Pharmacist Intervention to Improve Medication Adherence in Heart Failure

Context Patients sometimes have difficulty following complicated treatment regimens. Contribution In this trial, 314 low-income patients with congestive heart failure were randomly assigned to a pharmacist intervention or usual care. The pharmacist a... show more

Context Patients sometimes have difficulty following complicated treatment regimens. Contribution In this trial, 314 low-income patients with congestive heart failure were randomly assigned to a pharmacist intervention or usual care. The pharmacist assessed patient knowledge and provided instructions about medication use. During the 9-month intervention, patients in the intervention group had greater medication adherence than patients in the usual care group (79% vs. 68%). These differences dissipated within 3 months of stopping the intervention. Patients in the intervention group also had fewer exacerbations resulting in emergency department visits or hospitalizations than patients in the usual care group. Implication Ongoing educational intervention by a pharmacist can improve medication adherence and outcomes in patients with heart failure. The Editors In the United States, 5 million people have heart failure, with total health care costs exceeding $29 billion (1). These costs are largely derived from expensive exacerbations that require emergency visits and hospitalizations (1, 2). Regularly administered cardiovascular medications may preserve cardiac function, improve quality of life, and reduce risk for costly exacerbations. However, patients sometimes do not adhere to prescribed instructions and have poor outcomes (35). Researchers have estimated that approximately 50% of patients with chronic illnesses do not take their medications as prescribed (6). Reasons for nonadherence include lack of patient knowledge, skills, and support to appropriately self-manage complicated medication regimens (7, 8). Although chronic disease management programs abound, few studies have rigorously tested interventions aimed at improving patient adherence to prescribed medications and their effect on health outcomes (9, 10). We conducted a randomized clinical trial to assess the effect of a pharmacist intervention on patients who are socioeconomically disadvantaged and medically vulnerable. We hypothesized that the intervention would improve adherence to heart failure medications, reduce exacerbations requiring emergency department visits or hospitalization, improve disease-specific quality of life, increase patient satisfaction, and reduce health care costs. Methods Design Overview The methods for our randomized trial are described elsewhere (1113). We recruited patients from the general medicine and cardiology practices of Wishard Health Services, Indianapolis, Indiana, which serves socioeconomically disadvantaged and medically vulnerable patients. The study was conducted from February 2001 to June 2004. Patients took part in the study for 12 months and received 9 months of active intervention by the pharmacist or usual care followed by 3 months of postintervention assessment. Patients in the usual care and intervention groups visited the same pharmacy location, but the intervention pharmacist was instructed to have no contact with patients in the usual care group. The institutional review boards of Indiana UniversityPurdue University and the University of North Carolina at Chapel Hill approved this study. Setting and Patients Indiana University Medical Group, Indianapolis, is an academic primary care group practice composed of primary and specialty care clinics affiliated with Wishard Health Services. Faculty physicians, residents, and nurse practitioners provide care to 13000 adults (mean age, 57 years [SD, 15]; 60% women; 50% African American). Annually, these patients make approximately 50000 visits to practices, 72000 visits to emergency departments, and 135000 visits to pharmacies and have 16000 hospitalizations. We recruited patients from 4 identical general medicine practices, 1 cardiology practice, and Wishard Memorial Hospital. Practices met in half-day sessions per week that were attended by 2 or 3 faculty members and 3 to 5 residents or fellows from each practice. Faculty physicians practiced 1 to 5 half-days per week, whereas fellows practiced 1 to 2 half-days per week and residents attended the practice 1 half-day per week. Outpatients of Wishard Health Services fill their prescriptions at central or decentralized outpatient pharmacies located at the ambulatory care center or at 1 of several satellite pharmacies stationed at neighborhood clinics. Fully stocked decentralized pharmacies serviced all study patients. From February 2001 to January 2003, the study pharmacy was located in a building adjacent to the ambulatory care center. From February 2003 to June 2004, the study pharmacy was moved to a space adjacent to the general medicine practices in the ambulatory care center. Two pharmacists and 1 technician were stationed at the pharmacy. The study pharmacist was instructed to service patients in the intervention group only, and a second pharmacist serviced patients in the usual care group and filled prescriptions to be delivered to patients at outlying clinics. The technician filled prescriptions and read electronic adherence monitors. Weekly lists of eligible patients were created by using the Regenstrief Medical Record System (Regenstrief Institute, Indianapolis, Indiana) (14, 15). We invited clinically stable patients from general internal medicine practices, a cardiology clinic, and Wishard Memorial Hospital (at discharge) to participate in the study. Of 3034 patients with a diagnosis of heart failure, 1512 met criteria for enrollment. Patients were eligible if they were 50 years of age or older; planned to receive all of their care, including prescribed medications, at Wishard Health Services; had a diagnosis of heart failure confirmed by their primary care physician; regularly used at least 1 cardiovascular medication for heart failure (angiotensin-converting enzyme [ACE] inhibitor or angiotensin-receptor blocker, -adrenergic antagonist, diuretic, digoxin, or aldosterone antagonist); were not using or were not planning to use a medication container adherence aid (for example, a show less