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Published on 16 May 2007

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Pharmacist advice boosts adherence


An educational intervention delivered by pharmacists can improvepatients’ adherence to medication for heart failure – but only as longas it is ongoing, according to a US study.

A major proportionof the cost of caring for patients with heart failure comes fromtreating exacerbations. Appropriate medication can cut the frequency ofexacerbations, but regimens are often complex, with several drugs to betaken. Patients may find adherence to such regimens difficult, and thisstudy aimed to determine whether an educational intervention deliveredby the pharmacist dispensing the patient’s routine medication couldboost adherence.

Undertaken in a large academic primarycare centre in an economically disadvantaged area, the study involvedpatients with heart failure seen by general medical or cardiologyclinics or after hospital discharge, who were randomised tointervention or usual care.

Patients receiving care from thecentre got prescribed medicines from a central pharmacy or one ofseveral satellites. For the study, the central pharmacy was moved so asto be adjacent to the general medicine clinics treating heart failurepatients. It was staffed by the study pharmacist, who saw allintervention patients, and another pharmacist, who saw the usual-caregroup.

The study pharmacist reviewed each interventionpatient’s medication history and level of medication knowledge andskills. Based on this, patients were given personalised verbal andwritten education about their medication and how to take it. Primaryoutcomes were adherence (measured using electronic container lids) andclinical exacerbations needing emergency treatment or hospitalisation.Study duration was one year, with a nine-month intervention period andthree months’ post-intervention.

A total of 314 patients wererandomised from 1,512 potentially eligible. Study patients were similarto heart-failure patients seen by the centre overall (n=3,034). Of thestudy group, 192 were randomised to usual care and 122 to theintervention.

Adherence to medication was significantlygreater in the intervention than the control group: 78.8% vs 67.9%(difference 10.9 percentage points; 95% CI 5.0–16.7 percentage points)actually took their medication and 53.1% vs 47.2% (difference 5.9percentage points; 95% CI 0.4–11.5 percentage points) did so near thescheduled times. However, the effect dissipated fairly rapidly.Patients in the intervention group were 19.4% less likely to have anexacerbation needing emergency-department visit or hospitalisation(incidence rate ratio 0.82; 95% CI 0.73–0.93) and had lower healthcarecosts over the study period.

The authors conclude thatpharmacist intervention for outpatients with heart failure can boostadherence and cut exacerbations and costs, but probably needs to beongoing. Costs of the intervention were associated mainly with settingit up, and as more patients received it, the cost per patient declined,with a 14-fold return on investment calculated.

Ann Intern Med 2007;146:714-25


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