Can Phone-Based Motivational Interviewing Improve Medication Adherence to Antiplatelet Medications After a Coronary Stent Among Racial Minorities? A Randomized Trial

Abstract

BACKGROUND:Minorities have lower adherence to cardiovascular medications and have worst cardiovascular outcomes post coronary stent placement OBJECTIVE: The aim of this study is to compare the efficacy of phone-delivered Motivational Interviewing (MINT) to an educational video at improving adherence to antiplatelet medications among insured minorities. DESIGN: This was a randomized study. PARTICIPANTS: We identified minorities with a recently placed coronary stent from an administrative data set by using a previously validated algorithm. INTERVENTIONS: MINT subjects received quarterly phone calls and the DVD group received a one-time mailed video. MAIN MEASURES: Outcome variables were collected at baseline and at 12-month post-stent, using surveys and administrative data. The primary outcome was antiplatelet (clopidogrel and prasugrel) adherence measured by Medication Possession Ratio (MPR) and self-reported adherence (Morisky score). We also measured appropriate adherence defined as an MPR ≥ 0.80. KEY RESULTS: We recruited 452 minority subjects with a new coronary stent (44 % Hispanics and 56 % Black). The patients had a mean age of 69.5±8.8, 58 % were males, 78 % had an income lower than $30,000 per year and only 22 % had achieved high school education or higher. The MPR for antiplatelet medications was 0.77 for the MINT group compared to 0.70 for the DVD group (p<0.05). The percentage of subjects with adequate adherence to their antiplatelet medication was 64 % in the MINT group and 50 % in the DVD group (p<0.01). Self-reported adherence at 12 months was higher in the MINT group compared to the DVD group (p<0.01). Results were similar among drug-eluting stent (DES) recipients. CONCLUSIONS: Among racial minorities, a phone-based motivational interview is effective at improving adherence to antiplatelet medications post coronary stent placement. Phone-based MINT seems to be a promising and cost-effective strategy to modify risk behaviors among minority populations at high cardiovascular risk. BACKGROUNDThe safe use of coronary stents requires the daily use of thienopyridines for 3 to 12 months after percutaneous coronary intervention (PCI). 1 The premature discontinuation of these medications 1 is associated with an increased risk of instent thrombosis, cardiovascular events and death. 2-6 Unfortunately, lack of medication adherence is common and is associated with significant health care costs and mortality. 7,8 Vulnerable groups such as racial minorities and the elderly have a higher risk of poor adherence. 5,6,9,10 In the case of antiplateletet medications, blacks are more likely to not receive a clopidogrel prescription 11 or to not fill it after PCI. Further, our prior analyses of insurer claims data showed that minority populations were less adherent to antiplatelet medications post drug-eluting stent (DES) placement. 12 The lack of appropriate use of evidence-based therapies after PCI may partially contribute to the excess morbidity and mortality reported among minorities. 13,14,6 The improvement of med...

Motivational Interviewing Improves Medication Adherence: a Systematic Review and Meta-analysis

“…This was due to the variability in adherence measures that required further stratification of the (26,32,50), continuous (27); mixed MI: continuous (15,25); fidelity assessment: categorical (22,24,27,28,30,32), continuous (15, 15, 17-20, 22, 25, 27, 28, 33); no fidelity assessment: categorical (21,23,26,29), continuous (29); fidelity-based feedback: categorical (28,30,33), continuous (15,18,20,33,51); no fidelity-based feedback: categorical (21-24, 26, 27, 29, 32), continuous (19,22,25,27,29,34) Background of counselors: nurses: categorical (23,26,28,29), continuous (15,20,28,29); psychologist: continuous (17)(18)(19); pharmacists: categorical (32); master level: categorical (22,24), continuous ...…”

“…It is important to clarify the efficacy of different MI delivery modes 36 since they could improve MI's cost-effectiveness and reach among populations with access barriers. Solomon and Palacio et al 27,32 used administrative pharmacy claims and a phone-based delivery mode to identify and reach a large number of eligible subjects over wide geographic areas. Group-or peer-led MI could offer a more comfortable environment for subjects reluctant to participate in one-on-one sessions.…”

“…16,17,21 Thirteen reported no differences in characteristics by completion status, and one reported that subjects lost to follow-up in the MI group had a trend toward more depressive symptoms. 15 Of studies with objective adherence measures, seven reported having missing data, 18,19,[25][26][27][28][29] but only two studies had missing data in more than 20 % of the sample. 18,28 All described this occurrence as non-differential among study arms.…”

“…Studies that used telephone-based MI exclusively identified eligible subjects from either a registry 21 or from health or pharmacy benefit programs. 27,32 The most commonly evaluated medications were highly active antiretroviral therapy (HAART). Among the 13 studies that reported race/ethnicity, 12 focused on minorities and 1963 individuals (48 %) belonged to a racial minority.…”

“…The rater provided feedback to the RAs based on the audiotape recordings Palacio 27 3-Day workshop conducted by an experienced MI trainer and by a specialist in the MITI Coding system. Nurses also received 1-week training on coronary artery disease, antiplatelet medications, predictors of adherence and study-specific protocols Yes.…”