Rationale and design of a randomized cluster trial to improve guideline-adherence of secondary preventive drugs prescription after coronary artery bypass grafting in China: Measurement and Improvement Studies of Surgical Coronary Revascularization: Secondary Prevention (MISSION-1) Study

The of effect of partnership-based education on adherence to the treatment plans in open heart surgery

BACKGROUND

Adherence to the treatment plans is one of the most effective conducts to prevent and reduce postoperative side effects. Partnership-based education is one of the most efficient ways to shape health behaviors. The aim of the present study was to determine the effect of partnership-based education on adherence to the treatment plans in open heart surgery.

MATERIALS AND METHODS

This quasi-experimental study was conducted in 2019-2020 on the patients undergoing open heart surgery in Tehran (Capital of Iran). Sampling was done in one educational hospital. A total of 86 patients and their caregivers participated in the study. Sampling was done nonrandomly by tossing a coin, and patients were allocated into the odd week in the intervention group and the even week in the control group (n = 43 in each group), and data were collected before and after intervention using the Treatment Adherence Questionnaire concerning dietary, physical activity, and medication aspects. The educational intervention was carried out after the pretest analysis in five 20-45 min sessions (two individual and three group educations). Data were analyzed with Chi-square, independent t-test, and paired t-test using SPSS 19 at a significance level of P < 0.05.

RESULTS

Patients and caregivers in both groups did not have a significant difference in terms of demographic variables (P > 0. 05). In addition, there was no significant difference in the mean of dietary, physical activity, and medication plans before the intervention in both groups; however, after the intervention, the mean of the three aspects in the intervention group was significantly higher than that of control (P < 0.001).

CONCLUSION

Implementing partnership-based education with participation of patients and caregivers is influential in improving patients' adherence to the treatment plans and it is recommended as a clinical dynamic educational strategy.

Effect of a smartphone-based intervention on secondary prevention medication prescriptions after coronary artery bypass graft surgery: The MISSION-1 randomized controlled trial

BACKGROUND

Studies found that patients who underwent coronary artery bypass grafting (CABG) often fail to receive optimal evidence-based secondary prevention medications. We evaluated the effectiveness of a smartphone-based quality improvement effort on improving the prescription of medical therapies.

METHODS

In this cluster-randomized controlled trial, 60 hospitals were randomized to a control arm (n = 30) or to an intervention arm using smartphone-based multifaceted quality improvement interventions (n = 30). The primary outcome was the prescription of statin. The secondary outcomes were prescription of beta-blocker, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker (ACE inhibitor or ARB), and optimal medical therapy for eligible patients.

RESULTS

Between June 1, 2015 and September 15, 2016, a total of 10,006 CABG patients were enrolled (5,653 in 26 intervention and 4,353 in 29 control hospitals, 5 hospitals withdrew). Statin prescribing rate was 87.8% in the intervention arm and 84.4% in the control arm. We saw no evidence of an effect of intervention on statin prescribing in the intention-to-treat analysis (odds ratio [OR], 1.31; 95% confidence interval (CI), 0.68-2.54; P = .43) or in key patient subsets. The prescription rates of ACE inhibitor or ARB and optimal medical therapy were comparable between study groups, while beta-blocker was more often prescribed in the intervention arm. Post hoc analysis demonstrated a greater increase in statin prescribing rate over time in the intervention arm.

CONCLUSIONS

A smartphone-based quality improvement intervention compared with usual care did not increase statin prescribing for patients who received CABG. New studies focusing on the best practice of this technique may be warranted.

The effects of clinical decision support system for prescribing medication on patient outcomes and physician practice performance: a systematic review and meta-analysis

Background

Clinical Decision Support Systems (CDSSs) for Prescribing are one of the innovations designed to improve physician practice performance and patient outcomes by reducing prescription errors. This study was therefore conducted to examine the effects of various CDSSs on physician practice performance and patient outcomes.

Methods

This systematic review was carried out by searching PubMed, Embase, Web of Science, Scopus, and Cochrane Library from 2005 to 2019. The studies were independently reviewed by two researchers. Any discrepancies in the eligibility of the studies between the two researchers were then resolved by consulting the third researcher. In the next step, we performed a meta-analysis based on medication subgroups, CDSS-type subgroups, and outcome categories. Also, we provided the narrative style of the findings. In the meantime, we used a random-effects model to estimate the effects of CDSS on patient outcomes and physician practice performance with a 95% confidence interval. Q statistics and I² were then used to calculate heterogeneity.

Results

On the basis of the inclusion criteria, 45 studies were qualified for analysis in this study. CDSS for prescription drugs/COPE has been used for various diseases such as cardiovascular diseases, hypertension, diabetes, gastrointestinal and respiratory diseases, AIDS, appendicitis, kidney disease, malaria, high blood potassium, and mental diseases. In the meantime, other cases such as concurrent prescribing of multiple medications for patients and their effects on the above-mentioned results have been analyzed. The study shows that in some cases the use of CDSS has beneficial effects on patient outcomes and physician practice performance (std diff in means = 0.084, 95% CI 0.067 to 0.102). It was also statistically significant for outcome categories such as those demonstrating better results for physician practice performance and patient outcomes or both. However, there was no significant difference between some other cases and traditional approaches. We assume that this may be due to the disease type, the quantity, and the type of CDSS criteria that affected the comparison. Overall, the results of this study show positive effects on performance for all forms of CDSSs.

Conclusions

Our results indicate that the positive effects of the CDSS can be due to factors such as user-friendliness, compliance with clinical guidelines, patient and physician cooperation, integration of electronic health records, CDSS, and pharmaceutical systems, consideration of the views of physicians in assessing the importance of CDSS alerts, and the real-time alerts in the prescription.

Quality Measurement and Improvement Study of Surgical Coronary Revascularization: Medication Adherence (MISSION-2)

Background

Secondary preventive therapies play a key role in the prevention of adverse outcomes after coronary artery bypass grafting (CABG). However, medication adherence after CABG is often poor, and conventional interventions for improving adherence have limited success. With increasing penetration of smartphones, health-related smartphone applications might provide an opportunity to improve adherence. Carefully designed trials are needed to provide reliable evidence for the use of these applications in patients after CABG.

Methods

The Measurement and Improvement Studies of Surgical Coronary Revascularization: Medication Adherence (MISSION-2) study is a multicenter randomized controlled trial, aiming to randomize 1000 CABG patients to the intervention or control groups in a 1:1 ratio. We developed the multifaceted, patient-centered, smartphone-based Heart Health Application to encourage medication adherence in the intervention group through a health self-management program initiated during hospital admission for CABG. The application integrated daily scheduled reminders to take the discharge medications, cardiac educational materials, a dynamic dashboard to review cardiovascular risk factors and secondary prevention targets, and weekly questionnaires with interactive feedback. The primary outcome was secondary preventive medication adherence measured by the Chinese version of the 8-item Morisky Medication Adherence Scale at 6 months after randomization. Secondary outcomes included all-cause death, cardiovascular rehospitalization, and a composite of death, myocardial infarction, stroke, and repeat revascularization.

Discussion

Findings will not only provide evidence regarding the feasibility and effectiveness of the described intervention for improving adherence to CABG secondary preventive therapies but also explore a model for outpatient health self-management that could be translated to various chronic diseases and widely disseminated across resource-limited settings.

Trial Registration

https://clinicaltrials.gov (NCT02432469).