Improving Medication Adherence through Graphically Enhanced Interventions in Coronary Heart Disease (IMAGE-CHD): A Randomized Controlled Trial

Abstract

BACKGROUND: Up to 50 % of patients do not take medications as prescribed. Interventions to improve adherence are needed, with an understanding of which patients benefit most. OBJECTIVE: To test the effect of two low-literacy interventions on medication adherence. DESIGN: Randomized controlled trial, 2×2 factorial design. PARTICIPANTS: Adults with coronary heart disease in an inner-city primary care clinic. INTERVENTIONS: For 1 year, patients received usual care, refill reminder postcards, illustrated daily medication schedules, or both interventions. MAIN MEASURES: The primary outcome was cardiovascular medication refill adherence, assessed by the cumulative medication gap (CMG). Patients with CMG< 0.20 were considered adherent. We assessed the effect of the interventions overall and, post-hoc, in subgroups of interest. KEY RESULTS: Most of the 435 participants were elderly (mean age = 63.7 years), African-American (91 %), and read below the 9th-grade level (78 %). Among the 420 subjects (97 %) for whom CMG could be calculated, 138 (32.9 %) had CMG<0.20 during followup and were considered adherent. Overall, adherence did not differ significantly across treatments: 31.2 % in usual care, 28.3 % with mailed refill reminders, 34.2 % with illustrated medication schedules, and 36.9 % with both interventions. In post-hoc analyses, illustrated medication schedules led to significantly greater odds of adherence among patients who at baseline had more than eight medications (OR=2.2; 95 % CI, 1.21 to 4.04) or low self-efficacy for managing medications (OR=2.15; 95 % CI, 1.11 to 4.16); a trend was present among patients who reported non-adherence at baseline (OR= 1.89; 95 % CI, 0.99 to 3.60). CONCLUSIONS: The interventions did not improve adherence overall. Illustrated medication schedules may improve adherence among patients with low selfefficacy, polypharmacy, or baseline non-adherence, though this requires confirmation.KEY WORDS: coronary heart disease; medical adherence; medication management.

Association of age, health literacy, and medication management strategies with cardiovascular medication adherence

“…Subjects for this analysis were participants in a randomized controlled trial [19]. Full eligibility criteria are described elsewhere [10].…”

Self-reported questionnaires for assessment adherence to treatment in patients with cardiovascular diseases

“…Furthermore, it is easy to understand and feasible to apply among different groups of patients, even during everyday visits. It works well for the assessment of the level of adherence to medications in patients suffering from hypertension or coronary artery disease [3,[42][43][44][45]. However, it does not allow a comprehensive assessment of adherence behaviours because this scale does not provide adequate information regarding factors contributing to non-adherence to medication [42].…”

“…Considering that approximately half of the patients requiring treatment due to chronic disease do not adhere to the therapeutic plan, the assessment of patient adherence to treatment plays a pivotal role in the description and verification of the therapeutic process [43][44][73][74][75]. Thus, the search for available tools for adherence assessment as well as evaluation of their characteristics is necessary [76][77][78].…”

“…The Morisky Medication Adherence Scale (MMAS) is a short and easy survey identifying barriers to treatment adherence. So far, this is the most extensively studied scale, validated for a large number of diseases [35][36][37][38][39][40][41][42][43][44][45][46][47][48][49]. The Self-efficacy for Appropriate Medication Use (SEAMS) [50][51], the Hill-Bone Compliance Scale [52][53][54][55], the Brief Medication Questionnaire (BMQ) [56][57][58][59], the Treatment Adherence Questionnaire for Patients with Hypertension (TAQPH) [66], the Martin-Bayarre-Grau questionnaire (MBG) [67][68], and the Adherence Self-Report Questionnaire (ASRQ) [69] focus on patients with chronic cardiovascular diseases, mainly with hypertension.…”

Web-Based, Pictograph-Formatted Discharge Instructions for Low-Literacy Older Adults After Hip Replacement Surgery: Findings of End-User Evaluation of the Website

“…In addition, pictographs are well suited to show a step-by-step procedure that make an entire homecare action sequence easier to learn when compared to explanations in text only. Using pictographs increases the likelihood that the discharge instructions are accurately interpreted by older adults after discharge to home (Hawley et al, 2008;Kripalani, Schmotzer, & Jacobson, 2012).…”