Interventions to Support Long-Term Adherence aNd Decrease Cardiovascular Events Post-Myocardial Infarction (ISLAND)
研究概览
详细说明
EXECUTIVE SUMMARY
Background: In patients who have had a myocardial infarction (MI) and coronary disease, guidelines recommend cardiac rehabilitation services and the long-term use of cardiac medications to reduce the risk of recurrent cardiovascular events. Adherence to these recommendations substantially reduces morbidity and mortality post-MI. However, for a variety of patient, provider, and system-level reasons, adherence to cardiac medications declines to approximately 50% by 12 months. Likewise, only 30-40% of patients participate in cardiac rehabilitation. Thus, interventions to increase secondary prevention treatment adherence are urgently needed.
The Cardiac Care Network of Ontario (CCN) holds a registry of all patients in the province who have a coronary angiography. The registry has been used to identify gaps in care and to plan health system strategies for high-risk patients. More recently, a pilot trial was conducted in Hamilton by the trial team using data in the registry to send recurrent postal reminders regarding the importance of treatment adherence to patients, their pharmacists, and family physicians. A similar program is underway in Ottawa using automated phone calls with interactive voice response and nurse follow up. These interventions both have the potential to address known determinants of adherence. The CCN, Ministry of Health and Long-Term Care, Health Quality Ontario, and other stakeholders across Ontario are interested in evaluating the comparative effectiveness and costs of these interventions.
Research Questions: The research objectives were formed by the decision makers' need to evaluate whether and in what format to sustain and/or scale-up post-MI educational reminder interventions:
i. Can educational reminders delivered via post and/or using interactive voice response with personalized telephone follow up improve secondary prevention treatment adherence post-MI?
ii. How do different approaches to improve adherence to these recommendations compare in terms of clinical effectiveness and costs?
iii. Which subgroups are more/less likely to respond to reminders?
Research Approach: This is a pragmatic, randomized controlled trial with blinded outcome assessment. Patients in cardiac centres throughout Ontario who undergo a coronary angiography will be provided a letter of information explaining the study appended to the standard CCN letter of information. CCN will identify eligible patients (those with substantial coronary artery disease who survive their initial hospitalization post-MI) and provide the patient list back to the cardiac centre. A representative at the centre will securely send this list to the Population Health Research Institute in Hamilton. Patients will be randomized by the Population Health Research Institute team to one of three arms:
- - Usual care, with no standardized educational materials or reminders
- - Postal letters sent from Population Health Research Institute on behalf of each hospital's interventional cardiology team to the patient approximately 4, 8, 20, 32, and 44 weeks post-MI, with an insert for the family physician and pharmacist at approximately 4 and 8 weeks post-MI.
- - Postal letters as above plus interactive voice response phone calls to the patient delivered approximately 2 weeks after the letters, as well as personalized telephone follow up by trained lay health workers for patients identified by the interactive voice response system as non-adherent.
Patient self-report and administrative data will be used to assess outcomes 12 months post-MI. Analyses will be by intention to treat. The primary outcome is adherence to guideline-recommended treatments. Secondary outcomes include health services utilization (including outpatient visits to interventional cardiology), recurrent cardiovascular events, and mortality. During the trial, a theory-informed process questionnaire will be administered to a random sub-sample. An economic evaluation will be conducted from the perspective of the public health care payer.
Implications: This project has the potential to lead to improvements in care for patients at high cardiovascular risk as well as provide generalizable insights regarding how to optimize interventions to improve adherence. Further, it has the potential to inform how other health databases could be used to improve health system performance.
研究类型
注册 (实际的)
阶段
- 不适用
参与标准
资格标准
适合学习的年龄
接受健康志愿者
有资格学习的性别
描述
Inclusion Criteria:
- Patients aged 18 years and older having a coronary angiography following a myocardial infarction (ST-elevation myocardial infarction or non-ST-elevation myocardial infarction), with evidence of coronary artery disease (>50% blockage of left main or >70% blockage of ≥1 major cardiac arteries).
- Discharged from the catheterization centre alive, either home or to a local (non-cardiac) hospital
- Patients must be Ontario residents
Exclusion Criteria:
- Patients will be excluded if they expire during their hospitalization or if they have cardiogenic shock (Killip Class 4) at the time of their post-MI coronary angiography due to their poor prognosis.(El-Menyar et al., 2012)
- Patients will also be excluded if they require a translator to receive services in English as recorded in the CCN referral form, as it is infeasible to offer the interventions in multiple languages at this stage.
- Patients whose data are not complete and received in time to deliver the first post-procedure intervention will be excluded as they cannot receive the intervention as intended.
- Patients who do not have an Ontario health card number
学习计划
研究是如何设计的?
设计细节
- 主要用途:卫生服务研究
- 分配:随机化
- 介入模型:并行分配
- 屏蔽:单身的
武器和干预
参与者组/臂 |
干预/治疗 |
---|---|
无干预:Usual care
Usual care (no intervention)
|
|
实验性的:Usual care + letters
Usual care plus a series of postal educational reminders (including information for patients to share with clinicians)
|
A series of five postal educational reminders sent on behalf of each hospital's interventional cardiology team to the patient approximately 4, 8, 20, 32, and 44 weeks post-MI procedure, with an insert for the family physician and pharmacist at approximately 4 and 8 weeks post-MI procedure.
|
实验性的:Usual care + letters + automated calls
Usual care plus a series of postal educational reminders (including information for patients to share with clinicians), plus automated reminder interactive voice response phone calls to identify patients at being at risk for non-adherence and a trained lay health worker to provide additional support and navigation for such patients via telephone.
|
A series of five postal educational reminders as per the usual care + letters arm plus interactive voice response phone calls to the patient delivered approximately 2 weeks after the letters, as well as personalized telephone follow up by trained lay health workers for patients identified by the interactive voice response system as non-adherent.
The automated algorithm is designed to identify patients who are non-adherent and who may benefit from personalized educational phone call and/or system navigation support by the lay health worker.
Lay health workers will not provide clinical advice.
|
研究衡量的是什么?
主要结果指标
结果测量 |
措施说明 |
大体时间 |
---|---|---|
Medication adherence
大体时间:12 months post-MI
|
Number of cardiac medication classes with no missed tablets in last week (ordinal) [patient report]
|
12 months post-MI
|
Cardiac rehabilitation completion
大体时间:12 months post-MI
|
Patient attended at least one of the rehabilitation components and formal re-assessment at the conclusion of the program (dichotomous) [patient report]
|
12 months post-MI
|
次要结果测量
结果测量 |
措施说明 |
大体时间 |
---|---|---|
Cardiac rehabilitation attendance
大体时间:12 months post-MI
|
Participation, defined as attending at least one exercise session following enrolment assessment (dichotomous) [patient report]
|
12 months post-MI
|
Quality of life
大体时间:12 months post-MI
|
Seattle Angina Questionnaire-7 [patient report]
|
12 months post-MI
|
Treatment discussion
大体时间:12 months post-MI
|
Adherence to both medication and exercise discussed with providers in last three months (dichotomous) [patient report]
|
12 months post-MI
|
Smoking status
大体时间:12 months post-MI
|
Point-prevalence, smoking any cigarettes in last three months (dichotomous) [patient report]
|
12 months post-MI
|
Medication persistence
大体时间:12 months post-MI
|
Active prescription for ALL recommended medications (dichotomous) [patient report]
|
12 months post-MI
|
Medication persistence
大体时间:12 months post-MI
|
Active prescription for EACH recommended medication (dichotomous) [patient report]
|
12 months post-MI
|
Medication adherence
大体时间:12 months post-MI
|
No missed tablets in last week for ANY recommended medication (dichotomous) [patient report]
|
12 months post-MI
|
Medication adherence
大体时间:12 months post-MI
|
No missed tablets in last month for any recommended medication (dichotomous)[patient report]
|
12 months post-MI
|
Medication adherence
大体时间:12 months post-MI
|
No missed tablets in last month for ANY recommended medication (dichotomous) [patient report]
|
12 months post-MI
|
Medication adherence
大体时间:12 months post-MI
|
Number of missed tablets in last week for EACH recommended medication (continuous, 0 to 28) [patient report]
|
12 months post-MI
|
Medication adherence
大体时间:12 months post-MI
|
Number of missed tablets in last month for each recommended medication (continuous, 0 to 28) [patient report]
|
12 months post-MI
|
Medication adherence
大体时间:12 months post-MI
|
Medication possession ratio > 80% for ALL recommended medications in those 65+ (dichotomous) [administrative data]
|
12 months post-MI
|
Medication adherence
大体时间:12 months post-MI
|
Medication possession ratio > 80% for EACH of the recommended medications in those 65+ (dichotomous) [administrative data]
|
12 months post-MI
|
Medication adherence
大体时间:12 months post-MI
|
Mean medication possession ratio for ALL recommended medications in those 65+ (continuous, 0 to 100) [administrative data]
|
12 months post-MI
|
Medication adherence
大体时间:12 months post-MI
|
Mean medication possession ratio for EACH recommended medication in those 65+ (continuous, 0 to 100) [administrative data]
|
12 months post-MI
|
Cardiovascular event
大体时间:12 months post-MI
|
Coronary bypass surgery or stent or repeat MI (dichotomous) [administrative data]
|
12 months post-MI
|
Mortality
大体时间:12 months post-MI
|
Death during follow-up [administrative data]
|
12 months post-MI
|
Health utilization
大体时间:12 months post-MI
|
Outpatient visits (count) [administrative data]
|
12 months post-MI
|
Health utilization
大体时间:12 months post-MI
|
Emergency Room visits not leading to admission (count) [administrative data]
|
12 months post-MI
|
Health utilization
大体时间:12 months post-MI
|
Hospitalizations (count) [administrative data]
|
12 months post-MI
|
合作者和调查者
调查人员
- 首席研究员:Noah Ivers、Women's College Hospital
- 首席研究员:John-David Schwalm、Population Health Research Institute
- 首席研究员:Madhu Natarajan、Population Health Research Institute
- 首席研究员:Jeremy Grimshaw、Ottawa Hospital Research Institute
出版物和有用的链接
一般刊物
- El-Menyar A, Zubaid M, AlMahmeed W, Sulaiman K, AlNabti A, Singh R, Al Suwaidi J. Killip classification in patients with acute coronary syndrome: insight from a multicenter registry. Am J Emerg Med. 2012 Jan;30(1):97-103. doi: 10.1016/j.ajem.2010.10.011. Epub 2010 Dec 14.
- McCleary N, Ivers NM, Schwalm JD, Witteman HO, Taljaard M, Desveaux L, Bouck Z, Grace SL, Grimshaw JM, Presseau J. Impacts of two behavior change interventions on determinants of medication adherence: process evaluation applying the health action process approach and habit theory alongside a randomized controlled trial. J Behav Med. 2022 Oct;45(5):659-673. doi: 10.1007/s10865-022-00327-0. Epub 2022 May 20.
- Desveaux L, Saragosa M, Russell K, McCleary N, Presseau J, Witteman HO, Schwalm JD, Ivers NM. How and why a multifaceted intervention to improve adherence post-MI worked for some (and could work better for others): an outcome-driven qualitative process evaluation. BMJ Open. 2020 Sep 3;10(9):e036750. doi: 10.1136/bmjopen-2019-036750.
- Ivers NM, Schwalm JD, Bouck Z, McCready T, Taljaard M, Grace SL, Cunningham J, Bosiak B, Presseau J, Witteman HO, Suskin N, Wijeysundera HC, Atzema C, Bhatia RS, Natarajan M, Grimshaw JM. Interventions supporting long term adherence and decreasing cardiovascular events after myocardial infarction (ISLAND): pragmatic randomised controlled trial. BMJ. 2020 Jun 10;369:m1731. doi: 10.1136/bmj.m1731.
研究记录日期
研究主要日期
学习开始
初级完成 (实际的)
研究完成 (实际的)
研究注册日期
首次提交
首先提交符合 QC 标准的
首次发布 (估计)
研究记录更新
最后更新发布 (实际的)
上次提交的符合 QC 标准的更新
最后验证
更多信息
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