Heart Disease and Stroke Prevention: Tailored Pharmacy-based Interventions to Improve Medication Adherence

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Findings and Recommendations

The Community Preventive Services Task Force (CPSTF) recommends tailored pharmacy-based adherence interventions for cardiovascular disease prevention. Evidence shows interventions delivered by pharmacists in community and health system pharmacies increased the proportion of patients who reported taking medications as prescribed. The CPSTF also finds these interventions are cost-effective for cardiovascular disease prevention.

The full CPSTF Finding and Rationale Statement and supporting documents for Heart Disease and Stroke Prevention: Tailored Pharmacy-based Interventions to Improve Medication Adherence are available in The Community Guide Collection on CDC Stacks.

Intervention

Tailored pharmacy-based interventions aim to help patients who are at risk for cardiovascular disease take their medications as prescribed.

Interventions include the following:

  • Assessment interviews or assessment tools are used to identify adherence barriers (things that get in the way of patients taking their medications as prescribed)
  • Tailored guidance and services pharmacists use results of the assessment to develop and deliver tailored guidance and services that aim to reduce patients’ barriers
    • Guidance includes focused medication counseling or motivational interview sessions
    • Services include one or more of the following: patient tools such as pillboxes, medication cards and calendars, medication refill synchronization, enhanced follow-up

Interventions may be set in community or health system pharmacies. They may include additional components such as communication between the pharmacist and the patient’s primary care provider, or patient education materials. Interventions may be used alone, or they may be part of a broader intervention to reduce patients’ cardiovascular disease risk.

About The Systematic Review

The CPSTF finding is based on evidence from a systematic review of 48 studies (search period through August 2018).

Study Characteristics

  • Included studies were conducted in the United States (23 studies), Europe (12 studies), Canada (5 studies), Hong Kong (4 studies), and Australia (4 studies).
  • Studies were implemented in community pharmacies (27 studies), health system pharmacies (14 studies), or a combination of both (5 studies). Across all studies, the median age for patients was 61.6 years (43 studies), and 52.1% were female (46 studies).
  • Of the 48 included studies, 26 were randomized controlled trials, seven were other design with concurrent comparison, one was before and after with comparison, six used a retrospective cohort, and eight were before and after without a comparison.

Summary of Results

The systematic review included 48 studies that measured intervention effects on medication adherence.

Medication Adherence

The systematic review team converted outcomes from 27 studies into adherent or non-adherent, based on whether patients possessed, took, or refilled their cardiovascular disease prevention medications at least 80% of the time.

  • The proportion of patients considered adherent increased by a median of 6.9 percentage points (an increase of 9.9%)

The remaining 21 studies used various tools to measure adherence (e.g., objective provider counts or records, self-report) and reported generally favorable results.

Cardiovascular Disease Risk Conditions

A subset of 17 studies evaluated intervention effects on blood pressure control and lipid control.

  • There was a median increase of 13.9 percentage points in the proportion of patients who achieved blood pressure control (13 studies)
    • This represents a relative increase of 35.3% (12 studies)
  • Results were mixed for LDL (3 studies) and cholesterol (1 study).

Summary of Economic Evidence

A systematic review of economic evidence shows tailored pharmacy-based adherence interventions are cost-effective for cardiovascular disease prevention. For patients with existing cardiovascular disease, the evidence shows averted healthcare cost exceeds the cost of intervention for a favorable return on investment (ROI) from a healthcare system perspective.

The systematic review included 38 studies (search period through May 2019). The studies evaluated interventions to prevent (29 studies) or manage existing (9 studies) cardiovascular disease. Monetary values are reported in 2018 U.S. dollars.

Intervention Cost

  • The median cost per patient per year for interventions to prevent cardiovascular disease was $246 (19 studies).
  • The median cost per patient per year for interventions to manage cardiovascular disease was $292 (6 studies).

Healthcare Cost

  • The median change in healthcare cost per patient per year for interventions to prevent cardiovascular disease was -$355 (25 studies).
  • The median change in healthcare cost per patient per year for interventions to manage cardiovascular disease was -$1784 (8 studies).

Total Cost

  • The median total cost per patient per year for interventions to prevent cardiovascular disease was -$49 (21 studies). The total cost estimates for cardiovascular disease prevention were inconsistent, with about half of the studies reporting positive total cost and half reporting negative total cost.
  • The median total cost per patient per year for interventions to manage cardiovascular disease was -$1080 (7 studies). In all but one of the studies, the reduced healthcare cost exceeded the cost of intervention indicating net cost savings when implemented for patients with existing cardiovascular disease.

Cost-effectiveness

  • The median cost per quality adjusted life year (QALY) saved for interventions to prevent cardiovascular disease was $11,298, which is below a conservative $50,000 threshold (5 studies).
  • No studies reported cost-effectiveness outcomes for interventions to manage cardiovascular disease.

Applicability

Based on results from the review, the finding should be applicable to patients with cardiovascular disease risk factors who receive medications from community or health system pharmacies.

Evidence Gaps

  • How does intervention effectiveness vary with different intervention components? Are interventions more effective when tailored options include system-level approaches, such as refill synchronization or blister packaging?
  • Within a tailored approach, are some adherence barriers commonly addressed by specific intervention options? Does evidence indicate that some adherence barriers can be removed with a specific component, allowing for some standardization in tailored interventions?
  • How effective are tailored interventions when targeted to specific patients at risk for adherence barriers, such as patients with low income or low health-literacy?
  • How effective are tailored interventions when implemented in pharmacies that serve minority and low-income communities?
  • How effective are tailored interventions that engage community health workers and pharmacy technicians in appropriate assessment, coaching, or follow-up roles?
  • Are these interventions cost-effective for patients with existing cardiovascular disease?
  • What are the economic outcomes when interventions are implemented in rural areas?
  • What are the clinical outcomes associated with reductions in healthcare costs and increases in quality adjusted life years? Economic evaluations will be more helpful if they include patient health outcomes (e.g., blood pressure, cholesterol) in their reports.
  • Which components of healthcare use lead to the greatest changes in healthcare cost following implementation?

Implementation Considerations and Resources

  • Tailored interventions may be implemented as one component of the broader Pharmacists’ Patient Care Process (Joint Commission of Pharmacy Practitioners 2014). Steps in the process (i.e., collect, assess, plan, implement, follow-up, and monitor) closely align with the process for selecting tailored actions to remove or reduce patient adherence barriers.
  • The Million Hearts Initiative provides action guides that detail organizational considerations and options to address medication adherence for cardiovascular disease prevention.
  • The CPSTF recommends the following intervention approaches that complement this one.
  • This review did not evaluate adherence to medications for smoking cessation. Counseling and assisting tobacco-using patients to quit are important contributors to cardiovascular disease risk reduction (USPSTF). Pharmacists can play an important role in supporting patient efforts to obtain, initiate, and complete cessation treatments (Saba et al. 2014).
  • While pharmacists or pharmacy residents may need to be involved in decisions about counseling content and additional adherence services for patients, implementers might consider how other staff, such as pharmacy technicians, can support the interventions. Roles for technicians could include tool-based assessment of patient barriers, instruction on use of patient adherence tools, and delivery of adherence reminders.
  • Community health workers might also be able to play a role. The CPSTF recommends engaging community health workers for cardiovascular disease prevention. Implementation research could evaluate coordinated work between community health workers and community-based pharmacies in underserved communities.
  • Finding a space to provide tailored interventions may be a challenge for some pharmacies. Several included studies provided space in the patient’s primary care setting, while a few others delivered interventions by telephone.
  • In some settings, collaborative practice agreements (CPAs) may be used to formalize relationships between pharmacists and other healthcare providers. CPAs specify what functions (beyond a pharmacist’s typical scope of practice) can be delegated to pharmacists by the collaborating prescribers. Pharmacists should consult their state board of pharmacy before implementing a program.

Crosswalks

Healthy People 2030 icon Healthy People 2030 includes the following objectives related to this CPSTF recommendation.