Self-reported medication adherence and cardiovascular events in patients with stable coronary heart disease: the heart and soul study. Medication Adherence and the Risk of Cardiovascular Mortality and Hospitalization Among Patients With Newly Prescribed Antihypertensive Medications A text messaging intervention to promote medication adherence for patients with coronary heart disease: a randomized controlled trial. Improvements in 1-Year Cardiovascular Clinical Outcomes Associated with a Hospital-Based Discharge Medication Program Strategies to improve adherence with medications in chronic, ‘silent’ diseases representing high cardiovascular risk Patient-Centered Adherence Intervention After Acute Coronary Syndrome Hospitalization Controlled trial of effect of documented cardiovascular risk scores on prescribing Impact of pharmacy care upon adherence to cardiovascular medicines: a feasibility pilot controlled trial A multifaceted strategy using mobile technology to assist rural primary healthcare doctors and frontline health workers in cardiovascular disease risk management: protocol for the SMARTHealth India cluster randomised controlled trial A Cluster-Randomized, Controlled Trial of a Simplified Multifaceted Management Program for Individuals at High Cardiovascular Risk (SimCard Trial) in Rural Tibet, China, and Haryana, India Increasing the Detection and Response to Adherence Problems with Cardiovascular Medication in Primary Care through Computerized Drug Management Systems: A Randomized Controlled Trial Rationale and design of the Medication adherence Improvement Support App For Engagement-Blood Pressure (MedISAFE-BP) trial. Improving adherence to cardiovascular disease medications with information technology. Refill adherence and polypharmacy among patients with type 2 diabetes in general practice. IMProving Adherence using Combination Therapy (IMPACT): design and protocol of a randomised controlled trial in primary care. Effects of interactive patient smartphone support app on drug adherence and lifestyle changes in myocardial infarction patients: A randomized study. A pharmacist-led follow-up program for patients with established coronary heart disease in North Norway – a randomized controlled trial
BACKGROUND Nonadherence to physician treatment recommendations is an increasingly recognized cause of adverse outcomes and increased health care costs , particularly among patients with cardiovascular disease . Whether patient self-report can provide an accurate assessment of medication adherence in out patients with stable coronary heart disease is unknown . METHODS We prospect ively evaluated the risk of cardiovascular events associated with self-reported medication nonadherence in 1015 out patients with established coronary heart disease from the Heart and Soul Study . We asked participants a single question : " In the past month , how often did you take your medications as the doctor prescribed ? " Nonadherence was defined as taking medications as prescribed 75 % of the time or less . Cardiovascular events ( coronary heart disease death , myocardial infa rct ion , or stroke ) were identified by review of medical records during 3.9 years of follow-up . We used Cox proportional hazards analysis to determine the risk of adverse cardiovascular events associated with self-reported medication nonadherence . RESULTS Of the 1015 participants , 83 ( 8.2 % ) reported nonadherence to their medications , and 146 ( 14.4 % ) developed cardiovascular events . Nonadherent participants were more likely than adherent participants to develop cardiovascular events during 3.9 years of follow-up ( 22.9 % vs 13.8 % , P = .03 ) . Self-reported nonadherence remained independently predictive of adverse cardiovascular events after adjusting for baseline cardiac disease severity , traditional risk factors , and depressive symptoms ( hazards ratio , 2.3 ; 95 % confidence interval , 1.3 - 4.3 ; P = .006 ) . CONCLUSIONS In out patients with stable coronary heart disease , self-reported medication nonadherence is associated with a greater than 2-fold increased rate of subsequent cardiovascular events . A single question about medication adherence may be a simple and effective method to identify patients at higher risk for adverse cardiovascular events The importance of adherence to antihypertensive treatments for the prevention of cardiovascular disease has not been well eluci date d. This study evaluated the effect of antihypertensive medication adherence on specific cardiovascular disease mortality ( ischemic heart disease [ IHD ] , cerebral hemorrhage , and cerebral infa rct ion ) . Our study used data from a 3 % sample cohort that was r and omly extracted from enrollees of Korean National Health Insurance . Study subjects were aged ≥20 years , were diagnosed with hypertension , and started newly prescribed antihypertensive medication in 2003 to 2004 . Adherence to antihypertensive medication was estimated as the cumulative medication adherence . Subjects were divided into good ( cumulative medication adherence , ≥80 % ) , intermediate ( cumulative medication adherence , 50%–80 % ) , and poor ( cumulative medication adherence , < 50 % ) adherence groups . We used time-dependent Cox proportional hazards models to evaluate the association between medication adherence and health outcomes . Among 33 728 eligible subjects , 670 ( 1.99 % )  died of coronary heart disease or stroke during follow-up . Patients with poor medication adherence had worse mortality from IHD ( hazard ratio , 1.64 ; 95 % confidence interval , 1.16–2.31 ; P for trend=0.005 ) , cerebral hemorrhage ( hazard ratio , 2.19 ; 95 % confidence interval , 1.28–3.77 ; P for trend=0.004 ) , and cerebral infa rct ion ( hazard ratio , 1.92 ; 95 % confidence interval , 1.25–2.96 ; P for trend=0.003 ) than those with good adherence . The estimated hazard ratios of hospitalization for cardiovascular disease were consistent with the mortality end point . Poor medication adherence was associated with higher mortality and a greater risk of hospitalization for specific cardiovascular diseases , emphasizing the importance of a monitoring system and strategies to improve medication adherence in clinical practice OBJECTIVE Pharmacologic treatment for secondary prevention of coronary heart disease ( CHD ) is critical to prevent adverse clinical outcomes . In a r and omized controlled trial , we compared antiplatelet and statin adherence among patients with CHD who received : ( 1 ) text messages ( TM ) for medication reminders and education , ( 2 ) educational TM only , or ( 3 ) No TM .  METHODS A mobile health intervention delivered customized TM for 30 days . We assessed and analyzed medication adherence with electronic monitoring devices [ Medication Event Monitoring System ( MEMS ) ] by one-way ANOVA and Welch tests , two-way TM response rates by t-tests , and self-reported adherence ( Morisky Medication Adherence Scale ) by Repeated Measures ANOVA . RESULTS Among 90 patients ( 76 % male , mean age 59.2 years ) , MEMS revealed patients who received TM for antiplatelets had a higher percentage of correct doses taken ( p=0.02 ) , percentage number of doses taken ( p=0.01 ) , and percentage of prescribed doses taken on schedule ( p=0.01 ) .  TM response rates were higher for antiplatelets than statins ( p=0.005 ) . Self-reported adherence revealed no significant differences among groups . CONCLUSION TM increased adherence to antiplatelet therapy demonstrated by MEMS and TM responses . PRACTICE IMPLICATION S Feasibility and high satisfaction were established . Mobile health interventions show promise in promoting medication adherence Context Despite evidence to support the effectiveness of a variety of interventions for the secondary prevention of cardiovascular disease , many eligible patients do not receive these interventions . Contribution Compared with a baseline period , patients hospitalized with cardiovascular disease who received an  intervention that focused on discharge medications had higher rates of prescription of aspirin , -blockers , statins , angiotensin-converting enzyme inhibitors , and warfarin at hospital discharge . The risk for death and readmission was lower in the intervention period than in the baseline period . Caution s The prepost design of this study does not permit conclusions about a causal relationship between the intervention and the observed improvements . The Editors Cardiovascular disease remains the most common source of morbidity and mortality in western countries ( 1 ) . During the past 2 decades , a variety of significant medical advances have been made in the treatment and prevention of complications associated with major cardiovascular disorders , including coronary artery disease , congestive heart failure ( CHF ) , and atrial fibrillation . Many of these advances in secondary prevention relate simply to the appropriate use of certain medications , for example , aspirin and statins for coronary artery disease , -blockers and angiotensin-converting enzyme inhibitors for CHF , and warfarin for prevention of stroke and other embolic events in patients with atrial fibrillation . Each of these medical therapies has been proven in large , multicenter , r and omized , double-blind , placebo-controlled trials to save lives under appropriate circumstances ( 2 - 7 ) . However , despite the overwhelming evidence supporting the benefit of these medications , many studies have documented a significant treatment gap . Often , far fewer than 50 % of potential beneficiaries actually receive treatment ( 8 - 13 ) , and studies from our institution and others have shown that many patients do not receive indicated medications at hospital discharge ( 14 , 15 ) . On the other h and , the chances of long-term adherence are significantly higher when medications are provided at hospital discharge , and this difference is associated with decreased mortality rates ( 13 , 16 ) . Hospital discharge is a critical juncture in the process of care . Patients are available for consultation and are often more disposed to adopt health care recommendations . A hospital dischargebased intervention could be more easily implemented , more effectively managed and measured , and more cost-effective than other potential outpatient intervention strategies . Consequently , there is substantial justification for focusing on hospital discharge as the ideal time to improve prescription of medications for secondary prevention of cardiovascular disease . In the current study , our objectives were to 1 ) determine the feasibility of implementing a comprehensive quality improvement initiative in a large multihospital network to significantly increase rates of prescription at discharge of evidence -based , secondary prevention medications for life-threatening cardiovascular diseases ; 2 ) ascertain the effect of such a program on long-term clinical outcomes ; and 3 ) determine whether good adherence to such an initiative is sustainable . Methods Intermountain Health Care ( IHC ) is a nonprofit , integrated health care system including 20 hospitals , a system of health plans , and both employed and affiliated physicians . The approximately 400 employed physicians mainly practice primary care , and the approximately 2500 affiliated physicians are mostly specialists . Intermountain Health Care serves approximately 60 % of the population of Utah and southern Idaho . The system 's 10 largest hospitals were included in the quality improvement initiative , accounting for more than 90 % of the total population of cardiovascular patients . The major intent of this initiative was to ensure that appropriate secondary prevention medications were prescribed at discharge to all patients ( excluding those with documented contraindications ) who were hospitalized with a principal cardiovascular diagnosis of acute myocardial infa rct ion ( MI ) , coronary heart disease ( CHD ) , CHF , or atrial fibrillation . Table 1 shows the guidelines that were developed for each of the diagnostic categories , and Appendix Figure 1 shows the reference card that was developed to aid physicians and clinical staff . All of the guidelines were based on the current class IA American Heart Association/American College of Cardiology recommendations , except for the recommendation of a statin in all patients with CHD , including those with a low-density lipoprotein cholesterol level less than 2.59 mmol/L ( < 100 mg/dL ) . Our research ( 17 ) showed that a statin provided significant benefit in this population , a notion that has since been supported by a large clinical trial ( 18 ) . -Blocker therapy for patients with CHF was deferred until after discharge . Table 1 . Discharge Medication Guidelines for the Secondary Prevention of Cardiovascular Disorders Design and Implementation of the Quality Improvement Program In 1998 , before the new discharge medication program ( DMP ) was initiated , a new institution-wide data base was developed to assist in its implementation and long-term management . Simultaneously , all participating institutions began prospect ively tracking prescription of applicable discharge medications for all cardiac patients discharged from their respective cardiovascular departments ( Appendix Figure 2 ) . The DMP was implemented on 1 January 1999 , and tracking of discharge prescriptions continued . Maintenance of the discharge medication data base is ongoing , and information through February 2002 was included in this study . Appendix Figure 2 . Data collection form for the discharge medication program . Implementation of the DMP required support and commitment from every level of the health care system , including administration , physicians , nurses , and other staff . To gain this support , the IHC Cardiovascular Clinical Program leadership conducted an extensive education campaign in all participating hospitals . Before the actual initiation of the DMP , this group conducted an extensive tour to engage physicians , residents , and nurses with the program , its goals , and its rationale . The actual DMP implementation and documentation process varied from hospital to hospital but always included the essential core elements . The appropriate indication for each medication was printed directly on the patient discharge form , so physicians needed only to check the correct box or record the specific contraindication ( Appendix Figure 3 ) . This form served as a project management and data collection tool . When an appropriate medication was not prescribed , the discharge-planning nurse contacted the attending physician or resident directly , after which the missing medication could be added to the discharge prescriptions or an appropriate contraindication for its use could be documented . All information was entered into a computerized data base for tracking . Other than the additional re sources for data management , the DMP used existing hospital personnel . No organized effort was made to guarantee long-term adherence to prescribed medications after discharge . Appendix Figure 2 . Discharge orders form .. Documentation of Short-Term Success of the Program To measure and manage the short-term success of the program , monthly reports were generated showing the proportion of cardiovascular patients discharged with prescriptions for the indicated secondary prevention medications at each of the 10 hospitals . These reports were shared extensively with all participating health care providers from each contributing institution in an effort to further increase adherence . Long-Term Follow-up To monitor the effect of DMP implementation on long-term clinical outcomes , the baseline characteristics ( age , sex , and discharge diagnosis ) of each cardiovascular patient discharged from the 10 participating facilities were compiled from the central ized IHC informatics data base . Each patient was followed prospect ively for up to 1 year for hospital readmission due to a cardiovascular indication or for death . If no evidence of hospital readmission or death could be found for a patient , we assumed that the patient had not experienced either event . Information was included from 1996 , 3 years before DMP  initiation , to February 2002 , more than 3 years afterward . Rehospitalizations ( cardiovascular only ) were determined through the IHC informatics system 's electronic data warehouse , and death was ascertained by using the IHC system and the Social Security Administration 's death records . Such electronic follow-up , in our experience ( 16 ) , has proven more thorough and accurate than telephone surveys . Although a limited proportion of patients may have been readmitted to other hospitals for subsequent care , they were probably r and omly distributed between the pre-DMP and DMP sample s. Characteristics of patients admitted before ( 1996 to 1998 ) and after ( 1999 to 2002 ) DMP implementation were evaluated separately and compared . Statistical Analysis The chi-square test was used to evaluate differences in the proportions of patients receiving appropriate discharge prescriptions  in the  pre-DMP and DMP groups . To evaluate the effect of the DMP , we formed 4 mutually exclusive diagnostic or procedural categories for patients with the following index admissions : CHD without CHF , MI , or coronary artery bypass grafting ( CABG ) ; CHF without MI or CABG ; MI without CABG ; and CABG . The category of atrial fibrillation was not mutually exclusive of the other 4 categories . These categories reflected different patient sample s and were not design ed to evaluate groups on the basis of indications for each separate medication , since more than 1 medication could have been indicated in any given patient . Differences between baseline characteristics of the pre-DMP and DMP groups were Given the burden of illness related to diabetes , hypertension and dyslipidemia , it is very important to achieve glycemic control , optimal blood pressure and low-density lipoprotein cholesterol ( LDL-C ) in order to avoid severe long-term complications . Patients ’ adherence with , and persistence to , the treatment regimen is a critical factor in achieving this goal . Medication taking behavior in these chronic , nonsymptomatic ( ‘ silent ’ ) diseases is generally low , although a wide range of results have been reported . The literature has shown that nonadherence to medications is a multidimensional phenomenon ; relating factors can be grouped into the following categories : health system related , social/economic , condition-related , therapy-related and patient-related factors . Although several interventions exist to improve patients ’ medication-taking behavior , none appear to be clearly superior to others . The key steps to improve adherence are to identify individual barriers and to develop patient-specific self-management plans to overcome them ( called ‘ patient-centric ’ approach ) . When developing intervention strategies one should always remember that ‘ one size does not fit all ’ . Well design ed ( but not r and omized ) , observational studies ( for example , patient registries ) may be required with sufficient follow-up periods and multiple adherence measurements in order to advance the field Background — Adherence to cardioprotective medications in the year after acute coronary syndrome hospitalization is generally poor and is associated with increased risk of rehospitalization and mortality . Few interventions have specifically targeted this high-risk patient population to improve medication adherence . We hypothesize that a multifaceted patient-centered intervention could improve adherence to cardioprotective medications . Methods and Results — To evaluate this intervention , we propose enrolling 280 patients with a recent acute coronary syndrome event into a multicenter r and omized , controlled trial . The intervention comprises4 main components : ( 1 ) pharmacist-led medication reconciliation and tailoring ; ( 2 ) patient education ; ( 3 ) collaborative care between pharmacist and primary care provider/cardiologist ; and ( 4 ) 2 types of voice messaging ( educational and medication refill reminder calls ) . Patients in the intervention arm will visit with the study pharmacist ≈1 week post-hospital discharge . The pharmacist will work with the patient and collaborate with providers to reconcile medication issues . Voice messages will augment the educational process and remind patients to refill their cardioprotective medications . The study will compare the intervention versus usual care for 12 months . The primary outcome of interest is adherence using the ReComp method . Secondary and tertiary outcomes include achievement of targets for blood pressure and low-density lipoprotein , and reduction in the combined cardiovascular end points of myocardial infa rct ion hospitalization , coronary revascularization , and all-cause mortality . Finally , we will also evaluate the cost-effectiveness of the intervention compared with usual care . Conclusions — If the intervention is effective in improving medication adherence and demonstrating a lower cost , the intervention has the potential to improve cardiovascular outcomes in this high-risk patient population Cardiovascular disease causes the death of around 80 % of patients with type 2 diabetes.1 However , risk factors for cardiovascular disease in such patients are often untreated2 despite the proved benefits of intervention . 3 4 One way to help clinicians identify patients at high risk of cardiovascular disease is to use cardiovascular primary prevention risk tables . These tables integrate the multiple risk factors into a single score . We did a pilot study to test the hypothesis that documentation of a  cardiovascular risk score in the case notes would improve the management of cardiovascular risk factors . We recruited patients with type 2 diabetes who had no history of cardiovascular disease or renal disease . All patients were aged 35–75 years and attending a hospital Objective To investigate the feasibility and potential impact of a pharmacy care intervention , involving motivational interviews among patients with acute coronary syndrome , on adherence to medication and on health outcomes . Methods This article reports a prospect i ve , interventional , controlled feasibility/pilot study . Seventy one patients discharged from a London Heart Attack Centre following acute treatment for a coronary event were enrolled and followed up for 6 months . Thirty two pharmacies from six London boroughs were allocated into intervention or control sites . The intervention was delivered by community pharmacists face-to-face in the pharmacy , or by telephone . Consultations were delivered as part of the New Medicine Service or a Medication Usage Review . They involved a 15–20 min motivational interview aim ed at improving protective cardiovascular medicine taking . Results At 3 months , there was a statistically significant difference in adherence between the intervention group ( M=7.7 , SD=0.56 ) and the control group ( M=7.0 , SD=1.85 ) , p=0.026 . At 6 months , the equivalent figures were for the intervention group M=7.5 , SD=1.47 and for the controls M=6.1 , SD=2.09 ( p=0.004 ) . In addition , there was a statistically significant relationship between the level of adherence at 3 months and beliefs regarding medicines ( p=0.028 ) . Patients who reported better adherence expressed positive beliefs regarding the necessity of taking their medicines . However , given the small sample size , no statistically significant outcome difference in terms of recorded blood pressure and low density lipoprotein-cholesterol was observed over the 6 months of the study . Conclusions The feasibility , acceptability and potentially positive clinical outcome of the intervention were demonstrated , long with a high level of patient acceptability . It had a significant impact on cardiovascular medicine taking adherence . But these findings must be interpreted with caution . The intervention should be tested in a larger trial to ascertain its full clinical utility . Trial registration number Clinical Trials.gov identifier : NCT01920009 Background Blood Pressure related disease affected 118 million people in India in the year 2000 ; this figure will double by 2025 . Around one in four adults in rural India have hypertension , and of those , only a minority are accessing appropriate care . Health systems in India face substantial challenges to meet these gaps in care , and innovative solutions are needed . Methods We hypothesise that a multifaceted intervention involving capacity strengthening of primary healthcare doctors and non-physician healthcare workers through use of a mobile device-based clinical decision support system will result in improved blood pressure control for individuals at high risk of a cardiovascular disease event when compared with usual healthcare . This intervention will be implemented as a stepped wedge , cluster r and omised controlled trial in 18 primary health centres and 54 villages in rural And hra Pradesh involving adults aged ≥40 years at high cardiovascular disease event risk ( approximately 15,000 people ) . Cardiovascular disease event risk will be calculated based on World Health Organisation/International Society of Hypertension ’s region-specific risk charts . Cluster r and omisation will occur at the level of the primary health centres . Outcome analyses will be conducted blinded to intervention allocation . Expected outcomes The primary study outcome is the difference in the proportion of people meeting guideline -recommended blood pressure targets in the intervention period vs. the control period . Secondary outcomes include mean reduction in blood pressure levels ; change in other cardiovascular disease risk factors , including body mass index , current smoking , reported healthy eating habits , and reported physical activity levels ; self-reported use of blood pressure and other cardiovascular medicines ; quality of life ( using the EQ-5D ) ; and cardiovascular disease events ( using hospitalisation data ) . Trial outcomes will be accompanied by detailed process and economic evaluations . Significance The findings are likely to inform policy on a scalable strategy to overcome entrenched inequities in access to effective healthcare for under-served population s in low and middle income country setting s . Trial registration Clinical Trial Registry India CTRI/2013/06/003753 Background — In rural areas in China and India , the cardiovascular disease burden is high but economic and healthcare re sources are limited . This study ( the Simplified Cardiovascular Management Study [ SimCard ] ) aims to develop and evaluate a simplified cardiovascular management program delivered by community health workers with the aid of a smartphone-based electronic decision support system . Methods and Results — The SimCard study was a yearlong cluster-r and omized , controlled trial conducted in 47 villages ( 27 in China and 20 in India ) . Recruited for the study were 2086 individuals with high cardiovascular risk ( aged ≥40 years with self-reported history of coronary heart disease , stroke , diabetes mellitus , and /or measured systolic blood pressure ≥160 mm Hg ) . Participants in the intervention villages were managed by community health workers through an And roid-powered app on a monthly basis focusing on 2 medication use and 2 lifestyle modifications . In comparison with the control group , the intervention group had a 25.5 % ( P<0.001 ) higher net increase in the primary outcome of the proportion of patient-reported antihypertensive medication use pre- and post-intervention . There were also significant differences in certain secondary outcomes : aspirin use ( net difference : 17.1 % ; P<0.001 ) and systolic blood pressure ( –2.7 mm Hg ; P=0.04 ) . However , no significant changes were observed in the lifestyle factors . The intervention was culturally tailored , and country-specific results revealed important differences between the regions . Conclusions — The results indicate that the simplified cardiovascular management program improved quality of primary care and clinical outcomes in re source -poor setting s in China and India . Larger trials in more places are needed to ascertain the potential impacts on mortality and morbidity outcomes . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT01503814 Background . Adherence with antihypertensive and lipid-lowering therapy is poor , result ing in an almost 2-fold increase in hospitalization . Treatment side effects , cost , and complexity are common reasons for nonadherence , and physicians are often unaware of these potentially modifiable problems . Objective . To determine if a cardiovascular medication tracking and nonadherence alert system , incorporated into a computerized health record system , would increase drug profile review by primary care physicians , increase the likelihood of therapy change , and improve adherence with antihypertensive and lipid-lowering drugs . Methods . There were 2293 primary care patients prescribed lipid-lowering or antihypertensive drugs who were r and omized to the adherence tracking and alert system or active medication list alone  to determine if the intervention increased drug profile review , changes in cardiovascular drug treatment , and refill adherence in the first 6 months . An intention to treat analysis was conducted using generalized estimating equations to account for clustering within physician . Results . Overall , medication adherence was below 80 % for 36.3 % of patients using lipid-lowering drugs and 40.8 % of patients using antihypertensives at the start of the trial . There was a significant increase in drug profile review in the intervention compared to the control group ( 44.5 % v. 35.5 % ; P < 0.001 ) , a nonsignificant increase in drug discontinuations due to side effects ( 2.3 % v. 2.0 % ; P = 0.61 ) , and a reduction in therapy increases ( 28.5 % v. 29.1 % ; P = 0.86 ) . There was no significant change in refill adherence after 6 months of follow-up . Conclusion . An adherence tracking and alert system increases drug review but not therapy changes or adherence in prevalent users of cardiovascular drug treatment . Targeting incident users where adverse treatment effects are more common and combining adherence tracking and alert tools with motivational interventions provided by multidisciplinary primary care teams may improve the effectiveness of the intervention BACKGROUND Hypertension is a major contributor to the health and economic burden imposed by stroke , heart disease , and renal insufficiency . Antihypertensives can prevent many of the harmful effects of elevated blood pressure , but medication nonadherence is a known barrier to the effectiveness of these treatments . Smartphone-based applications that remind patients to take their medications , provide education , and allow for social interactions between individuals with similar health concerns have been widely advocated as a strategy to improve adherence but have not been subject to rigorous testing . METHODS / DESIGN The MedISAFE-BP study is a prospect i ve , r and omized control trial design ed to evaluate the impact on blood pressure and medication adherence of an mhealth application ( Medisafe ) .  Four hundred thirteen patients with uncontrolled hypertension have been enrolled and r and omized in a 1:1 fashion to usual care or to the use of the Medisafe mhealth platform  . Patients will be followed up for 12 weeks and the trial 's co- primary outcomes will be change in systolic blood pressure and self-reported medication adherence . DISCUSSION The MedISAFE-BP trial is the first study to rigorously evaluate an mhealth application 's effect on blood pressure and medication adherence . The results will inform the potential effectiveness of this simple system in improving cardiovascular disease risk factors and clinical outcomes OBJECTIVES Evaluate the utility of 2 electronic medical record (EMR)-linked , automated phone reminder interventions for improving adherence to cardiovascular disease medications . STUDY DESIGN A 1-year , parallel arm , pragmatic clinical trial in which 21,752 adults were r and omized to receive either usual care ( UC ) or 1 of 2 interventions in the form of interactive voice recognition calls-regular ( IVR ) or enhanced ( IVR+ ) . The interventions used automated phone reminders to increase adherence to cardiovascular disease medications . The primary outcome was medication adherence ; blood pressure and lipid levels were secondary outcomes . METHODS The study took place in 3 large health maintenance organizations . We enrolled participants who were 40 years or older , had diabetes mellitus or atherosclerotic cardiovascular disease , and were suboptimally adherent .  IVR participants received automated phone calls when they were due or overdue for a refill . IVR+ participants received these phone calls , plus personalized reminder letters , live outreach calls , EMR-based feedback to their primary care providers , and additional mailed material s. RESULTS Both interventions significantly increased adherence to statins and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers ( ACEIs/ARBs ) compared with UC ( 1.6 to 3.7 percentage points ) . Adherence to ACEIs/ARBs was also significantly higher for IVR+ relative to IVR participants . These differences persisted across subgroups . Among statin users , IVR+ participants had significantly lower low-density lipoprotein ( LDL ) levels at follow-up compared with UC ( Δ = -1.5 ; 95 % CI , -2.7 to -0.2 mg/dL ) ; this effect was seen mainly in those with baseline LDL levels ≥ 100 mg/dL ( Δ = -3.6 ; 95 % CI , -5.9 to -1.3 mg/dL ) . CONCLUSIONS Technology-based tools , in conjunction with an EMR , can improve adherence to chronic disease medications and measured cardiovascular disease risk factors BACKGROUND AND AIMS Non-adherence is considered a major barrier to better outcomes of diabetes care . A relationship has been established between polypharmacy and patients ' adherence . This study aims to investigate the occurrence of polypharmacy and non-adherence in general practice , their mutual relationship and the association between adherence and the intermediate outcomes of diabetes care . MATERIAL S AND METHODS We used the baseline and follow-up data of a r and omised controlled trial ( RCT ) that compared usual care with care in accordance with a locally adapted national guideline . This study took place in the Netherl and s and involved 30 general practice s and 1283 patients . We obtained a complete medication profile of all participants and calculated the number of prescribed drugs and the adherence indices ( AI )  for oral blood glucose , blood pressure and cholesterol lowering drugs .  Patients with an adherence index < 0.8 were considered non-adherent . Clustering at practice level and case-mix were taken into account . RESULTS Approximately 80 % of the participating patients demonstrated an adherence index > or= 0.8 for oral blood glucose , blood pressure and cholesterol lowering drugs . In the intervention group , increase of drug prescriptions exceeded that of controls ( 1.1 + /- 2.0 vs. 0.6 + /- 1.5 , p < 0.001 , adjusted p < 0.05 ) . There was evidence of an inverse relationship between the number of drugs that had been prescribed during the last 6 months of the study and patients ' adherence to blood pressure lowering medications ( adjusted OR 0.84 , 95%CI 0.78 - 0.91 ) . After one year , HbA1c and total cholesterol levels were significantly lower in adherent patients . CONCLUSION During the intervention the mean number of drug prescriptions increased in both the study groups . This did not result in a lower adherence to blood glucose and cholesterol lowering medications . Given the relationship between the number of medications and patients ' adherence to blood pressure lowering drugs , it may be wise to discuss adherence before prescribing multiple drug regimens BACKGROUND Cardiovascular disease ( CVD ) is the leading cause of death , and principal reason for the large difference in life expectancy between indigenous Māori and the non-indigenous population in New Zeal and . CVD guidelines recommend that people who are at high risk or who have had previous CVD should be offered aspirin , blood pressure lowering and lipid lowering therapies . However , prescribing and adherence rates are low and CVD events remain high . AIM To assess whether a medication strategy using a fixed dose combination pill ( ' polypill ' ) could improve prescribing and adherence to recommended medications , lower blood pressure and improve lipids compared with current care over 12 months . METHODS IMProving Adherence using Combination Therapy ( IMPACT ) is an open-label r and omised controlled trial comparing a once-daily polypill containing four preventive medications with usual care .  Six hundred participants who have had previous CVD events or are at high risk of CVD will be enrolled , including 300 Māori . Participants are identified , enrolled and prescribed either the polypill or current medications at their usual primary health care practice , with medications ( including the polypill ) dispensed through local community pharmacies . The polypill contains 75 mg aspirin , 40 mg simvastatin , 10 mg lisinopril and either 12.5 mg hydrochlorothiazide or 50 mg atenolol . Primary outcomes are adherence to guidelines -recommended medications and changes in systolic blood pressure and low density lipoprotein at 12 months . Secondary outcomes include other lipids , medication dispensing , barriers to adherence , CVD and other serious adverse events , quality of life and prescriber acceptability . The trial is registered with the Australian New Zeal and Clinical Trial Registry ( ACTRN12606000067572 ) BACKGROUND Patients with myocardial infa rct ion ( MI ) seldom reach recommended targets for secondary prevention . This study evaluated a smartphone application ( " app " ) aim ed at improving treatment adherence and cardiovascular lifestyle in MI patients . DESIGN Multicenter , r and omized trial . METHODS A total of 174 ticagrelor-treated MI patients were r and omized to either an interactive patient support tool ( active group ) or a simplified tool ( control group ) in addition to usual post-MI care . Primary end point was a composite nonadherence score measuring patient-registered ticagrelor adherence , defined as a combination of adherence failure events ( 2 missed doses registered in 7-day cycles ) and treatment gaps ( 4 consecutive missed doses ) . Secondary end points included change in cardiovascular risk factors , quality of life ( European Quality of Life-5 Dimensions ) , and patient device satisfaction ( System Usability Scale ) . RESULTS Patient mean age was 58 years , 81 % were men , and 21 % were current smokers . At 6 months , greater patient-registered drug adherence was achieved in the active vs the control group ( nonadherence score : 16.6 vs 22.8 [ P = .025 ] ) . Numerically , the active group was associated with higher degree of smoking cessation , increased physical activity , and change in quality of life ; however , this did not reach statistical significance . Patient satisfaction was significantly higher in the active vs the control group ( system usability score : 87.3 vs 78.1 [ P = .001 ] ) . CONCLUSIONS In MI patients , use of an interactive patient support tool improved patient self-reported drug adherence and may be associated with a trend toward improved cardiovascular lifestyle changes and quality of life . Use of a disease-specific interactive patient support tool may be an appreciated , simple , and promising complement to st and ard secondary prevention Objectives : The aim of the study was twofold ; 1 ) to develop a clinical pharmacist-led 12 month lasting follow-up program for patients with established coronary heart disease ( CHD ) discharged from the University Hospital of North Norway , and 2 ) to explore the impact of the program with regards to adherence to a medication assessment tool for secondary prevention of CHD and change in biomedical risk factors . Methods : A total of 102 patients aged 18 - 82 years were enrolled in a non-blinded r and omized controlled trial with an intervention group and a control group . The intervention comprised medication reconciliation , medication review and patient education during three meetings ; at discharge , after three months and after twelve months . The control group received st and ard care from their general practitioner . Primary outcomes were adherence to clinical guideline recommendations concerning prescription , therapy goal achievement and lifestyle education  defined in the medication assessment tool for secondary prevention of CHD ( MAT-CHDSP ) . Secondary outcomes included changes in the biomedical risk factors cholesterol , blood pressure and blood glucose . Results : Ninety-four patients completed the trial , 48 intervention group patients and 46 controls . Appropriate prescribing was high , but therapy goal achievement was low in both groups . Overall adherence to MAT-CHDSP criteria increased in both groups and was significantly higher in the intervention group at study end , 78.4 % vs. 62.0 % , p<0.001 . The difference was statistically significant for the documented lifestyle advices in intervention group patients . No significant improvements in biomedical risk factors were observed in favor of the intervention group . Conclusions : The study showed an increased guideline adherence in both study groups . This indicates that attention to clinical practice guideline recommendations in itself increases adherence – which may be a clinical pharmacist task . A larger adequately powered study is needed to show a significant difference in biomedical risk factor improvements in favor of the intervention . Amendments to the follow-up program are suggested before implementation in st and ard patient care can be recommended
Limitations of trials included small sample sizes , short duration of follow-up , self-reported outcomes , and insufficient assessment of unintended harms and financial implication s. Current evidence suggests that mHealth tools can improve medication adherence in patients with cardiovascular diseases .
Cardiovascular disease is a leading cause of morbidity and mortality worldwide , and a key barrier to improved outcomes is medication non-adherence .
The aim of this study is to review the role of mobile health ( mHealth ) tools for improving medication adherence in patients with cardiovascular disease .