From the 2019 HVPAA National Conference
Dr. Jeffrey Chidester (University of Texas Southwestern), Dr. Daniel Bennett (University of Texas Southwestern), Dr. Kim Berger (University of Texas Southwestern), Mrs. Laurie Beall (Parkland Health & Hospital System), Mrs. Tiffany Denkins (Parkland Health & Hospital System), Mr. Chris Mathew (Parkland Health & Hospital System), Mrs. Kristin Alvarez (Parkland Health & Hospital System), Dr. Michael Luna (University of Texas Southwestern), Dr. Tayo Addo (University of Texas Southwestern), Dr. Rebecca Vigen (University of Texas Southwestern), Dr. Sandeep Das (University of Texas Southwestern)
Background
Poor adherence to dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) is associated with poor outcomes including stent thrombosis, rehospitalization, and mortality. Safety-net patients are at high risk for low adherence due to poor health literacy and financial constraints. Understanding and overcoming barriers to patient adherence to DAPT after PCI may reduce the risk of adverse outcomes in safety-net patients.
Objective
A multidisciplinary team of Nurses, Pharmacists, Internal Medicine Residents, and Cardiologists designed and implemented a telephone-based intervention to improve adherence to DAPT after PCI at Parkland Health & Hospital System (PHHS), a safety-net hospital system in Dallas, Texas.
Methods
Beginning 9/1/17, nurses from the Parkland Cardiac Catheterization Laboratory called all PCI patients 7, 30, and 90 days post-PCI. Patients were reminded of the importance of DAPT and asked if they had concerns about their medications. Specific issues that arose were handled by the multidisciplinary team via interventions such as: provision of vouchers for reduced-cost medications, change in pharmacy or medication to lower cost, appointment with Pharmacy or Cardiology clinicians to discuss medication, confirmation of active refills. The total number of patients with self-reported nonadherence was quantified, as was proportion of days covered (PDC) on DAPT at 6 months, defined as the total number of days filled in the first 6 months post-PCI divided by 180 days.
Results
From 9/1/17 – 2/28/18, 189 patients underwent PCI at Parkland. Of these patients, 67% (127 of 189) were able to be contacted, with 10% (13 of 127) of contacted patients reporting problems with medications resulting in complete nonadherence and requiring intervention. Of the total treated patients, 65% (123 of 189) had prescriptions filled at PHHS pharmacies which allowed for manual calculation of adherence data and 72% (89 of 123) of these patients were successfully contacted. Median PDC was 94% at 6 months, with PDC >90% in 59% (72 of 123) of all patients and 62% (55 of 89) of successfully contacted patients. A historical control sample (N=154) who underwent PCI at Parkland from 1/1/16 – 8/31/17 and filled prescriptions at PHHS pharmacies had a median PDC of 92% at 6 months, with PDC >90% in 55% (84 of 154). There was no significant difference in median PDC (p=0.4) or proportion of patients with PDC >90% in either all-study (p=0.37) or successful contact (p=0.19) patient populations compared to this control.
Conclusion
A telephone-based intervention allowed for identification and resolution of potentially catastrophic barriers to DAPT adherence in 1 in 10 contacted patients within 6 months post-PCI. However, it was unable to significantly improve medication adherence as measured by PDC, indicating that this adherence metric may not be an adequate measure of impact in this context.
