Study of an Intervention to Improve Use of Life-saving Medications for Heart Disease

Heart disease is the leading cause of death for men and women in the United States. For patients with documented coronary artery disease (CAD), anti-platelet agents, beta-blockers and statins have all been shown to improve survival and reduce the frequency of myocardial infarction. Yet, previous research by the Duke CERTs has shown that in a population of over 28,000 patients with documented CAD, only 21% reported consistent use of triple therapy with aspirin, beta-blockers and lipid lowering therapy. These results stimulated the Duke CERTs to devise an intervention to improve adherence to these life-saving medications.

Comparisons: Patients admitted to Duke University Hospital or Southeastern Regional Medical Center (SRMC) with CAD or CAD plus heart failure who agree to participate, will be randomized to an intervention or control arm. The control group will receive usual care, which consists of routine discharge counseling performed by the patient-care nurse and a letter/discharge summary from the Duke physician to the community physician. In addition to usual care, the intervention group will receive focused medication counseling in the hospital by the clinical pharmacist-investigator, who will identify and address potential barriers to medication adherence and will reinforce the importance of taking evidence-based medications long term. Discharge medications will be shared with the community pharmacist. The community pharmacist will monitor for problems with adherence and communicate issues back to the patient and the patient's care team.

• Behavioral: oral education & written tips for remembering medications
  Clinical pharmacist will review purpose of medications of interest (beta-blockers, statins, Angiotensin Converting Enzyme Inhibitor (ACEI)/Angiotensin Receptor Blocker (ARB), aspirin, and other anti-platelets) with the subject. A written list of tips for remembering medications will be provided and reviewed.
  Other Name: Cue-dose training
• Device: pill box
  Subject is provided a pill box and briefly instructed on how to use the box.
  Other Names:

  • Pill box organizer
  • pillbox
• Device: pocket medication card
  Subject is provided with a card that contains space for prescription and non-prescription medications. If desired the clinical pharmacist-investigator will complete the card for the subject.
  Other Names:

  • Medication List
  • List of Medications
• Behavioral: sharing information with community pharmacist
  A fax is sent to the designated community pharmacy at the time of the subject's discharge from the hospital. The fax contains the subject's medications of interest, barriers to medication adherence, and physicians' contact information.
  Other Name: increased communication with community pharmacist
• Behavioral: Medication use evaluations by community pharmacist
  The community pharmacist will assess use of medications of interest at time of first medication fill and by reviewing the subject's computerized medication profile at the pharmacy. Assessments occur at first visit to pharmacy, 6-weeks, 12-weeks, 18-weeks, and 24-weeks. If there are issues with any medications of interest the subject will be called. If needed, the subject's health care team will be notified.
  Other Name: medcation adherence verification
• Behavioral: informing physician if patient has stopped a medication
  The community pharmacist or clinical pharmacist-investigator will fax the subject's physician to notify that a medication has been stopped.
  Other Name: Communication with physician about patient's medication use
• Behavioral: Routine discharge counseling
  Both groups received routine discharge counseling performed by the patient-care nurse.
  Other Name: Discharge instructions
• Other: Letter to physician/discharge summary
  A letter/discharge summary from the hospital physician to the community physician listing the discharge medications, procedures, and recommendations.
  Other Name: Communication to physician about hospital course.

• Experimental: Intervention
  Patients enrolled in the intervention arm received inpatient education on the importance of medication and assessment of barriers to adherence. A pill box, pocket medication card, and tips for remembering to take medications were provided. The community pharmacist was notified of the subject's enrollment. The community pharmacist was asked to reinforce importance of evidence-based medications and assess the subject's medication adherence every 6 weeks for 6 months. If a problem was noted, the subject's health care team will be notified.
  Interventions:

  • Behavioral: oral education & written tips for remembering medications
  • Device: pill box
  • Device: pocket medication card
  • Behavioral: sharing information with community pharmacist
  • Behavioral: Medication use evaluations by community pharmacist
  • Behavioral: informing physician if patient has stopped a medication
  • Behavioral: Routine discharge counseling
  • Other: Letter to physician/discharge summary
• Active Comparator: Usual Care
  The usual care group received routine discharge counseling performed by the patient-care nurse and a letter/discharge summary from the hospital physician to the community physician listing the discharge medications, procedures, and recommendations. Enrolled patients in the usual care arm were not disclosed to the community pharmacy until the end of the study period when refill records were requested.
  Interventions:

  • Behavioral: Routine discharge counseling
  • Other: Letter to physician/discharge summary

• Newby LK, LaPointe NM, Chen AY, Kramer JM, Hammill BG, DeLong ER, Muhlbaier LH, Califf RM. Long-term adherence to evidence-based secondary prevention therapies in coronary artery disease. Circulation. 2006 Jan 17;113(2):203-12. Epub 2006 Jan 9.
• Calvert SB, Kramer JM, Anstrom KJ, Kaltenbach LA, Stafford JA, Allen LaPointe NM. Patient-focused intervention to improve long-term adherence to evidence-based medications: a randomized trial. Am Heart J. 2012 Apr;163(4):657-65.e1. doi: 10.1016/j.ahj.2012.01.019.

Inclusion Criteria:

• 18 years of age or older
• Utilize a pharmacy in Durham, Robeson, Person, Granville, or Vance County, NC

• Have coronary artery disease (CAD) documented in the medical record by one of the following:

  1. A diagnosis of unstable angina or acute myocardial infarction (ST segment elevation or non-ST segment elevation myocardial infarction)
  2. A cardiac catheterization demonstrating CAD greater than or equal to 50 narrowing of artery)
  3. Prior angioplasty
  4. Prior coronary artery stent
  5. Prior coronary artery bypass graft surgery (CABG)
• Plan to have their prescription medications filled and refilled by one of the participating pharmacies
• Prescribed aspirin or another antiplatelet, a beta-blocker and statin agent (referred to as triple therapy for this study) at discharge. If a patient has a true contraindication to any of the three medication groups in triple therapy, they will still be eligible for the study

Exclusion Criteria:

• Providers predict an anticipated hospital stay of less than 48 hours
• Patient plans to use a pharmacy outside of Durham, Robeson, Person, Granville, or Vance County, NC
• Patient is unable to give consent (cognitively impaired, does not speak English, or has altered mental status)
• Patient transferred to Cardiothoracic Surgery service for CABG
• Patient has terminal condition and may not survive until 6-month follow-up
• Patient lives in a correctional or long-term care facility
• Patient will be unable to participate in follow-up phone call (hearing impaired without caregiver who can help or does not have a phone)
• Patient is a known participant in the Duke Heart Failure Program
• Patient does not agree to use only the one Durham, Robeson, Person, Granville, or Vance County pharmacy throughout the study period

• Pfizer
• Agency for Healthcare Research and Quality (AHRQ)