Interventions supporting long term adherence and decreasing cardiovascular events after myocardial infarction (ISLAND): pragmatic randomised controlled trial

• Published in: BMJ (Online) Vol. 369; p. m1731
• Main Authors: Ivers, Noah M, Schwalm, Jon-David, Bouck, Zachary, McCready, Tara, Taljaard, Monica, Grace, Sherry L, Cunningham, Jennifer, Bosiak, Beth, Presseau, Justin, Witteman, Holly O, Suskin, Neville, Wijeysundera, Harindra C, Atzema, Clare, Bhatia, R Sacha, Natarajan, Madhu, Grimshaw, Jeremy M
• Format: Journal Article
• Language: English
• Published: London BMJ Publishing Group LTD 10.06.2020; BMJ Publishing Group Ltd
• Subjects: Automation; Cardiovascular disease; Coronary artery; Coronary vessels; Heart attacks; Heart diseases; Medical imaging; Medical personnel; Medical research; Mortality; Myocardial infarction; Participation; Patients; Prescription drugs; Rehabilitation; Research centers; Workers
• ISSN: 1756-1833; 0959-8138; 1756-1833
• DOI: 10.1136/bmj.m1731

AbstractObjectiveTo test a scalable health system intervention to improve long term adherence to secondary prevention treatments among patients who have had a recent myocardial infarction.DesignThree arm, pragmatic randomised controlled trial with blinded outcome assessment.SettingNine cardiac centres in Ontario, Canada.Participants2632 patients with obstructive coronary artery disease after a myocardial infarction, identified from a centralised cardiac registry.InterventionsParticipants were randomised 1:1:1 to receive usual care, five mail-outs developed through a user centred design process, or mail-outs plus phone calls. The phone calls were delivered first by an interactive automated system to screen for non-adherence to treatment. Trained lay health workers followed up as necessary. Interventions were coordinated centrally but delivered from each patient’s hospital site.Main outcome measuresCo-primary outcomes were completion of cardiac rehabilitation and adherence to recommended medication. Data were collected by blinded assessors through patient report and from administrative health databases at 12 months.Results2632 patients (mean age 66, 71% male) were randomised: 878 to the full intervention (mail plus phone calls), 878 to mail only, and 876 to usual care. Of the respondents, 174 (27%) of 643 in the usual care group, 200 (32%) of 628 in the mail only group, and 196 (37%) of 531 allocated to the full intervention completed cardiac rehabilitation (adjusted odds ratio 1.55, 95% confidence interval 1.18 to 2.03). In the mail plus phone group, 11.7%, 6.0%, 14.4%, 32.9%, and 35.0% reported adherence to 0, 1, 2, 3, and 4 drug classes after one year, respectively, in comparison with 12.5%, 6.8%, 13.6%, 30.2%, and 36.8% in the mail only group, and 12.2%, 8.4%, 13.1%, 30.3%, and 36.1% in the usual care group, respectively (mail only v usual care, odds ratio 0.98, 95% confidence interval 0.81 to 1.19; full intervention v usual care, 0.99, 0.82 to 1.20).ConclusionsScalable interventions delivered by mail plus phone can increase completion of cardiac rehabilitation after myocardial infarction but not adherence to medication. More intensive interventions should be tested to improve adherence to medication and to evaluate the association between attendance at cardiac rehabilitation and adherence to medication.Trial registrationClinicalTrials.gov NCT02382731, registered 9 March 2015 before any patient enrolment.