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Telephone intervention to improve adherence to dual-antiplatelet therapy following percutaneous coronary intervention at Parkland Hospital and Health System

» Daniel Bennett (Parkland Health and Hospital System), Jeffrey Chidester (UTSW), Kamal Shemisa (Northeast Ohio Medical University), Houman Khalili (UTSW), Laurie Beall (Parkland Health and Hospital System), Tiffany Denkins (Parkland Health and Hospital System), Chris Mathew (Parkland Health and Hospital System), Kristin Alvarez (Parkland Health and Hospital System), Tayo Addo (UTSW), Sandeep Das (UTSW)

Background

Adherence to P2Y12 inhibitors following stent placement reduces risk of multiple serious complications.  Khalili et al. (2016) previously reported poor adherence rates to P2Y12 inhibitors at Parkland Health and Hospital System (PHHS). Rinfret et al. (2013) demonstrated improvement in adherence to these medications with patient phone calls following discharge.

Objectives

The primary objective was to improve adherence as measured by proportion of days covered (PDC) at Parkland Health and Hospital System. The secondary objective was to identify system-level processes contributing to poor medication adherence.

Methods

We instituted a nursing-led patient phone call initiative at the following time intervals after PCI: within 1 week, 30 days, and 90 days. Median PDC rates were compared with a historical control using a Mann-Whitney U test. Patients who were identified as needing subsequent individual interventions were referred by the nurse to a pharmacist or physician depending on their specific needs.

Results

To assess the effect of our intervention on medication adherence, we limited our data analysis to those patients who underwent PCI between 9/1/2017 and 10/31/2017 and filled their medications at a PHHS pharmacy. In total, 43 patients during a median follow-up of 120 days were included in the analysis. Those receiving phone calls had higher PDC rates compared to a historical control with median adherence rates of 92.2% and 88.5%, respectively (p-value 0.0095; 95% CI).

Additionally, between 9/1/2017 and 3/16/2018, a nurse was successfully able to speak with 132 (60.8%) patients at 7 or 30 days following PCI. Of these, 15 (11.4%) patients needed individual interventions such as one-on-one education with a pharmacist, change in medicine due to cost or side-effect, or prescription coupons or vouchers in order to afford their P2Y12 inhibitor.

Conclusion

At a single safety-net hospital, a nursing-led phone call intervention successfully improved adherence rates of P2Y12 inhibitors following percutaneous coronary intervention and identified multiple areas for process improvement with regards to providing patients with timely and affordable access to medications. Moreover, 1 in 10 patients who were successfully contacted required subsequent individual interventions.

Implications for the Patient

These individual cases have led to multiple system-wide initiatives including production of a patient educational video, an emphasis on identifying patients currently without funding and providing them with prescription coupons prior to discharge to reduce patient cost of care, and multi-disciplinary improvements in transitions of care.