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Improving Patient Care |

Pharmacist Intervention to Improve Medication Adherence in Heart Failure: A Randomized Trial

Michael D. Murray, PharmD, MPH; James Young, PharmD; Shawn Hoke, BA; Wanzhu Tu, PhD; Michael Weiner, MD, MPH; Daniel Morrow, PhD; Kevin T. Stroupe, PhD; Jingwei Wu, MS; Daniel Clark, PhD; Faye Smith, MA; Irmina Gradus-Pizlo, MD; Morris Weinberger, PhD; and D. Craig Brater, MD
[+] Article and Author Information

From the University of North Carolina School of Pharmacy, Chapel Hill, North Carolina; Wishard Health Services, Indiana University School of Medicine, and Regenstrief Institute, Indianapolis, Indiana; University of Illinois, Champaign-Urbana, Illinois; Hines Veterans Affairs Hospital, Hines, Illinois; and Feinberg School of Medicine and Northwestern University, Chicago, Illinois.


Grant Support: In part by National Institutes of Health grants R01 AG19105 and R01 HL 69399 (Dr. Murray, principal investigator) and AG01799 (Dr. Brater, principal investigator; Dr. Murray, co-principal investigator).

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Michael D. Murray, PharmD, MPH, Center for Pharmaceutical Outcomes and Policy, School of Pharmacy, University of North Carolina at Chapel Hill, CB 7360 Kerr Hall, Chapel Hill, NC 27599-7360.

Current Author Addresses: Dr. Murray: Center for Pharmaceutical Outcomes and Policy, School of Pharmacy, University of North Carolina at Chapel Hill, CB 7360 Kerr Hall, Chapel Hill, NC 27599-7360.

Dr. Young: Wishard Health Services, 1001 West 10th Street, Indianapolis, IN 46202.

Mr. Hoke: Health Services Research and Development Service, Roudebush Veterans Affairs Medical Center, 1050 Wishard Boulevard, Indianapolis, IN 46202.

Dr. Tu and Ms. Wu: Division of Biostatistics, Department of Medicine, Indiana University School of Medicine, Regenstrief Institute, 1050 Wishard Boulevard, Indianapolis, IN 46202.

Drs. Weiner and Clark: Division of General Internal Medicine and Geriatrics, Department of Medicine, Indiana University School of Medicine, Regenstrief Institute, 1050 Wishard Boulevard, Indianapolis, IN 46202.

Dr. Morrow: Institute of Aviation, Human Factors Division, University of Illinois, Willard Airport, One Airport Road, Q5, MC-394, Savoy, IL 61874.

Dr. Stroupe: Midwest Center for Health Services and Policy Research, Cooperative Studies Program Coordinating Center, Hines Veterans Affairs Hospital, PO Box 5000 (151 H), 5th Avenue and Roosevelt Road, Building 1B260, Hines, IL 60141.

Ms. Smith: Regenstrief Institute, 1050 Wishard Boulevard, Indianapolis, IN 46202.

Dr. Gradus-Pizlo: Krannert Institute of Cardiology, Department of Medicine, Indiana University School of Medicine, 1800 North Capitol Avenue, Indianapolis, IN 46202.

Dr. Weinberger: Department of Health Policy and Administration, University of North Carolina at Chapel Hill, 1101-D McGavran-Greenberg Hall, CB# 7411, Chapel Hill, NC 27599.

Dr. Brater: Indiana University School of Medicine, Indiana University-Purdue University Indianapolis, 1120 South Drive, Fesler Hall, Indianapolis, IN 46202.

Author Contributions: Conception and design: M.D. Murray, W. Tu, M. Weiner, D. Morrow, D. Clark, I. Gradus-Pizlo, M. Weinberger, D.C. Brater.

Analysis and interpretation of the data: M.D. Murray, J. Young, W. Tu, M. Weiner, D. Morrow, K.T. Stroupe, J. Wu, F. Smith, I. Gradus-Pizlo, M. Weinberger, D.C. Brater.

Drafting of the article: M.D. Murray, W. Tu, J. Wu, M. Weinberger.

Critical revision of the article for important intellectual content: M.D. Murray, S. Hoke, W. Tu, M. Weiner, D. Morrow, K.T. Stroupe, J. Wu, I. Gradus-Pizlo, M. Weinberger, D.C. Brater.

Final approval of the article: M.D. Murray, M. Weiner, K.T. Stroupe, J. Wu, D. Clark, I. Gradus-Pizlo, M. Weinberger, D.C. Brater.

Provision of study materials or patients: M.D. Murray, S. Hoke, W. Tu.

Statistical expertise: W. Tu, K.T. Stroupe, J. Wu.

Obtaining of funding: M.D. Murray, D.C. Brater.

Administrative, technical, or logistic support: M.D. Murray, S. Hoke, D.C. Brater.

Collection and assembly of data: M.D. Murray, J. Young, S. Hoke, F. Smith.


Ann Intern Med. 2007;146(10):714-725. doi:10.7326/0003-4819-146-10-200705150-00005
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The Figure shows the flow of patients through the study. Compared with all potentially eligible patients (n = 1512), the 314 patients enrolled in the study were younger (63 vs. 67 years; P < 0.001) and were more likely to be women (67% vs. 59%; P = 0.009). At baseline, however, patients were otherwise similar to the total population of patients with heart failure (n = 3034; mean age, 60 years), of whom 66% were women. Randomization resulted in well-balanced groups (Table 1), except that more patients in the usual care group than the intervention group had a history of coronary artery disease (76% vs. 63%). Follow-up rates were similar in the intervention (87%) and usual care (85%) groups.

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Heart Failure Adherence to Medication by Intervention
Posted on May 15, 2007
Munir E Nassar, M.D., Ph.D.
No Affiliation
Conflict of Interest: None Declared

This paper by Murray D M and colleagues(1) is of interest because it may open new avenues for further care by health care workers for patients in congestive heart failure. To reach these new avenues, it would have been more informative to address the bottom line issue of mortality in the two groups, the intervention group and the group of usual care, at 3 months, 9 months and after cessation of intervention, and whether there was a statistically signifacnt difference in mortality outcomes, irrespective of intervention and hospital admissions. The new avenues of care that may open up is to formulate teams conisting of a home visiting nurse with a social worker,and the pharnacist, to evaluate clinical heart failure adherence to medications, and the activities of daily living, backed by a primary care physician by phone or via the internet, if it is to be determined by further studies, that close and continued supervision of patients in heart faillure is sensible and effective way of treating heart.

Ref.: (1) Ann Intern Med; 146: 714-725

Conflict of Interest:

None declared

Interventions for Improving Adherence in Developing Countries
Posted on May 23, 2007
Nudrat N Qureshi
Aga Khan University, Karachi, Pakistan
Conflict of Interest: None Declared

This study brings forward an interesting set of results with respect to pharmacist intervention for improving medication adherence in heart failure (1). I particularly find interesting in this research, the study population being low income individuals with low health literacy. This not only reflects the economically vulnerable group in a developed country, but also the group constituting a majority in developing countries. Hence the fact that the authors show a statistically significant impact of intervention on medication adherence may also suggest the intervention's potential benefit in the developing world. It therefore opens new avenues of research in the field of adherence in Pakistan. Another research in this context has already shown the need of such interventions to improve medication compliance (2). Qidwai and group highlight that explaining treatment and purpose of medication to patient was viewed as important by the study participants in improving patient compliance. In this respect intervention such as training pharmacists, general practitioners, nurses etc. can and have proven to be successful in improving adherence to medication(3). By focusing on the implications of such research, policies should be devised to design, pilot and promote effective intervention strategies in the community to improve adherence to medication. Improved adherence to medication would thereby lead to lowering the burden of consequent chronic cardiovascular illnesses.

References:

(1) Ann Intern Med; 146: 714-725

(2) Qidwai W, Noor N, Azam SI. Patient compliance among family practice patients. J Coll Physicians Surg Pak. 2004 Jun;14(6):339-42

(3) Harmon G, Lefante J, Krousel-Wood M. Overcoming barriers: the role of providers in improving patient adherence to antihypertensive medications. Curr Opin Cardiol 2006;21(4):310-5.

Conflict of Interest:

None declared

Diversion of Resources from Primary Care?
Posted on June 26, 2007
Jeffrey R. Jaeger
University of Pennsylvania School of Medicine
Conflict of Interest: None Declared

I read with interest the paper by Murray et al detailing the impressive outcomes achieved with the addition of a pharmacist to the team caring for outpatients with heart failure.

I cannot help but view their intervention in the context of the recent spate of articles detailing the imminent demise of primary care and proposals to rescue it. The intervention detailed in the paper involved a highly trained medical professional delivering services to patients outside the medical office. The pharmacist collected data and implemented educational strategies at a pharmacy affiliated with but not located at the site where the patient received medical care. Communication between the pharmacist and the medical team was not detailed, but it was indicated that such communication occurred "as needed".

Team-based care is one of the goals of redesign of healthcare systems, identified as a marker of high- functioning systems. While this intervention would certainly seem to encompass that label, I worry that payers and systems will be prompted to set up similar systems also similarly located outside the doctor's office. While the authors' detailing of cost savings would ideally promote the addition of off-site services without a shift in resources away from primary care practices, it is not hard to imagine that the creation and support of a team of disease-specific pharmacists would drain resources from already strapped practices. I worry that this will not improve the lot of the doctors caring for the patients, and will not help to further the important goal of fostering the creation or maintenance of practices that might attract trainees to follow in our footsteps.

One would like to have seen an intervention with similar resources placed in the physician's office, with pharmacist interventions detailed in the medical record. It would seem that onsite services would better facilitate true team care and go further towards creating a care environment in which everyone--attending, trainee, patient, pharmacist--is best able to use and learn from the strengths of all the stakeholders involved in the care of the patient.

Conflict of Interest:

None declared

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