Abstract
BackgroundBased on high-quality evidence, guidelines recommend the long-term use of secondary prevention medications post-myocardial infarction (MI) to avoid recurrent cardiovascular events and death. Unfortunately, discontinuation of recommended medications post-MI is common. Observational evidence suggests that prescriptions covering a longer duration at discharge from hospital are associated with greater long-term medication adherence. The following is a proposal for the first interventional study to evaluate the impact of longer prescription duration at discharge post-MI on long-term medication adherence.ObjectiveThe overarching goal of this study is to reduce morbidity and mortality among post-MI patients through improved long-term cardiac medication adherence. The specific objectives include the following. First, we will assess whether long-term cardiac medication adherence improves among elderly, post-MI patients following the implementation of (1) standardized discharge prescription forms with 90-day prescriptions and 3 repeats for recommended cardiac medication classes, in combination with education and (2) education alone compared to (3) usual care. Second, we will assess the cost implications of prolonged initial discharge prescriptions compared with usual care. Third, we will compare clinical outcomes between longer (>60 days) versus shorter prescription durations. Fourth, we will collect baseline information to inform a multicenter interventional study.MethodsWe will conduct a quasiexperimental, interrupted time series design to evaluate the impact of a multifaceted intervention to implement longer duration prescriptions versus usual care on long-term cardiac medication adherence among post-MI patients. Intervention groups and their corresponding settings include: (1) intervention group 1: 1 cardiac center and 1 noncardiac hospital allocated to receive standardized discharge prescription forms supporting the dispensation of 90 days’ worth of cardiac medications with 3 repeats, coupled with education; (2) intervention group 2: 4 sites (including 1 cardiac center) allocated to receive education only; and (3) control group: all remaining hospitals within the province that did not receive an intervention (ie, usual care). Administrative databases will be used to measure all outcomes. Adherence to 4 classes of cardiac medications — statins, beta blockers, angiotensin system inhibitors, and secondary antiplatelets (ie, prasugrel, clopidogrel, or ticagrelor) — will be assessed.ResultsEnrollment began in September 2017, and results are expected to be analyzed in late 2020.ConclusionsThe results have the potential to redefine best practices regarding discharge prescribing policies for patients post-MI. A policy of standardized maximum-duration prescriptions at the time of discharge post-MI is a simple intervention that has the potential to significantly improve long-term medication adherence, thus decreasing cardiac morbidity and mortality. If effective, this low-cost intervention to implement longer duration prescriptions post-MI could be easily scaled.Trial RegistrationClinicalTrials.gov NCT03257579; https://clinicaltrials.gov/ct2/show/NCT03257579International Registered Report Identifier (IRRID)DERR1-10.2196/18981
Highlights
BackgroundInternational guidelines recommend the long-term use of secondary preventative cardiac medications following a myocardial infarction (MI) [1,2,3]
The Myocardial Infarction Prescription Adherence Duration (MIPAD) study will use a quasiexperimental, interrupted time series design to evaluate the impact of standardized prolonged discharge prescription forms and education versus usual care on long-term cardiac medication adherence among elderly, post-MI patients in Ontario who were discharged from hospital following a cardiac catheterization procedure between September 1, 2015 and August 31, 2018
We calculated that 24 pre-intervention and 12 post-intervention intervals in each group will achieve 80% power to detect an immediate increase of 10% in the monthly proportion of patients with adherence to their cardiac medication regimen at 1 year
Summary
International guidelines recommend the long-term use of secondary preventative cardiac medications following a myocardial infarction (MI) [1,2,3]. The medication classes used for secondary prevention post-MI include both a primary antiplatelet (aspirin) and secondary antiplatelet (eg, prasugrel, clopidogrel, or ticagrelor), statins, beta blockers, and angiotensin system inhibitors (ie, an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker). These medications provide an expected 60% relative risk reduction of recurrent cardiovascular events [1,2]. Based on high-quality evidence, guidelines recommend the long-term use of secondary prevention medications post-myocardial infarction (MI) to avoid recurrent cardiovascular events and death. The following is a proposal for the first interventional study to evaluate the impact of longer prescription duration at discharge post-MI on long-term medication adherence
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