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Yu C, Liu C, Du J, Liu H, Zhang H, Zhao Y, Yang L, Li X, Li J, Wang J, Wang H, Liu Z, Rao C, Zheng Z. Smartphone-based application to improve medication adherence in patients after surgical coronary revascularization. Am Heart J 2020; 228:17-26. [PMID: 32745732 DOI: 10.1016/j.ahj.2020.06.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 06/30/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Secondary preventive therapies play a key role in the prevention of adverse events after coronary artery bypass grafting (CABG). However, adherence to secondary preventive drugs after CABG is often poor. With the increasing penetration of smartphones, health-related smartphone applications might provide an opportunity to improve medication adherence. We aimed to evaluate the effectiveness and feasibility of using a smartphone-based application to improve medication adherence in patients after CABG. METHODS The Measurement and Improvement Studies of Surgical coronary revascularizatION: medication adherence (MISSION-2) study is a multicenter randomized controlled trial that planned to enroll over 1000 patients who underwent isolated CABG at one of four large teaching hospitals in China; all enrolled participants had access to a smartphone and were able to operate at least three smartphone applications. The investigators randomly assigned the participants to one of two groups: (1) the intervention group with an advanced smartphone application for 6 months which was designed specifically for this trial and did not exist before. Participants could receive medication reminders and cardiac health education by the smartphone application or (2) the control group with usual care. The primary outcome was CABG secondary preventive medication adherence as measured by the translated Chinese version of the 8-item Morisky Medication Adherence Scale (MMAS-8) at 6 months after randomization. The secondary outcomes were mortality, major adverse cardiovascular and cerebrovascular events (MACCE), cardiovascular rehospitalization, self-reported secondary preventive medication use after 6 months of follow-up, blood pressure (BP), body mass index (BMI), and self-reported smoking status. All analyses were conducted using the intention-to-treat principle. RESULTS A total of 1000 patients (mean age, 57.28 [SD, 9.09] years; 85.5% male) with coronary heart disease after CABG were enrolled between September 2015 and September 2016 and were randomly assigned to the intervention (n = 501) or control group (n = 499). At 6 months, the proportion of low-adherence participants, categorized by MMAS-8 scores, was 11.8% in the intervention group and 11.7% in the control group (RR = 1.005, 95% CI 0.682 to 1.480, P = 1.000). Similar results were found in sensitivity analyses that considered participants who withdrew from the study, or were lost to follow-up as nonadherent. There were no significant differences in the secondary clinical outcome measures, and there were no significant differences in the primary outcome across the subgroups tested. In the intervention group, the proportion of participants who used and operated the application during the first month after CABG was 88.1%; however, the use rate decreased sharply from 42.5% in the second month to 9.2% by the end of the study (6 months). CONCLUSIONS A smartphone-based application supporting secondary prevention among patients after CABG did not lead to a greater adherence to secondary preventive medications. The limited room for improvement in medication adherence and the low participants' engagement with the smartphone applications might account for these non-significant outcomes.
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Affiliation(s)
- Chunyu Yu
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chongyang Liu
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Junzhe Du
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hanning Liu
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Heng Zhang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Zhao
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Limeng Yang
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xi Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jue Wang
- Department of Thoracic and Cardiovascular Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Huishan Wang
- Department of Cardiovascular Surgery, General Hospital of Shenyang Military Region, Shenyang, Liaoning, China
| | - Zhigang Liu
- Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Tianjin, China
| | - Chenfei Rao
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Zhe Zheng
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Lazar HL. The surgeon's role in optimizing medical therapy and maintaining compliance with secondary prevention guidelines in patients undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg 2020; 160:691-698. [DOI: 10.1016/j.jtcvs.2019.09.195] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 09/26/2019] [Accepted: 09/28/2019] [Indexed: 12/30/2022]
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Barry AR, Wang EH, Chua D, Pearson GJ. Comparison of Preventive Cardiovascular Pharmacotherapy in Surgical vs Percutaneous Coronary Revascularization. CJC Open 2019; 1:297-304. [PMID: 32159124 PMCID: PMC7063635 DOI: 10.1016/j.cjco.2019.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 09/10/2019] [Indexed: 11/27/2022] Open
Abstract
Background Data suggest that patients who undergo coronary artery bypass grafting (CABG) have a lower rate of secondary preventive cardiovascular pharmacotherapy use compared with patients who undergo percutaneous coronary intervention (PCI). This study sought to assess the rate of use of preventive pharmacotherapy at discharge in patients who underwent CABG vs PCI post–acute coronary syndrome (ACS). Methods A prospective cohort study was conducted at St Paul’s Hospital in Vancouver, Canada. Patients aged ≥ 18 years who presented with an ACS and underwent CABG or PCI between January and November 2018 were included. Data on preventive pharmacotherapy use and reasons for justified nonuse (eg, intolerance, contraindication) were collected. Results A total of 275 patients were included. Mean age was 65 years, and 83% were male. Overall, 141 patients (51%) underwent CABG and 134 patients (49%) underwent PCI. All patients received acetylsalicylic acid, but more patients who underwent CABG received 325 mg (vs 80-81 mg) compared to PCI (25% vs 1%, P < 0.01). Use of P2Y12 inhibitors was higher in patients who underwent PCI (primarily ticagrelor) compared with patients who underwent CABG (primarily clopidogrel) (99% vs 26%, P < 0.01). All patients who underwent CABG received a β-blocker vs 96% of patients who underwent PCI (P = 0.017). Use of angiotensin-modulating agents was higher in patients who underwent PCI (98% vs 65%, P < 0.01). Statin use was similar between groups (99% vs 99%, P = 0.96), but more patients who underwent PCI received maximum-dose therapy (89% vs 64%, P < 0.01). Conclusions Use of acetylsalicylic acid, β-blockers, and statins in patients post-ACS was high regardless of revascularization strategy, whereas P2Y12 inhibitors and angiotensin-modulating agents were underused in patients who underwent CABG even after adjusting for justified nonuse.
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Liu CY, Du JZ, Rao CF, Zhang H, Liu HN, Zhao Y, Yang LM, Li X, Li J, Wang J, Wang HS, Liu ZG, Cheng ZY, Zheng Z. Quality Measurement and Improvement Study of Surgical Coronary Revascularization: Medication Adherence (MISSION-2). Chin Med J (Engl) 2018; 131:1480-1489. [PMID: 29873315 PMCID: PMC6006808 DOI: 10.4103/0366-6999.233767] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background Secondary preventive therapies play a key role in the prevention of adverse outcomes after coronary artery bypass grafting (CABG). However, medication adherence after CABG is often poor, and conventional interventions for improving adherence have limited success. With increasing penetration of smartphones, health-related smartphone applications might provide an opportunity to improve adherence. Carefully designed trials are needed to provide reliable evidence for the use of these applications in patients after CABG. Methods The Measurement and Improvement Studies of Surgical Coronary Revascularization: Medication Adherence (MISSION-2) study is a multicenter randomized controlled trial, aiming to randomize 1000 CABG patients to the intervention or control groups in a 1:1 ratio. We developed the multifaceted, patient-centered, smartphone-based Heart Health Application to encourage medication adherence in the intervention group through a health self-management program initiated during hospital admission for CABG. The application integrated daily scheduled reminders to take the discharge medications, cardiac educational materials, a dynamic dashboard to review cardiovascular risk factors and secondary prevention targets, and weekly questionnaires with interactive feedback. The primary outcome was secondary preventive medication adherence measured by the Chinese version of the 8-item Morisky Medication Adherence Scale at 6 months after randomization. Secondary outcomes included all-cause death, cardiovascular rehospitalization, and a composite of death, myocardial infarction, stroke, and repeat revascularization. Discussion Findings will not only provide evidence regarding the feasibility and effectiveness of the described intervention for improving adherence to CABG secondary preventive therapies but also explore a model for outpatient health self-management that could be translated to various chronic diseases and widely disseminated across resource-limited settings. Trial Registration https://clinicaltrials.gov (NCT02432469).
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Affiliation(s)
- Chong-Yang Liu
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100073, China
| | - Jun-Zhe Du
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100073, China
| | - Chen-Fei Rao
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College; Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100073, China
| | - Heng Zhang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College; Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100073, China
| | - Han-Ning Liu
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College; Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100073, China
| | - Yan Zhao
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100073, China
| | - Li-Meng Yang
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100073, China
| | - Xi Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100073, China
| | - Jing Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College; Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100073, China
| | - Jue Wang
- Department of Thoracic and Cardiovascular Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Hui-Shan Wang
- Department of Cardiovascular Surgery, General Hospital of Shenyang Military Region, Shenyang, Liaoning 110016, China
| | - Zhi-Gang Liu
- Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Tianjin 300457, China
| | - Zhao-Yun Cheng
- Department of Cardiovascular Surgery, Henan Provincial People's Hospital, Fuwai Central China Cardiovascular Hospital, Zhengzhou, Henan 450003, China
| | - Zhe Zheng
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College; Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100073, China
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Daci A, Bozalija A, Cavolli R, Alaj R, Beretta G, Krasniqi S. Pharmacotherapy Evaluation and Utilization in Coronary Artery Bypass Grafting Patients in Kosovo during the Period 2016-2017. Open Access Maced J Med Sci 2018; 6:498-505. [PMID: 29610608 PMCID: PMC5874373 DOI: 10.3889/oamjms.2018.132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 02/15/2018] [Accepted: 02/17/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND: Coronary Artery Bypass Grafting (CABG) is realised in patients with critical or advanced disease of coronary arteries. There are different pharmacotherapeutic approaches which are used as management, treatment and preventive therapy in cardiovascular disease or related comorbidities. Performing a successful surgery, pharmacotherapy, and increase of bypass patency rate remains a serious challenge. AIM: This study aims to analyse the patient characteristics undergoing CABG and evaluation of their drug utilisation rate and daily dosages in the perioperative period. MATERIAL AND METHODS: Data were collected from 102 patients in the period 2016-2017 and detailed therapeutic prescription and dosages, patient characteristics were analysed before the operation, after the operation and visit after operation in the Clinic of Cardiac surgery-University Clinical Center of Kosovo. RESULTS: Our findings had shown that patients provided to have normal biochemical parameters in the clinic before the operation, and were related to cardiovascular diseases and comorbidities and risk factors with mainly elective intervention. The, however, higher utilisation of cardiovascular drugs such as beta blockers, diuretics, anticoagulants, statins and lower calcium blockers, ACEi, ARBs, hydrochlorothiazide, amiodarone were founded. ARBs, beta blockers, statins, nitrates and nadroparin utilisation decreased after operation and visit after the operation, whereas amiodarone only in the visit after the operation. Diuretics are increased after the operation which decreases in the visit after the operation. Regarding the daily dosage, only metoprolol was increased in the visit after operation (P < 0.001) and visit after operation (P < 0.05) whereas losartan and furosemide were increased (P < 0.01) and (P < 0.05) respectively. CONCLUSION: The study showed that beta blockers, statins, aspirin, nitrates (before the operation), furosemide and spironolactone are the most utilised drugs. However, we found low utilisation rate for ACEi, ARBs, clopidogrel, nadroparin, warfarin, xanthines, amiodarone, calcium blockers. Daily dosages were different compared to before CABG only in metoprolol, losartan, and furosemide.
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Affiliation(s)
- Armond Daci
- Department of Pharmacy, Faculty of Medicine, University of Prishtina, Prishtina, Kosovo
| | - Adnan Bozalija
- Department of Pharmacy, Faculty of Medicine, University of Prishtina, Prishtina, Kosovo
| | - Raif Cavolli
- Cardiovascular Surgery Clinic, University Clinical Center of Kosovo, Prishtina, Kosovo
| | - Rame Alaj
- Cardiovascular Surgery Clinic, University Clinical Center of Kosovo, Prishtina, Kosovo
| | - Giangiacomo Beretta
- Department of Pharmaceutical Sciences, Università degli Studi di Milano, Milan, Italy
| | - Shaip Krasniqi
- Department of Pharmacology, Faculty of Medicine, University of Prishtina, Prishtina, Kosovo
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O'Neal WT, Efird JT, Davies SW, O'Neal JB, Griffin WF, Ferguson TB, Chitwood WR, Kypson AP. Discharge β-Blocker Use and Race after Coronary Artery Bypass Grafting. Front Public Health 2014; 2:94. [PMID: 25121083 PMCID: PMC4114325 DOI: 10.3389/fpubh.2014.00094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 07/09/2014] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The use of discharge β-blockers after cardiac surgery is associated with a long-term mortality benefit. β-Blockers have been suggested to be less effective in black cardiovascular patients compared with whites. To date, racial differences in the long-term survival of coronary artery bypass grafting (CABG) patients who receive β-blockers at discharge have not been examined. METHODS A retrospective cohort study was conducted on patients undergoing CABG between 2002 and 2011. Long-term survival was compared in patients who were and who were not discharged with β-blockers. Hazard ratios (HR) and 95% confidence intervals (CI) were computed using a Cox regression model. P-for-interaction between race and discharge β-blocker use was computed using a likelihood ratio test. RESULTS A total of 853 (88%) black (n = 970) and 3,038 (88%) white (n = 3,460) patients had a history of β-blocker use at discharge (N = 4,430). Black patients who received β-blockers survived longer than those not receiving β-blockers and the survival advantage was comparable with white patients (black, adjusted HR = 0.33, 95% CI = 0.23-0.46; white, adjusted HR = 0.48, 95% CI = 0.39-0.58; p-for-interaction = 0.74). Among patients discharged on β-blockers, we did not observe a long-term survival advantage for white compared with black patients (HR = 1.2, 95% CI = 0.95-1.5). CONCLUSION β-Blocker use at discharge was associated with a survival advantage among black patients after CABG and a similar association was observed in white patients.
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Affiliation(s)
- Wesley T O'Neal
- Department of Internal Medicine, Wake Forest School of Medicine , Winston-Salem, NC , USA
| | - Jimmy T Efird
- East Carolina Heart Institute, Department of Cardiovascular Sciences, Brody School of Medicine, East Carolina University , Greenville, NC , USA ; Center for Health Disparities, Brody School of Medicine, East Carolina University , Greenville, NC , USA
| | - Stephen W Davies
- Department of General Surgery, University of Virginia School of Medicine , Charlottesville, VA , USA
| | - Jason B O'Neal
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School , Boston, MA , USA
| | - William F Griffin
- East Carolina Heart Institute, Department of Cardiovascular Sciences, Brody School of Medicine, East Carolina University , Greenville, NC , USA
| | - T Bruce Ferguson
- East Carolina Heart Institute, Department of Cardiovascular Sciences, Brody School of Medicine, East Carolina University , Greenville, NC , USA
| | - W Randolph Chitwood
- East Carolina Heart Institute, Department of Cardiovascular Sciences, Brody School of Medicine, East Carolina University , Greenville, NC , USA
| | - Alan P Kypson
- East Carolina Heart Institute, Department of Cardiovascular Sciences, Brody School of Medicine, East Carolina University , Greenville, NC , USA
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Olomu AB, Stommel M, Holmes-Rovner MM, Prieto AR, Corser WD, Gourineni V, Eagle KA. Is quality improvement sustainable? Findings of the American college of cardiology's guidelines applied in practice. Int J Qual Health Care 2014; 26:215-22. [DOI: 10.1093/intqhc/mzu030] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Barry AR, Koshman SL, Norris CM, Ross DB, Pearson GJ. Evaluation of Preventive Cardiovascular Pharmacotherapy after Coronary Artery Bypass Graft Surgery. Pharmacotherapy 2013; 34:464-72. [DOI: 10.1002/phar.1380] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Arden R. Barry
- Pharmacy Services; Mazankowski Alberta Heart Institute; Edmonton Alberta Canada
| | - Sheri L. Koshman
- Division of Cardiology; Faculty of Medicine & Dentistry; University of Alberta; Edmonton Alberta Canada
| | - Colleen M. Norris
- Division of Cardiology; Faculty of Medicine & Dentistry; University of Alberta; Edmonton Alberta Canada
- Division of Cardiac Surgery; Faculty of Medicine & Dentistry; University of Alberta; Edmonton Alberta Canada
- Faculty of Nursing; University of Alberta; Edmonton Alberta Canada
- Cardiovascular Health and Stroke Strategic Clinical Network; Edmonton; Alberta Canada
| | - David B. Ross
- Division of Cardiac Surgery; Faculty of Medicine & Dentistry; University of Alberta; Edmonton Alberta Canada
| | - Glen J. Pearson
- Division of Cardiology; Faculty of Medicine & Dentistry; University of Alberta; Edmonton Alberta Canada
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Kulik A, Desai NR, Shrank WH, Antman EM, Glynn RJ, Levin R, Reisman L, Brennan T, Choudhry NK. Full prescription coverage versus usual prescription coverage after coronary artery bypass graft surgery: analysis from the post-myocardial infarction free Rx event and economic evaluation (FREEE) randomized trial. Circulation 2013; 128:S219-25. [PMID: 24030410 DOI: 10.1161/circulationaha.112.000337] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Eliminating out-of-pocket costs for patients after myocardial infarction (MI) improves adherence to preventive therapies and reduces clinical events. Because adherence to medical therapy is low among patients treated with coronary artery bypass graft surgery (CABG), we evaluated the impact of providing full prescription coverage to this patient subgroup. METHODS AND RESULTS The MI Free Rx Event and Economic Evaluation (FREEE) trial randomly assigned 5855 patients with MI to full prescription coverage or usual formulary coverage for all statins, β-blockers, angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers. We assessed the impact of full prescription coverage on adherence, clinical outcomes, and healthcare costs using adjusted models among the 1052 patients who underwent CABG at the index hospitalization and 4803 who did not. CABG patients were older and had more comorbid illness (P<0.01). After MI, CABG patients were significantly more likely to receive β-blockers and statins but were less likely to receive angiotensin-converting enzyme inhibitor/angiotensin receptor blocker therapy (P<0.01). Receiving full drug coverage increased rates of adherence to all preventative medications after CABG (all P<0.05). Full coverage was also associated with nonsignificant reductions in the rate of major vascular events or revascularization for patients treated with CABG (hazard ratio, 0.91; 95% confidence interval, 0.66-1.25) or without CABG (hazard ratio, 0.93; 95% confidence interval, 0.82-1.06), with no interaction noted (Pint=NS). After CABG, full prescription coverage significantly reduced patient out-of-pocket spending for drugs (P=0.001) without increasing overall health expenditures (P=NS). CONCLUSIONS Eliminating drug copayments after MI provides consistent benefits to patients treated with or without CABG, leading to increased medication adherence, trends toward improved clinical outcomes, and reduced patient out-of-pocket expenses.
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Affiliation(s)
- Alexander Kulik
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.K., N.R.D., W.H.S., E.M.A., R.J.G., R.L., N.K.C.); Lynn Heart and Vascular Institute, Boca Raton Regional Hospital, Boca Raton, FL (A.K.); Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL (A.K.); Aetna, Hartford, CT (L.R.); and CVS Caremark, Woonsocket, RI (T.B.)
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Short- and long-term impact of an inpatient quality improvement initiative: results of the CABG-GAP Practice Improvement Project. J Cardiopulm Rehabil Prev 2013; 33:212-9. [PMID: 23719148 DOI: 10.1097/hcr.0b013e3182930cd0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE A significant percentage of patients undergoing coronary artery bypass graft (CABG) surgery leave the hospital without appropriate preventive medications. Little is known about this prevention gap and its solutions. We studied the short- and long-term impacts of a quality improvement (QI) project aimed at reducing this prevention gap. METHODS A sequential 3-phase QI project was performed in patients undergoing CABG surgery in Olmsted County, MN, from April 2001 to March 2002. In phase 1 (n = 213), cardiovascular surgery team members were given a pocket reminder card with preventive medication guidelines. In phase 2 (n = 182), monthly team feedback reports were added. In phase 3 (n = 199), a "refrigerator magnet" patient reminder card listing prescribed medications was added. A baseline comparison group (n = 305) was selected randomly from patients undergoing CABG surgery in 2000. Patient receipt of preventive medications and all-cause mortality were compared. RESULTS Prescription of lipid-lowering medications (LLM) increased with each incremental QI tool as compared with baseline (P < .001). Nonsignificant trends were noted for aspirin, angiotensin-converting enzyme inhibitors, and β-blockers. At 1 year, the use of LLM was similarly high in all groups and was associated with cardiac rehabilitation use. Short- and long-term mortality rates did not differ between study groups. CONCLUSIONS Our inpatient QI tools resulted in early, high LLM use, but the treatment advantage of the interventions was erased by 1 year and no survival benefit was noted. Our study illustrates the importance of tracking long-term outcomes in QI projects and suggests that outpatient cardiac rehabilitation is associated with long-term use of LLM.
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Krzych LJ. Treatment of hypertension in patients undergoing coronary artery by-pass grafting. Curr Opin Pharmacol 2012; 12:127-33. [PMID: 22342165 DOI: 10.1016/j.coph.2012.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2011] [Revised: 01/15/2012] [Accepted: 01/16/2012] [Indexed: 11/30/2022]
Abstract
Hypertension occurs in up to 80% of patients scheduled to coronary artery by-pass grafting (CABG). In hemodynamically stable patients all anti-hypertensive drugs should be continued till a day of surgery. For vast majority of patients there is no need to use blood pressure lowering agents during CABG, however it is necessary to maintain blood pressure level and avoid extreme blood pressure variations. Upon CABG hypotensive therapy should be modified to the needs of the individual patient and should be monitored individually. Treatment of hypertension ought to be started with caution with lowest possible dosage. Aggressive therapy is strongly discouraged to avoid hemodynamic collapse. Beta-blockers should be administered to all CABG patients unless contraindicated.
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Affiliation(s)
- Lukasz J Krzych
- 1st Department of Cardiac Surgery, Medical University of Silesia, Katowice, Poland.
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Benedetto U, Melina G, di Bartolomeo R, Angeloni E, Sansone D, Falaschi G, Capuano F, Comito C, Roscitano A, Sinatra R. n-3 Polyunsaturated Fatty Acids After Coronary Artery Bypass Grafting. Ann Thorac Surg 2011; 91:1169-75. [DOI: 10.1016/j.athoracsur.2010.11.068] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Revised: 11/24/2010] [Accepted: 11/29/2010] [Indexed: 11/17/2022]
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Chan AY, McAlister FA, Norris CM, Johnstone D, Bakal JA, Ross DB. Effect of β-blocker use on outcomes after discharge in patients who underwent cardiac surgery. J Thorac Cardiovasc Surg 2010; 140:182-7, 187.e1. [DOI: 10.1016/j.jtcvs.2010.03.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2009] [Revised: 01/25/2010] [Accepted: 03/09/2010] [Indexed: 01/27/2023]
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Kulik A, Ruel M. Statins and coronary artery bypass graft surgery: preoperative and postoperative efficacy and safety. Expert Opin Drug Saf 2009; 8:559-71. [DOI: 10.1517/14740330903188413] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Khanderia U, Townsend KA, Erickson SR, Vlasnik J, Prager RL, Eagle KA. Medication adherence following coronary artery bypass graft surgery: assessment of beliefs and attitudes. Ann Pharmacother 2008; 42:192-9. [PMID: 18198242 DOI: 10.1345/aph.1k497] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND The medication management of patients following coronary artery bypass graft (CABG) surgery may include antiplatelet agents, beta-blockers, angiotensin-converting enzyme inhibitors, and statins. However, poor adherence is common, and patient attitudes and beliefs play a role in adherence. OBJECTIVE To evaluate the association between self-reported adherence and the beliefs patients have about cardiovascular medicines used after CABG. METHODS Adults were surveyed 6-24 months following CABG. The validated Beliefs about Medicines Questionnaire (BMQ) assessed attitudes concerning the Specific Necessity, Specific Concerns, General Harm, and General Overuse of medicines. The validated medication adherence scale assessed self-reported adherence. Analysis included univariate comparison (BMQ scales) and multivariate logistic regression (identification of adherence predictor variables). RESULTS Of 387 patients surveyed, 132 (34%) completed the questionnaire. Nonparticipants were more likely to be female and have undergone 1- or 2-vessel CABG procedures compared with 3- or 4-vessel procedures. Subjects were primarily English-speaking, white, and male. Adherent behavior was reported in 73 of 132 patients (55%). The average period between CABG and the survey was 16 months. Nonadherent patients were in stronger agreement on the General Overuse (p = 0.01) and General Harm (p = 0.04) scales. The adjusted odds of adherent behavior were significantly lower, with an increasing General Overuse score (OR 0.83; 95% CI 0.72 to 0.95; p = 0.007); an annual income of $50,000 to $100,000 relative to less than $20,000 (OR 0.36; 95% CI 0.14 to 0.91; p = 0.031), and a living status of "alone" compared with "with adults and no children" (OR 0.20; 95% CI 0.06 to 0.65; p = 0.007). The odds ratio of self-reported adherence was higher with increasing age (OR 1.05; 95% CI 1.01 to 1.09; p = 0.023). CONCLUSIONS In summary, patient beliefs and attitudes regarding medications, along with other social, economic, and demographic factors, help explain differences in self-reported adherence to standard drug therapy following CABG.
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Affiliation(s)
- Ujjaini Khanderia
- College of Pharmacy, University of Michigan, Ann Arbor, MI 48109, USA.
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Kulik A, Levin R, Ruel M, Mesana TG, Solomon DH, Choudhry NK. Patterns and predictors of statin use after coronary artery bypass graft surgery. J Thorac Cardiovasc Surg 2007; 134:932-8. [PMID: 17903510 DOI: 10.1016/j.jtcvs.2007.05.039] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2007] [Revised: 05/04/2007] [Accepted: 05/14/2007] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The benefits of statin therapy for patients with coronary artery disease have been well documented, including those occurring after coronary artery bypass graft surgery. The purposes of this study were to assess statin prescription rates in patients who have undergone coronary artery bypass graft surgery and to identify the determinants of postoperative statin administration. METHODS A retrospective cohort of 9284 Medicare patients aged 65 years or older who underwent coronary artery bypass graft surgery (1995-2004) was assembled by using linked hospital and pharmacy claims data. Rates of statin use after hospital discharge were calculated, and predictors of postoperative statin use were identified by using generalized estimating equations. RESULTS Overall, 35.9% of patients received statins within 90 days of coronary artery bypass graft surgery discharge. Use of statins within 90 days after coronary artery bypass graft surgery steadily improved during the study period, from 13.1% in 1995 to 60.9% in 2004. Patient factors independently associated with an increase in postoperative statin therapy included preoperative statin use (odds ratio, 7.69), later year of operation (odds ratio, 1.22 per additional year), and additional postoperative medications (odds ratio, 1.16 per additional medication). Factors independently associated with a decrease in postoperative statin therapy included peripheral vascular disease (odds ratio, 0.60), diabetes mellitus (odds ratio, 0.67), stroke (odds ratio, 0.77), and older age (odds ratio, 0.96 per additional year). Surgeon and hospital characteristics were not independently associated with postoperative statin use. CONCLUSIONS Statins are considerably underused after coronary artery bypass graft surgery, although recent prescription rates are increasing. Patterns of use do not appear to correlate with coronary artery disease risk. These findings highlight the need for targeted quality improvement initiatives to increase the rate of statin administration to this at-risk population.
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Affiliation(s)
- Alexander Kulik
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Canada
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