Developing and piloting a pharmacist-led intervention to support medication adherence following acute coronary syndrome

Abstract

Suboptimal medication adherence is common among patients with acute coronary syndrome (ACS) and is associated with poor clinical outcomes. There is a need to develop and test novel, theory-driven strategies to support medication-taking in this patient group. Pharmacists have been identified as a potentially underused resource to help address adherence-related issues. The aim of this PhD was to develop and pilot a pharmacy-led intervention to support medication adherence among patients hospitalised with ACS. The intervention was developed using existing behaviour change frameworks, namely the Perceptions and Practicalities Approach (PAPA) and the Capability, Opportunity, Motivation-Behaviour (COM-B) model. This thesis contains five studies in total. First, a systematic review with meta-analysis was conducted to identify psychosocial predictors of non-adherence following ACS. Seventeen studies were included. Depression (k = 7, OR 2.00, 95% CI 1.57 - 3.33, I2 = 61.9%), Type D personality type and treatment beliefs (i.e. the Necessity-Concerns Framework) were associated with non-adherence. Second, a qualitative study was conducted to explore the early experiences of ACS survivors (n = 17) in the UK and US. UK patients tended to experience more disruption after discharge. Despite this being a source of frustration among patients, it did not appear to impact directly on adherence. Pharmacy input was viewed favourably by patients. Third, a systematic review with meta-analysis was undertaken to identify healthcare provider (HCP)-led interventions to support medication adherence following ACS. A total of 27 studies were included. HCP-led interventions increased the odds of adherence by 54% compared to control interventions (k = 23, OR 1.54, 95% CI 1.26 - 1.88, I2 = 57.5%). Just six studies utilised pharmacists in their delivery and only four were based on behavioural theory. Data from these preliminary studies were used to inform the design of a behavioural intervention which comprised two brief inpatient sessions to address perceptual (e.g. negative or erroneous treatment beliefs) and practical (e.g. suboptimal action planning) barriers to adherence. The fourth study of this PhD involved feasibility and acceptability testing of our proposed intervention (n = 15). Treatment beliefs were measured pre-post intervention. Necessity beliefs were significantly higher post-intervention, and the intervention was deemed acceptable based on quantitative and qualitative patient feedback. The fifth and final study involved piloting the intervention with hospital-based pharmacists. A non-randomised study design was adopted with two comparable groups: control (n = 29) vs. treatment (n = 27). Treatment beliefs and self-reported medication adherence were the main 3 study outcomes, measured at 6-week and 12-week follow up. The intervention produced an initial shift towards more positive treatment beliefs although this effect was not maintained over time. Medication adherence did not differ between groups. There were several design and methodological issues which may have contributed to this lack of effect. Fidelity of the intervention was poor and should be prioritised moving forward. Future research should consider enhancing the intervention to include a post-discharge component to support patients across care transition.

Date of Award	1 May 2019
Original language	English
Awarding Institution	King's College London
Supervisor	John Weinman (Supervisor) & Vivian Auyeung (Supervisor)