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Physician Effectiveness in Interventions to Improve Cardiovascular Medication Adherence: A Systematic Review

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Abstract

BACKGROUND

Medications for the prevention and treatment of cardiovascular disease save lives but adherence is often inadequate. The optimal role for physicians in improving adherence remains unclear.

OBJECTIVE

Using existing evidence, we set the goal of evaluating the physician’s role in improving medication adherence.

DESIGN

We conducted systematic searches of English-language peer-reviewed publications in MEDLINE and EMBASE from 1966 through 12/31/2008.

SUBJECTS AND INTERVENTIONS

We selected randomized controlled trials of interventions to improve adherence to medications used for preventing or treating cardiovascular disease or diabetes.

MAIN MEASURES

Articles were classified as either (1) physician “active”—a physician participated in designing or implementing the intervention; (2) physician “passive”—physicians treating intervention group patients received patient adherence information while physicians treating controls did not; or (3) physicians noninvolved. We also identified studies in which healthcare professionals helped deliver the intervention. We did a meta-analysis of the studies involving healthcare professionals to determine aggregate Cohen’s D effect sizes (ES).

KEY RESULTS

We identified 6,550 articles; 168 were reviewed in full, 82 met inclusion criteria. The majority of all studies (88.9%) showed improved adherence. Physician noninvolved studies were more likely (35.0% of studies) to show a medium or large effect on adherence compared to physician-involved studies (31.3%). Among interventions requiring a healthcare professional, physician-noninvolved interventions were more effective (ES 0.47; 95% CI 0.38–0.56) than physician-involved interventions (ES 0.25; 95% CI 0.21–0.29; p < 0.001). Among physician-involved interventions, physician-passive interventions were marginally more effective (ES 0.29; 95% CI 0.22–0.36) than physician-active interventions (ES 0.23; 95% CI 0.17–0.28; p = 0.2).

CONCLUSIONS

Adherence interventions utilizing non-physician healthcare professionals are effective in improving cardiovascular medication adherence, but further study is needed to identify the optimal role for physicians.

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Acknowledgements and Conflicts of Interest Disclosure

This work was supported by a research grant from CVS Caremark. All data analysis and evaluation took place at Brigham and Women’s Hospital. CVS Caremark did not play a role in the design and conduct of the study, the collection, management, analysis, or interpretation of the data, the preparation, review or approval of the manuscript. Josh Liberman and Troy Brennan, both co-authors, are employees of CVS Caremark. Dr. Shrank is supported by a career development award from the National Heart, Lung and Blood Institute (HL-090505). Dr. Brookhart is supported by a career development award from the National Institute of Health (AG-027400). Dr. Cutrona has had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

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Authors and Affiliations

  1. Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, 1620 Tremont St, Suite 3030, Boston, MA, 02120, USA

    Sarah L. Cutrona MD, MPH, Niteesh K. Choudhry MD, PhD, Margaret Stedman PhD, Amber Servi BA, Michael A. Fischer MD, MPH, M. Alan Brookhart PhD & William H. Shrank MD, MSHS

  2. Strategic Research, CVS Caremark, 11311 McCormick Road, Suite 230, Hunt Valley, MD, 21031, USA

    Joshua N. Liberman PhD & Troyen Brennan MD, JD

  3. Center for American Political Studies, Faculty of Arts and Sciences, Harvard University, 1737 Cambridge Street, Cambridge, MA, 02138, USA

    William H. Shrank MD, MSHS

  4. Milford Regional Medical Center, TCMA Hospitalists, 14 Prospect Street, Milford, MA, 01757, USA

    Sarah L. Cutrona MD, MPH

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  1. Sarah L. Cutrona MD, MPH
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  2. Niteesh K. Choudhry MD, PhD
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Correspondence to Sarah L. Cutrona MD, MPH.

Additional information

At the 32nd annual national meeting of the Society of General Internal Medicine on May 14, 2009, Dr. Cutrona presented findings from this paper as a nominee for Milton W. Hamolsky Award.

This work was supported by a research grant from CVS Caremark. Josh Liberman and Troy Brennan, both co-authors, are employees of CVS Caremark. All data analysis and evaluation took place at Brigham and Women’s Hospital. Dr. Shrank is supported by a career development award from the National Heart, Lung and Blood Institute (HL-090505). Dr. Brookhart is supported by a career development award from the National Institute of Health (AG-027400).

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Table 1

Physician-Active Adherence Interventions (DOC 55 kb)

Table 2

Physician-Passive Adherence Interventions (DOC 67 kb)

Table 3

Physician-Noninvolved Adherence Interventions: Reminder/Reinforcement, Behavioral and Educational (DOC 72 kb)

Table 4

Physician-Noninvolved Adherence Interventions: Complex/Combination Interventions (DOC 71 kb)

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Cutrona, S.L., Choudhry, N.K., Stedman, M. et al. Physician Effectiveness in Interventions to Improve Cardiovascular Medication Adherence: A Systematic Review. J GEN INTERN MED 25, 1090–1096 (2010). https://doi.org/10.1007/s11606-010-1387-9

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