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2019 HSR&D/QUERI National Conference Abstract

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4138 — Qualitative Process Evaluation of a Complex Medication Adherence Intervention within Veteran Affairs Medical Centers.

Lead/Presenter: Kamal Henderson,  COIN - Seattle/Denver
All Authors: Henderson KH (Division of Cardiology, University of Colorado School of Medicine), McCreight MS (Veteran Affairs Center of Innovation, Denver Veteran Affairs Medical Center), Ho M (Veteran Affairs Center of Innovation, University of Colorado School of Medicine)

Objectives:
P2Y12 inhibitors such as clopidogrel are important for secondary prevention of coronary artery disease for those suffering from a heart attack and reduces the risk of stent thrombosis after percutaneous coronary stent placement. Unfortunately, P2Y12 inhibitor adherence among patients is often poor, leading to adverse outcomes for patients. We recently completed a randomized multi-site hybrid effectiveness-implementation study of a complex intervention to address P2Y12 inhibitor adherence that consisted of the following: (1)P2Y12 inhibitor medication brought to bedside prior to discharge; (2) patient medication education; (3) and automated interactive-voice response (IVR) calls to remind them to place subsequent refills. We performed multi-stakeholder qualitative process evaluations to inform implementation.

Methods:
In this qualitative process evaluation, 62 key informant semi-structured interviews were performed across 3 stakeholder groups important to implementing our intervention (i.e. cardiac catheterization laboratory providers, inpatient pharmacists, and patients). Attributes important to program implementation were assessed (i.e. perceived factors important to implementation and stakeholder perspectives of the intervention). Data analysis were conducted from 2014 to 2018 using ATLAS.ti software.

Results:
Among stakeholders, 41 cardiac catheterization laboratory providers and inpatient pharmacists were interviewed with 21 patients interviewed. Providers described participating in the study as a positive experience and "worth the effort." Implementation barriers included lack of staff time and poor post-discharge communication between tertiary hospitals and primary care referral facilities regarding the need for continuous clopidogrel treatment. Patients expressed appreciation for the intervention. Providers and patients offered recommendations to improve the study intervention for sequential roll-out at other sites, including: 1) standardizing the number of days supplied for refills; 2) obtaining more buy-in from pharmacy staff; and 3) implementing follow-up provider phone calls to reinforce the information received at discharge.

Implications:
By including multi-stakeholder perspectives as part of our qualitative process evaluations for a complex intervention, we were able to gain valuable insights to improve the intervention and implementation process across multiple VHA sites. Subsequent analysis will pair our qualitative process evaluations with study outcomes to provide additional insights on factors that contributed to effective implementation.

Impacts:
Assessing multi-stakeholder perspectives helps identify contextual factors that inform tailoring, implementation, and maintenance of complex health services interventions.