“How can SCAI and industry partners increase adherence and educate interventionalists on optimal medical therapy?”

Citations Over TimeTop 24% of 2018 papers

Abstract

The Society for Cardiovascular Angiography and Interventions (SCAI) Think Tank is held annually bringing together expert opinion from interventional cardiologists, administrative partners, and select members of the cardiovascular industry community in a collaborative venue. During the SCAI 2018 Scientific Session, topics in interventional cardiology felt to be relevant to the contemporary practice of the field were identified with the goals of defining the state of the field, current challenges, and future directions. By publishing the proceedings, the wider cardiovascular community can participate in this discussion and add their voice to the debate, helping SCAI proceed with specific action items in the future. The Think Tank is a partnership between SCAI, the SCAI Emerging Leader Mentorship Program (ELM), select SCAI committees, and industry partners within the SCAI Corporate Community. We thank them for their participation in this venture. Heart disease remains the leading cause of death within the United States, accounting for approximately 630 000 deaths in 2015,1, 2 despite 40–50% reduction in cardiovascular morbidity and mortality.3, 4 In patients with coronary heart disease (CHD), over 40% of the decrease in death is attributable to the widespread adoption of evidence-based pharmacotherapies.4 Yet, the witnessed progress has been attenuated by the suboptimal prescription and adherence to optimal medical therapy. Approximately half of patients with CHD do not adhere to their prescribed medical regimens,5-7 and nonadherence has been associated with adverse clinical outcomes and increased health care costs.8, 9 Within the Kaiser Permanente of Colorado CAD registry, nonadherence to β-blockers, statins, or angiotensin-converting enzyme (ACE) inhibitors for secondary prevention commonly occurred and was independently associated with increased risk of all-cause mortality, cardiovascular mortality, hospitalization for myocardial infarction or heart failure, and coronary revascularization.9 In addition, low vs high adherence for secondary prevention of CHD equates to 10–18% increase in annual health care costs.8 There is therefore an urgent unmet need for quality improvement initiatives to bolster medication adherence in patients with heart disease. Here, we will review the causes of cardiac medication nonadherence and highlight strategies that may be adopted or supported by SCAI to improve medication adherence for cardiovascular patients. Medication adherence includes three distinct processes: (1) initiation, (2) implementation, and (3) discontinuation.10 Medication initiation occurs when the patient fills their prescription and takes the first dose. Implementation refers to the manner by which the patient takes a medication over time as directed by the prescriber. Discontinuation refers to a patient stopping a medication for any reason, regardless of whether a health care provider was involved in the decision.6 Breakdown of any one of these stages results in medication nonadherence and may be remediable by directed interventions. For example, after PCI with a drug-eluting stent (DES), 20% of Medicare patients do not fill prescriptions for clopidogrel within 7 days, a failure of drug initiation.11 Implementation is limited for cardiovascular drugs as well. In patients prescribed statin therapy, less than half persistently took statin drugs as prescribed over the first year.12 Furthermore, at 1 year after acute myocardial infarction, 55% of surviving and insured patients had discontinued β-blocker therapy.13 Given the multifactorial nature of medication nonadherence, no single intervention will universally enhance adherence. For example, within the MI FREEE study, elimination of copayments for medications prescribed after myocardial infarction only resulted in a 4% to 6% increase in adherence.5 While the study demonstrated a successful intervention that improved medication adherence, reduced rates of first major vascular event, and decreased patient out of pocket expenses without increasing overall health costs, rates of full adherence remained < 40% despite the intervention. Several interventions have been tested to improve medication adherence, many of which could serve as the basis for SCAI efforts to improve medication adherence.6 Furthermore, opportunities exist for partnerships between health care providers and industry to improve the shared goal of increasing patient adherence. But in order to design and implement targeted interventions to enhance medication adherence, we first need to gather data on the factors that drive nonadherence for cardiovascular drugs. The development of an adherence registry that leverages SCAI resources and relationships with industry to quantify adherence to cardiovascular medications as well as reasons for nonadherence and its clinical consequences would inform future efforts. Given the impact of patient perspectives, beliefs, and motivation on medication adherence, facilitating patient engagement is a key goal.10 Patients must feel that they are vital members of the health care management team and understand the objectives and goals of the treatment plan. The teach-back method, in which providers asking patients to repeat and explain the treatment plan, is an easily adopted intervention to confirm patient comprehension.6 To enhance patient engagement and participation within their own care, shared decision-making tools may be employed regarding pharmacotherapy. Patient involvement with individualized discharge plans and the clear identification and setting of treatment goals can facilitate initiation and implementation of the treatment regimen. Finally, regularly scheduled (monthly) telephone or in-person follow-up visits with pharmacists, nurses, health care counselors, or physicians to review goals, reconcile medications, identify and address adverse effects and other hinderances, and provide and reinforce patient education may further improve medication adherence.15, 16 Within the course of providing cardiovascular care, there is a need to identify teachable moments at which patients are primed for educational interventions (ie, discharge after myocardial infarction, after PCI, etc.). Interventions at these critical moments should not only seek to increase patient comprehension of their disease state, but also provide personalized education regarding pharmacotherapy and lifestyle modification. Counseling on behavior modification, self-care, and health maintenance can supplement educational tools provided to patients.6 Mobile health technologies utilizing smart phones, tablets, short message service (SMS), and web-based tools are relatively low-cost methods by which to engage patients, reinforce treatment objectives and goals, and provide further patient education beyond the clinic visit or hospital discharge.6, 17-19 Limited data suggest that such interventions can effectively increase medication adherence. Mobile health technologies have been used to remind patients to take their medications and also to allow patients to immediately confirm medication intake and report symptoms and disease status (ie, blood pressure, blood sugars, etc.). The development of such tools is an obvious opportunity for partnership between health care providers, SCAI, and industry. The aforementioned interventions necessitate the allocation of resources (ie, provider time, technology costs, care team expansion, etc.) to target and improve medication adherence. As health care transitions from fee for service to value- and outcome-based reimbursement, opportunities exist to reallocate vital resources to lower cost methods of maximizing health. One approach involves leveraging incentives to health care systems and providers to shift attention to patient medication adherence. It may prove fruitful to include medication adherence in performance measures that impact reimbursement rates. Finally, the affordability of medicines and care contributes to medication nonadherence.5, 6 Efforts to improve access to medications are vital to increasing medication adherence. Universal coverage and/or policies to ensure affordable prices for evidence-based medical regimens should be sought. Industry-sponsored co-pay cards and drug discount cards can be utilized when possible to limit out-of-pocket costs. SCAI has a long tradition of providing patient education, and through the SCAI Political Action Committee (SCAI PAC), of advocating for policies to maximize health for patients with cardiovascular disease. Medication nonadherence has a tremendous impact on clinical outcomes and health care costs for patients with CHD. Medication adherence is therefore a priority for the Society. Identifying and discussing topics for which we need a more concrete path forward is a key goal within SCAI. The above discussions and presentations will hopefully serve to inform the cardiovascular and interventional community regarding SCAI's vision for the future directions. While in some cases, the discussion will result in a discrete action item, such as a consensus document, new advocacy goals, or specific committee or education work, in other cases the discussion will serve to broaden our understanding especially with regards to the state of consensus, or lack thereof. The group welcomes the larger interventional community's analysis of these discussions and participation in shaping the profession's future.

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