measures of DAPT adherence, proportion of patients evaluated early after hospital discharge, and unplanned 30-day readmissions before and after the initiative. Following initiation of the transition of care pathway, DAPT adherence increased from 56% pre-intervention to 92% post-intervention (P < 0.0001). The proportion of patients scheduled for early clinic follow-up after discharge increased and unplanned 30-day readmissions decreased following initiation of the pathway. A transition of care pathway for post-MI patients using readily available resources was associated with increased DAPT adherence and decreased 30-day unplanned readmissions.

Intentional and unintentional nonadherence to hydroxyurea among people with sickle cell disease: a qualitative study

Hydroxyurea is an efficacious treatment for sickle cell disease (SCD), but adoption is low among individuals with SCD. The objective of this study was to examine barriers to patients' adherence to hydroxyurea use regimens by using the intentional and unintentional medication nonadherence framework. We interviewed individuals with SCD age 15 to 49.9 years who were participants in the Sickle Cell Disease Implementation Consortium (SCDIC) Needs Assessment. The intentional and unintentional medication nonadherence framework explains barriers to using hydroxyurea and adds granularity to the understanding of medication adherence barriers unique to the SCD population. In total, 90 semi-structured interviews were completed across 5 of the 8 SCDIC sites. Among interviewed participants, 57.8% (n = 52) were currently taking hydroxyurea, 28.9% (n = 26) were former hydroxyurea users at the time of the interview, and 13.3% (n = 12) had never used hydroxyurea but were familiar with the medication. Using a constructivist grounded theory approach, we discovered important themes that contributed to nonadherence to hydroxyurea, which were categorized under unintentional (eg, Forgetfulness, External Influencers) and intentional (Negative Perceptions of Hydroxyurea, Aversion to Taking Any Medications) nonadherence types. Participants more frequently endorsed adherence barriers that fell into the unintentional nonadherence type (70%) vs intentional nonadherence type (30%). Results from this study will help SCD health care providers understand patient choices and decisions as being either unintentional or intentional, guide tailored clinical discussions regarding hydroxyurea therapy, and develop specific, more nuanced interventions to address nonadherence factors.

A qualitative study of patient's perceptions of two cardiac rehabilitation models

BACKGROUND

Understanding patients' perceptions about rehabilitation can guide healthcare administrators on modifications of program elements, which can ultimately improve cardiac rehabilitation (CR) use, adherence of heart-health behaviors, and improvements in clinical outcomes.

OBJECTIVE

To examine the perception of patients about their participation in CR.

METHODS

Qualitative study using semi-structured interviews, performed in a public CR center in Brazil. Twenty-eight patients were interviewed 2-years following participation in two CR models: exercise-based and comprehensive CR.

RESULTS

Themes identified included: knowledge acquisition, improvement in functionality, and psychosocial well-being. It appeared that the perceived benefits of CR participation were overall positive and similar between the two models; however, those in the comprehensive CR identified additional subthemes: self-care need and knowledge transfer.

CONCLUSIONS

This study suggested that patients from two different CR models perceived in the long term that the CR participation positively impacted their disease-related knowledge, promoted functional gains, and improved psychosocial well-being. Structured educational interventions seemed to be associated with improved participants' perception about CR, which could contribute to long-term maintenance of heart-health behavior and better outcomes.

Cultural adoption, and validation of the Persian version of the coronary artery disease education questionnaire (CADE-Q): a second-order confirmatory factor analysis

BACKGROUND

Evaluating knowledge in patients with coronary artery disease requires a specific measure. The aim of the present study was to translate and evaluate the CADE-Q in patients with coronary artery disease in Iran.

METHODS

Forward-backward procedure was applied to translate the questionnaire from English into Persian. Then a cross-sectional study was conducted to evaluate psychometric properties of the questionnaire. A sample of patients with coronary artery disease attending to cardiac departments of teaching hospitals affiliated to medical universities in Tehran, Iran completed the 19-item CADE-Q from April to December 2017. Structural validity of CADE-Q was assessed using both exploratory and confirmatory factor analyses. Reliability was examined using Cronbach's alpha coefficient. Stability was evaluated by estimation intraclass correlation coefficient.

RESULTS

In all 500 patients participated in the study. The mean age of patients was 53.63. (SD = 14.36) years, and 57% were male. The results obtained from the exploratory factor analysis showed a four factor solution (lifestyle habits and exercise, risk factors, diagnosis and treatment, signals & symptoms and medicine) that jointly explained 48.9% of the total variance observed. However, the second-order confirmatory factor analysis supported the three-factor solution while convergent and divergent validity were not confirmed. Finally, the Cronbach's alpha coefficient of 0.84 ranging from 0.50 to 0.82 was obtained for the scale and its subscales. In addition, the ICC value of 0.88 showed satisfactory stability for the questionnaire.

CONCLUSION

The Coronary Artery Disease Education Questionnaire was found to be a multidimensional instrument. The results confirmed the factor structure of the questionnaire with a second-order analysis. Since the convergent and divergent validity of the scale were not confirmed, further assessment is essential to establish fitness of the questionnaire in Iran.

Impact of a Copayment Reduction Intervention on Medication Persistence and Cardiovascular Events in Hospitals With and Without Prior Medication Financial Assistance Programs

Background

Hospitals commonly provide a short‐term supply of free P2Y₁₂ inhibitors at discharge after myocardial infarction, but it is unclear if these programs improve medication persistence and outcomes. The ARTEMIS (Affordability and Real‐World Antiplatelet Treatment Effectiveness After Myocardial Infarction Study) trial randomized hospitals to usual care versus waived P2Y₁₂ inhibitor copayment costs for 1‐year post‐myocardial infarction. Whether the impact of this intervention differed between hospitals with and without pre‐existing medication assistance programs is unknown.

Methods and Results

In this post hoc analysis of the ARTEMIS trial, we examined the associations of pre‐study free medication programs and the randomized copayment voucher intervention with P2Y₁₂ inhibitor persistence (measured by pharmacy fills and patient report) and major adverse cardiovascular events using logistic regression models including a propensity score. Among 262 hospitals, 129 (49%) offered pre‐study free medication assistance. One‐year P2Y₁₂ inhibitor persistence and major adverse cardiovascular events risks were similar between patients treated at hospitals with and without free medication programs (adjusted odds ratio 0.93, 95% CI, 0.82–1.05 and hazard ratio 0.92, 95% CI, 0.80–1.07, respectively). The randomized copayment voucher intervention improved persistence, assessed by pharmacy fills, in both hospitals with (53.6% versus 44.0%, adjusted odds ratio 1.45, 95% CI, 1.20–1.75) and without (59.0% versus 48.3%, adjusted odds ratio 1.46, 95% CI, 1.25–1.70) free medication programs (P_interaction=0.71). Differences in patient‐reported persistence were not significant after adjustment.

Conclusions

While hospitals commonly report the ability to provide free short‐term P2Y₁₂ inhibitors, we did not find association of this with medication persistence or major adverse cardiovascular events among patients with insurance coverage for prescription medication enrolled in the ARTEMIS trial. An intervention that provided copayment assistance vouchers for 1 year was successful in improving medication persistence in hospitals with and without pre‐existing short‐term medication programs.

Registration

URL: https://www.clini​caltr​ials.gov/. Unique identifier: NCT02406677.

Moving the Dial on Heart Failure Patient Adherence Rates

INTRODUCTION

Heart failure remains a substantive contributor to patient morbidity and mortality rates worldwide and represents a significant burden on the healthcare ecosystem. Faced with persistent physical symptoms and debilitating social consequences, patients follow complex treatment regimens and often have difficulty adhering to them.

PURPOSE

In this manuscript, we review factors which contribute to low adherence rates and advance potential single- and multi-factor-based interventions. It is hoped that these observations can lead to improvements in managed care of this vulnerable population of patients.

METHODS

A narrative review of the primary literature was performed on contributing factors with primary focus on the period 2015-2020 using available databases and search engines. Adherence pain points identified were mapped against a series of potential solutions which are presented.

RESULTS

Enhancement of treatment adherence relies on two approaches viz. single-factor and multi-factor solutions. Single factors identified include electronic reminders, enhanced health education, financial incentives, gamification strategies, community drivers, persona-based modeling, and burden relief of poly pharmacy. Multi-factor solutions combine two or more of the seven approaches offering the potential for flexible interventions tailored to the individual.

DISCUSSION AND CONCLUSION

Heart failure patients with poor adherence have increased mortality, hospitalization needs, and healthcare costs. This review highlights current single-factor and multi-factor adherence methods. Against a backdrop of diversity of approaches, multi-factor solutions cast the widest net for positively influencing adherent behaviors. A key enabler lies in the development and leveraging of patient personas in the synthesis of successful intervention methods. Deployable solutions can also be envisioned in clinical trials where adherence tracking represents an essential component.

Contemporary NSTEMI management: the role of the hospitalist

Non-ST-segment elevation myocardial infarction (NSTEMI) is defined as elevated cardiac biomarkers of necrosis in the absence of persistent ST-segment elevation in the setting of anginal symptoms or other acute event. It carries a poorer prognosis than most ST-segment elevation events, owing to the typical comorbidity burden of the older NSTEMI patients as well as diverse etiologies that add complexity to therapeutic decision-making. It may result from an acute atherothrombotic event ('Type 1') or as the result of other causes of mismatch of myocardial oxygen supply and demand ('Type 2'). Regardless of type and other clinical factors, the hospital medicine specialist is increasingly responsible for managing or coordinating the care of these patients. Following published guidelines for risk stratification and basing anti-anginal, anticoagulant, antiplatelet, other pharmacologic therapies, and overall management approach on that individualized patient risk assessment can be expected to result in better short- and long-term clinical outcomes, including near-term readmission and recurrent events. We present here a review of the evidence basis and expert commentary to assist the hospitalist in achieving those improved outcomes in NSTEMI. Given that the Society for Hospital Medicine cites care of patients with acute coronary syndrome as a core competency for hospitalists, it is essential that those specialists stay current on optimal NSTEMI care.Abbreviations: ACC: American college of cardiology; ACCOAST: comparison of prasugrel at the time of diagnosis in patients with non-ST elevation myocardial infarction; ACS: acute coronary syndrome; ADP: adenosine diphosphate; AHA: American heart association; ARB: angiotensin II receptor blocker; ASA: acetylsalicylic acid; CABG: coronary artery bypass graft: CAD: coronary artery disease; CCTA: coronary computed tomography angiography; cTn: cardiac troponin; CRUSADE: can rapid risk stratification of unstable angina patients suppress adverse outcomes with early implementation of the ACC/AHA guidelines; CURE: clopidogrel in unstable angina to prevent recurrent events; CURRENT: OASIS-7 clopidogrel and aspirin optimal dose usage to reduce recurrent events-seventh organization to assess strategies in ischemic syndromes; ECG: electrocardiogram; ED: emergency department; ESRD: endstage renal disease; ESC: European society of cardiology; FDA: food and drug administration; GRACE: global registry of acute coronary events; LVEF: left ventricular ejection fraction; MACE: major adverse cardiac event; MI: myocardial infarction; MVO₂: myocardial oxygen demand; NSTEMI: non-ST-segment-elevation myocardial infarction; NTG: Nitroglycerin; PCI: percutaneous coronary intervention; plato: platelet inhibition and patient outcomes; PPI: proton pump inhibitor; PURSUIT: platelet glycoprotein IIb/IIIa in unstable angina: Receptor Suppression Using Integrilin Therapy; RAAS: Renin-Angiotensin-Aldosterone System; SHM: society of hospital medicine; STEMI: ST-segment-elevation myocardial infarction; TIMI: Thrombolysis in Myocardial Infarction; TRITON-TIMI:trial to assess improvement in therapeutic outcomes by optimizing platelet inhibition with prasugrel-thrombolysis in myocardial infarction.

When a Short-Term Outlook Is the Best Long-Term Strategy: Time-Varying Risk of Readmission After Acute Myocardial Infarction

See Article by Khot et al

[The Pathways to Increase the Efficacy of Drug Therapy in Patients with Ischemic Heart Disease after Coronary Artery Bypass Grafting]

PURPOSE

to assess drug therapy and achievement of target parameters of treatment in patients with ischemic heart disease (IHD) during 3-5 years of follow-up aſter coronary bypass surgery.

MATERIALS AND METHODS

From the initial sample of the coronary bypass surgery registry (n=680) we selected for this study 111 men (mean age 61 [55; 65] years) hospitalized in 2011 with clinical picture of IHD for coronary artery bypass graſting (CABG).

RESULTS

Mean duration of follow-up was 4.2 years. Mortality was 11.7 % (n=13), 11 deaths were cardiovascular, 2 - from unknown causes. End points defined as repeat hospitalizations and IHD progression were registered in 18 of 98 patients (18.4 %). Only in 25 % of patients during 3-5 years of observation aſter CABG there were no clinical signs of angina. Five patients (5.1 %) developed new type 2 diabetes. Drug therapy: 80 patients (81.6 %) received acetylsalicylic acid, 60 (61.2 %) - angiotensin converting enzyme inhibitors, 80 (81.6 %) - β-adrenoblockers. Eighty-one men (82.6 %) received statins, but only 20 of 98 re-examined patients (20.4 %) took high doses. Target levels of low density lipoprotein cholesterolConclusion. Data of clinical practice illustrate insufficient quality of basic and antianginal therapy in patients with IHD aſter CABG. Indicators of control of angina, heart rate, achievement of target levels of parameters of lipid metabolism remain unsatisfactory.

The Unmet Challenge of Medication Nonadherence

Medication nonadherence for patients with chronic diseases is extremely common, affecting as many as 40% to 50% of patients who are prescribed medications for management of chronic conditions such as diabetes or hypertension. This nonadherence to prescribed treatment is thought to cause at least 100,000 preventable deaths and $100 billion in preventable medical costs per year. Despite this, the medical profession largely ignores medication nonadherence or sees it as a patient problem and not a physician or health system problem. Much of the literature on nonadherence focuses on barriers to adherence, with the assumption that appropriate adherence is the normal course of events and nonadherence is an aberration. This approach minimizes and oversimplifies the problem. It is not easy for humans to change their behavior, even for what many physicians see as a minor change such as taking prescription medications. Improving medication adherence has not been well studied, but a Cochrane review shows that multifactorial interventions are more effective. In at least one integrated health care system, Kaiser Permanente Northern California, a combination of approaches centered on the electronic health record has improved medication adherence rates to above 80%. Using similar elements would be feasible in other health care systems but would require motivation and planning. Effective change will not happen until key players decide to take on this challenge and reimbursement systems are changed to reward health systems that improve medication adherence and chronic disease control.

An innovative and comprehensive technique to evaluate different measures of medication adherence: The network meta-analysis

BACKGROUND

Poor medication adherence is associated with adverse health outcomes and higher costs of care. However, inconsistencies in the assessment of adherence are found in the literature.

OBJECTIVE

To evaluate the effect of different measures of adherence in the comparative effectiveness of complex interventions to enhance patients' adherence to prescribed medications.

METHODS

A systematic review with network meta-analysis was performed. Electronic searches for relevant pairwise meta-analysis including trials of interventions that aimed to improve medication adherence were performed in PubMed. Data extraction was conducted with eligible trials evaluating short-period adherence follow-up (until 3 months) using any measure of adherence: self-report, pill count, or MEMS (medication event monitoring system). To standardize the results obtained with these different measures, an overall composite measure and an objective composite measure were also calculated. Network meta-analyses for each measure of adherence were built. Rank order and surface under the cumulative ranking curve analyses (SUCRA) were performed.

RESULTS

Ninety-one trials were included in the network meta-analyses. The five network meta-analyses demonstrated robustness and reliability. Results obtained for all measures of adherence were similar across them and to both composite measures. For both composite measures, interventions comprising economic + technical components were the best option (90% of probability in SUCRA analysis) with statistical superiority against almost all other interventions and against standard care (odds ratio with 95% credibility interval ranging from 0.09 to 0.25 [0.02, 0.98]).

CONCLUSION

The use of network meta-analysis was reliable to compare different measures of adherence of complex interventions in short-periods follow-up. Analyses with longer follow-up periods are needed to confirm these results. Different measures of adherence produced similar results. The use of composite measures revealed reliable alternatives to establish a broader and more detailed picture of adherence.