Non-physician health workers for improving adherence to medications and healthy lifestyle following acute coronary syndrome: 24-month follow-up study

Improving medication adherence among persons with cardiovascular disease through m-health and community health worker-led interventions in Kerala; protocol for a type II effectiveness-implementation research-(SHRADDHA-ENDIRA)

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of mortality worldwide, and at present, India has the highest burden of acute coronary syndrome and ST-elevation myocardial infarction (MI). A key reason for poor outcomes is non-adherence to medication.

METHODS

The intervention is a 2 × 2 factorial design trial applying two interventions individually and in combination with 1:1 allocation ratio: (i) ASHA-led medication adherence initiative comprising of home visits and (ii) m-health intervention using reminders and self-reporting of medication use. This design will lead to four potential experimental conditions: (i) ASHA-led intervention, (ii) m-health intervention, (iii) ASHA and m-health intervention combination, (iv) standard of care. The cluster randomized trial has been chosen as it randomizes communities instead of individuals, avoiding contamination between participants. Subcenters are a natural subset of the health system, and they will be considered as the cluster/unit. The factorial cluster randomized controlled trial (cRCT) will also incorporate a nested health economic evaluation to assess the cost-effectiveness and return on investment (ROI) of the interventions on medication adherence among patients with CVDs. The sample size has been calculated to be 393 individuals per arm with 4-5 subcenters in each arm. A process evaluation to understand the effect of the intervention in terms of acceptability, adoption (uptake), appropriateness, costs, feasibility, fidelity, penetration (integration of a practice within a specific setting), and sustainability will be done.

DISCUSSION

The effect of different types of intervention alone and in combination will be assessed using a cluster randomized design involving 18 subcenter areas. The trial will explore local knowledge and perceptions and empower people by shifting the onus onto themselves for their medication adherence. The proposal is aligned to the WHO-NCD aims of improving the availability of the affordable basic technologies and essential medicines, training the health workforce and strengthening the capacity of at the primary care level, to address the control of NCDs. The proposal also helps expand the use of digital technologies to increase health service access and efficacy for NCD treatment and may help reduce cost of treatment.

TRIAL REGISTRATION

The trial has been registered with the Clinical Trial Registry of India (CTRI), reference number CTRI/2023/10/059095.

The interventions to improve medication adherence in coronary heart disease patient: A systematic review

Objective

The clinical outcome and quality of life of CHD patients are greatly influenced by medication adherence. Non-adherence of CHD patients to treatment results in sub-optimal clinical outcomes and increasing costs. This study aims to describe effectiveness of the intervention to improve the medication adherence in CHD patients.

Methods

Systematic review methodology was used in this study. Scopus and PubMed were used to search the relevant article systematically. The outcome measured was medication adherence in coronary heart disease patients.

Results

Final screening was 31 articles that met the inclusion criteria in this study of 788 articles. Selection processes the article used the PRISMA guideline. Most of the articles (15 articles) use interventions that utilize information technology (IT) as known with m-health in the form of text messages, website, and smartphone-based applications in increasing medication adherence in CHD patients. The non m-health interventions developed are in the form of self-efficacy programs, monitoring and education by health workers or care workers, pharmacy care by clinical pharmacists, and the use of drugs in the form of multi-capsules. The results of most intervention with m-health can improve the medication adherence in CHD patient effectively. Education and motivation program by professional health care and multi-capsules also increasing the medication adherence in the intervention control. There was a decrease of medication adherence in some articles with long time follow-up that can be attention for the professional health care to manage the patient adherent.

Conclusion

The medication adherence in CHD patient can be improve by various program. Modification of m-health and non m-health intervention can be resolved to increase the communication, motivation, and knowledge about medication adherence in CHD patients.

A systematic review investigating the role and impact of pharmacist interventions in cardiac rehabilitation

BACKGROUND

Cardiovascular disease (CVD) is a predominant cause of mortality. Pharmacists play an important role in secondary prevention of CVD, however, their role in cardiac rehabilitation is under-reported and services are under-utilised.

AIM

To explore the role of pharmacists in cardiac rehabilitation, the impact of their interventions on patient outcomes, and prospects of future role development.

METHOD

Databases searched were PubMed, Embase, Medline, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and PsycINFO from January 2006 to October 2021. Randomised and non-randomised controlled trials were selected if they assessed the role of pharmacists in cardiac rehabilitation. Cochrane risk of bias tool, Joanna Briggs Institute (JBI) Critical Appraisal Tool for Quasi-Experimental Studies and the National Heart, Lung and Blood Institute (NIH) quality assessment tool, were used to assess quality and a narrative synthesis was conducted.

RESULTS

The search yielded 786 studies, only five met the inclusion criteria. The pharmacist-led interventions included patient education, medication review and reconciliation, and medication adherence encouragement. Four out of the five studies showed that pharmacist-led interventions in cardiac rehabilitation significantly improved patient clinical and non-clinical outcomes. One study showed a statistically significant reduction in low density lipoprotein-cholesterol (LDL-C) levels to optimal target of < 70 mg/dL (80% vs 60%, p = 0.0084). Two studies reported better medication adherence, and two studies showed greater improvement in all domains of health-related quality of life observed in the intervention group.

CONCLUSION

Pharmacist-led interventions in cardiac rehabilitation could lower CVD risk factors and hence recurrence. Although these findings support pharmacists' involvement in cardiac rehabilitation, larger intervention studies are needed to evaluate the feasibility of pharmacist-led interventions and their impact on hospital admissions and mortality risk.

Characteristics and Outcomes of Community Health Worker Training to Improve the Prevention and Control of Cardiometabolic Diseases in Low and Middle-Income Countries: A Systematic Review

Community health workers (CHWs) play an important role in controlling non-communicable diseases in low- and middle-income countries. The aim of this review was to describe the characteristics and outcomes of CHW training programs that focused on the prevention and control of cardiometabolic diseases in low- and middle-income countries (LMICs). Medline, CINAHL Complete, Academic Search Complete, Directory of Open Access Journal, ScienceDirect, ERIC, Gale Academic, and OneFile). Studies that described the training programs used to train CHWs for prevention and control of cardiovascular diseases and type2 diabetes mellitus in LMICs. Only studies that evaluated the outcomes of training programs in at least one of the 4 levels of Kirkpatrick's training evaluation model were included in the review. CHWs who underwent training focused on the prevention and control of cardiovascular disease and type 2 diabetes mellitus. We summarized the resulting evidence using qualitative synthesis through a narrative review. Training outcomes were assessed in relation to (1) CHW reactions to training, their degree of learning, and their behaviors following training, and (2) changes in biochemical and anthropometric indicators in target populations following the CHW program implementation. PROSPERO (CRD42020162116). Thirty-two studies were included. Methods used to train CHWs included: face-to-face lectures, interactive group activities, and blended teaching with online support. Training focused on identifying people with elevated risk of cardiometabolic diseases and their risk factors as well as supporting people to adopt healthy lifestyles. Many studies that utilized trained CHWs did not publish CHW training methods and evaluations, and therefore could not be included in this study. Training programs resulted in an increase in knowledge and skills among CHWs demonstrating that there are certain activities that can be shifted to CHWs following training.

Medication Adherence Interventions for Cardiovascular Disease in Low- and Middle-Income Countries: A Systematic Review

PURPOSE

The burden of cardiovascular diseases (CVD) is high in low- and middle-income countries (LMICs). Medications are integral to the management and control of CVD; however, suboptimal adherence impacts health outcomes. This systematic review aims to critically examine interventions targeted at improving medication adherence among persons with CVD in LMICs.

METHODS

In this systematic review, we searched online databases PubMed, Embase, and CINAHL for studies that evaluated a medication adherence intervention for CVD, reported adherence as an outcome measure, were conducted in LMICs and reported the strategy or tool used to measure adherence. We included articles published in English, available in full text, peer-reviewed, and published between 2010 and 2020.

RESULTS

We included 45 articles in this review. The majority of the studies implemented counseling and educational interventions led by nurses, pharmacists, or community health workers. Many of the studies delivered medication-taking reminders in the form of phone calls, text messages, short message services (SMS), and in-phone calendars. Multi-component interventions were more effective than unifocal interventions. Interventions involving technology, such as mobile phone calls, electronic pillboxes, and interactive phone SMS reminders, were more effective than generic reminders. The outcomes reported in the studies varied based on the complexity and combination of strategies. When interventions were implemented at both the patient level, such as reminders, and at the provider level, such as team-based care, the effect on medication adherence was larger.

CONCLUSION

In LMICs, medication adherence interventions among persons with CVD included a combination of patient education, reminders, fixed-dose combination therapy and team-based care approach were generally more effective than singular interventions. Among patients who had CVD, the medication adherence interventions were found to be moderately effective. Future studies focusing on improving medication adherence in LMICs should consider non-physician-led interventions and appropriately adapt the interventions to the local context.

Investigating the Effect of Family-Centered Self-Care Program based on Home Visits Regarding Dietary and Medication Regimen Adherence of Discharged Patients with Acute Coronary Syndrome

Background

Dietary and medication regimen adherence in patients with history of Acute Coronary Syndrome (ACS) is very important in preventing readmission and reducing the complications of the disease. The objective of the present study was to investigate the effect of the family-centered self-care program based on home visits dietary and medication regimen adherence in patients with ACS discharged from Shahid Chamran Hospital during 2017-2018.

Materials and Methods

This clinical trial was conducted on 80 ACS patients. The samples by using the random numbers table, were randomly divided into control and experimental groups. The routine interventions were administered for the control group, and family-centered self-care was conducted on patients of the experiment group. In order to obtain the quantitative data of this study, three questionnaires were used including demographic characteristics, Morisky questionnaire, and dietary adherence.

Results

The difference between the mean score of medication and diet regimen adherence in both groups before the intervention was not significant (p > 0.05). data was demonstrated that scores of medication and diet regimen adherence were significantly higher immediately and 6 weeks after the intervention; (f = 64.06, p < 0.001).

Conclusions

Family-centered self-care program based on home visits can be used as an effective method to increase the dietary and medication regimen adherence in ACS patients.

Leveraging role of non-physician health workers in prevention and control of non-communicable diseases in India: Enablers and challenges

Due to upsurge of non-communicable disease (NCD) burden, there is accentuated emphasis on task sharing and shifting NCDs-related health care delivery to non-physician healthcare workers especially nursing personnel and grass root level health professionals. This narrative review summates role of non-physician health workers, highlights various enablers and challenges while engaging them in delivery of NCD services so as to prevent and control various NCDs in India. Pubmed, Google scholar databases were searched using various keywords and Mesh terminologies. In addition, reference lists of selected articles were also screened. It is concluded that with regular update of knowledge, training, and supervision, these workers can efficiently deliver promotive, preventive, curative, and rehabilitative NCD-related healthcare services to needy. While engagement of this workforce in NCDs mitigation is a transforming concept, it also has its own challenges and issues which need to be explored and addressed in order to utilize this human resource to their maximum potential.

An intervention study for impact assessment of health education by empowered community health workers in improving treatment and diet adherence in hypertension

Context:

Medication and low salt diet adherence play as an essential factor in blood pressure target achievement. Community health worker empowerment was reported to be a highly effective social intervention to medication and low salt diet adherence.

Aims:

This study aimed to investigate the effect of structured health education regarding hypertension on community health workers on medication and low salt diet adherence among hypertensive patients in Malang.

Subjects and Methods:

A quasi-experimental study was conducted in health workers and their hypertensive patients who join in the Integrated Health Service Post for the Elderly (IHSP-Elderly) program in Malang. Medication adherence was measured by the medication adherence questionnaire and low salt diet adherence was measured by dietary salt restriction questionnaire. The data were analyzed by Chi-square analysis for categorical data and independent t-test for numerical data.

Results:

This study showed that hypertensive patients in the intervention group had better knowledge regarding hypertension compared to those of the control group (P < 0.05). The patients' satisfaction in intervention group improved significantly after health education (P < 0.01). The proportion of patients with good medication adherence improved significantly (P < 0.01) from 20% to 70% after health education in intervention group. Moreover, the proportion of patients with good low salt diet compliance improved significantly (P < 0.01) from 39% to 85%. Conversely, the proportion of good medication and low salt diet adherence in control group relatively similar between pre- and post-test.

Conclusions:

This study showed that health education on community health workers improved hypertensive patients' medication and low salt diet adherence.

Copayment Reduction Voucher Utilization and Associations With Medication Persistence and Clinical Outcomes

Background:

Cost is frequently cited as a barrier to optimal medication use, but the extent to which copayment assistance interventions are used when available, and their impact on evidence-based medication persistence and major adverse cardiovascular events is unknown.

Methods and Results:

The ARTEMIS trial (Affordability and Real-World Antiplatelet Treatment Effectiveness After Myocardial Infarction Study) randomized 301 hospitals to usual care versus the ability to provide patients with vouchers that offset copayment costs when filling P2Y 12 inhibitors in the 1 year post-myocardial infarction. In the intervention group, we used multivariable logistic regression to identify patient and medication cost characteristics associated with voucher use. We then used this model to stratify both intervention and usual care patients by likelihood of voucher use, and examined the impact of the voucher intervention on 1-year P2Y 12 inhibitor persistence (no gap in pharmacy supply >30 days) and major adverse cardiovascular events (all-cause death, myocardial infarction, or stroke). Among 10 102 enrolled patients, 6135 patients were treated at hospitals randomized to the copayment intervention. Of these, 1742 (28.4%) never used the voucher, although 1729 (99.2%) voucher never-users filled at least one P2Y 12 inhibitor prescription in the 1 year post-myocardial infarction. Characteristics most associated with voucher use included: discharge on ticagrelor, planned 1-year course of P2Y 12 inhibitor treatment, white race, commercial insurance, and higher out-of-pocket medication costs (c-statistic 0.74). Applying this propensity model to stratify all enrolled patients by likelihood of voucher use, the intervention improved medication persistence the most in patients with high likelihood of voucher use (adjusted interaction P =0.03, odds ratio, 1.86 [95% CI, 1.48–2.33]). The intervention did not significantly reduce major adverse cardiovascular events in any voucher use likelihood group, although the odds ratio was lowest (0.86 [95% CI, 0.56–1.16]) among patients with high likelihood of voucher use (adjusted interaction P =0.04).

Conclusions:

Among patients discharged after myocardial infarction, those with higher copayments and greater out-of-pocket medication costs were more likely to use a copayment assistance voucher, but some classes of patients were less likely to use a copayment assistance voucher. Patients at low likelihood of voucher use benefitted least from copayment assistance, and other interventions may be needed to improve medication-taking behaviors and clinical outcomes in these patients.

Registration:

URL: https://www.clinicaltrials.gov . Unique identifier: NCT02406677.

An integrated intervention for chronic care management in rural Nepal: protocol of a type 2 hybrid effectiveness-implementation study

BACKGROUND

In Nepal, the burden of noncommunicable, chronic diseases is rapidly rising, and disproportionately affecting low and middle-income countries. Integrated interventions are essential in strengthening primary care systems and addressing the burden of multiple comorbidities. A growing body of literature supports the involvement of frontline providers, namely mid-level practitioners and community health workers, in chronic care management. Important operational questions remain, however, around the digital, training, and supervisory structures to support the implementation of effective, affordable, and equitable chronic care management programs.

METHODS

A 12-month, population-level, type 2 hybrid effectiveness-implementation study will be conducted in rural Nepal to evaluate an integrated noncommunicable disease care management intervention within Nepal's new municipal governance structure. The intervention will leverage the government's planned roll-out of the World Health Organization's Package of Essential Noncommunicable Disease Interventions (WHO-PEN) program in four municipalities in Nepal, with a study population of 80,000. The intervention will leverage both the WHO-PEN and its cardiovascular disease-specific technical guidelines (HEARTS), and will include three evidence-based components: noncommunicable disease care provision using mid-level practitioners and community health workers; digital clinical decision support tools to ensure delivery of evidence-based care; and training and digitally supported supervision of mid-level practitioners to provide motivational interviewing for modifiable risk factor optimization, with a focus on medication adherence, and tobacco and alcohol use. The study will evaluate effectiveness using a pre-post design with stepped implementation. The primary outcomes will be disease-specific, "at-goal" metrics of chronic care management; secondary outcomes will include alcohol and tobacco consumption levels.

DISCUSSION

This is the first population-level, hybrid effectiveness-implementation study of an integrated chronic care management intervention in Nepal. As low and middle-income countries plan for the Sustainable Development Goals and universal health coverage, the results of this pragmatic study will offer insights into policy and programmatic design for noncommunicable disease care management in the future.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04087369. Registered on 12 September 2019.

Enhancing Primary Adherence to Prescribed Medications through an Organized Health Status Assessment-Based Extension of Primary Healthcare Services

This study was part of monitoring an intervention aimed at developing a general practitioner cluster (GPC) model of primary healthcare (PHC) and testing its effectiveness in delivering preventive services integrated into the PHC system. The aim was to demonstrate whether GPC operation could increase the percentage of drugs actually dispensed. Using national reference data of the National Health Insurance Fund for each anatomical-therapeutic chemical classification ATC group of drugs, dispensed-to-prescribed ratios standardized (sDPR) for age, sex, and exemption certificate were calculated during the first quarter of 2012 (before-intervention) and the third quarter of 2015 (post-intervention). The after-to-before ratios of the sDPR as the relative dispensing ratio (RDR) were calculated to describe the impact of the intervention program. The general medication adherence increased significantly in the intervention area (RDR = 1.064; 95% confidence interval (CI): 1.054-1.073). The most significant changes were observed for cardiovascular system drugs (RDR = 1.062; 95% CI: 1.048-1.077) and for alimentary tract and metabolism-specific drugs (RDR = 1.072; 95% CI: 1.049-1.097). The integration of preventive services into a PHC without any specific medication adherence-increasing activities is beneficial for medication adherence, especially among patients with cardiovascular, alimentary tract, and metabolic disorders. Monitoring the percentage of drugs actually dispensed is a useful element of PHC-oriented intervention evaluation frames.

Medication adherence, biological and lifestyle risk factors in patients with myocardial infarction: a ten-year follow-up on socially differentiated cardiac rehabilitation

Objective: There is strong evidence that medication adherence and lifestyle changes are essential in patients undergoing secondary cardiovascular disease prevention. Cardiac rehabilitation (CR) increases medication adherence and improves lifestyle changes. Patients with cardiac diseases and a low educational level and patients with little social support are less responsive to improve medication adherence and to adapt lifestyle changes. The aim of the present study was to investigate the long-term effects of a socially differentiated CR intervention on medication adherence as well as changes in biological and lifestyle risk factors at two- five- and ten-year follow-up. Design: A prospective cohort study. Setting: The cardiac ward at Aarhus University Hospital, Denmark. Intervention: A socially differentiated CR intervention in addition to the standard CR program. Subjects: Patients admitted with first-episode myocardial infarction between 2000 and 2004, N = 379. Patients were defined as socially vulnerable or non-socially vulnerable according to their educational level and extent of social network. Main outcome measures: Primary outcome was medication adherence to antithrombotics, beta-blockers, statins and angiotensin-converting enzyme inhibitors. Secondary outcomes were biological and lifestyle risk factors defined as; total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, glycated hemoglobin, blood pressure and smoking status. Results: No significant long-term effect of the intervention was found. Conclusions: The results indicate a non-significant effect of the intervention. However, it was found that equality in health was improved in the study population except concerning smoking. General practitioners manage to support the long-term secondary cardiovascular disease prevention in all patients regardless of social status. Key points The socially differentiated intervention did not significantly improve medication adherence or biological and lifestyle risk factors. Despite the non-significant effect of the intervention, equality in health was improved except concerning smoking. General practitioners managed to support the long-term secondary cardiovascular disease prevention in all patients regardless of social status.

Management of pharmacotherapy-related problems in acute coronary syndrome: Role of clinical pharmacist in cardiac rehabilitation unit

Acute coronary syndrome (ACS) is one of the leading causes of mortality worldwide and negatively impacts healthcare costs, productivity and quality of life. Polymorbidity and polypharmacy predispose ACS patients to medication discrepancies between cardiologist-prescribed medication and drug use by the patient, drug-related problems (DRPs) and inadequate drug adherence. This study aimed to evaluate the impact of clinical pharmacist-provided services on the outcome of ACS patients. This was a prospective, randomized, controlled study on ACS patients participating in a cardiac rehabilitation programme. Forty ACS patients were randomly assigned to either control group, who received standard medical care, or intervention group, who received standard medical care plus clinical pharmacist-provided services. Services included DRP management, clinical assessment and enforcing the patient education and adherence. For both groups, the following were assessed at baseline and after 3 months: DRPs, adherence (assessed by 8-item Morisky Adherence Questionnaire), patient's knowledge (assessed by Coronary Artery Disease Questionnaire), 36-Short Form Health Survey (SF-36), heart rate, systolic and diastolic blood pressure, low-density lipoprotein (LDL), total cholesterol (TC) and fasting blood glucose (FBG). After 3 months, there was a significant difference between the intervention and control groups in the per cent change of DRPs (median: -100 vs 5.882, P = 0.0001), patient's adherence score (median: 39.13 vs -14.58, P = 0.0001), knowledge score (median: 30.28 vs -5.196, P = 0.0001), SF-36 scores, heart rate (mean: -10.04 vs 6.791, P = 0.0001), diastolic blood pressure (mean: -17.87 vs 10.45, P = 0.0001), systolic blood pressure (mean: -16.22 vs 4.751, P = 0.0001), LDL (median: -25.73 vs -0.2538, P = 0.0071), TC (median: -14.62 vs 4.123, P = 0.0005) and FBG (median: -11.42 vs 5.422, P = 0.0098). Clinical pharmacists can play an important role as part of a cardiac rehabilitation team through patient education and interventions to minimize DRPs.

Cardiovascular Disease Among Women From Vulnerable Populations: A Review

On a global scale, cardiovascular disease (CVD) is the leading cause of mortality. It is also the number 1 cause of death among women, resulting in 8.6 million deaths annually and constituting one third of all deaths in women worldwide. The burden of CVD and related risk factors has taken priority in the policy development for noncommunicable diseases. However, vulnerable populations, defined here as women who are socially or economically disadvantaged (eg, low income), nonwhite (specifically South Asian and indigenous women), and those who are elderly have often been overlooked in these discussions. These additional vulnerabilities, which may exist independently or in combination, place such women at higher risk for CVD. Specifically, these vulnerabilities include low socioeconomic status, a low sense of control, high stress, South Asian or indigenous ancestry, and increased age. Thus it is vital that we initiate a multipronged approach to CVD prevention that includes rigorous monitoring of CVD risk factors in high-risk populations and the implementation of timely, accurate, and contextually tailored prevention programs, services, and treatments. Well-trained nonphysician health care workers can support the accurate monitoring and management of CVD and CVD risk factors so that groups of women who may otherwise be overlooked can receive adequate attention.

Healthcare provider-led interventions to support medication adherence following ACS: a meta-analysis

We conducted a systematic review and meta-analysis to determine the effectiveness of healthcare provider-led (HCPs) interventions to support medication adherence in patients with acute coronary syndrome (ACS). A systematic search of Cochrane Library, Medline, EMBASE, PsycINFO, Web of Science, IPA, CINAHL, ASSIA, OpenGrey, EthOS, WorldCat and PQDT was undertaken. Interventions were deemed eligible if they included adult ACS patients, were HCP-led, measured medication adherence and randomised participants to parallel groups. Intervention content was coded using the Behaviour Change Technique (BCT) Taxonomy and data were pooled for analysis using random-effects models. Our search identified 8870 records, of which 27 were eligible (23 primary studies). A meta-analysis (n=9735) revealed HCP-led interventions increased the odds of medication adherence by 54% compared to control interventions (k=23, OR 1.54, 95% CI 1.26 to 1.88, I2=57.5%). After removing outliers, there was a 41% increase in the odds of medication adherence with moderate heterogeneity (k=21, OR 1.41, 95% CI 1.21 to 1.65, I2=35.3%). Interventions that included phone contact yielded (k=12, OR 1.63, 95% CI 1.25 to 2.12, I2=32.0%) a larger effect compared to those delivered exclusively in person. A total of 32/93 BCTs were identified across interventions (mean=4.7, SD=2.2) with 'information about health consequences' (BCT 5.1) (19/23) the most common. HCP-led interventions for ACS patients appear to have a small positive impact on medication adherence. While we were able to identify BCTs among interventions, data were insufficient to determine the impact of particular BCTs on study effectiveness.

PROSPERO registration number

CRD42016037706.