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SDP 12-179 – HSR&D Study

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SDP 12-179
Hybrid Effectiveness-Implementation Study to Improve Clopidogrel Adherence
P. Michael Ho MD PhD
Rocky Mountain Regional VA Medical Center, Aurora, CO
Aurora, CO
Funding Period: November 2012 - October 2017

BACKGROUND/RATIONALE:
Over 10,000 veterans undergo stent implantation for coronary artery disease in the VA annually. Following the procedure, patients are prescribed clopidogrel, an anti-platelet medication for up to 1 year and it is important to take the medication regularly to prevent recurrent cardiovascular events. However, many patients delay filling clopidogrel at hospital discharge or discontinue the medication early prior to the intended treatment duration. This is a hybrid effectiveness-implementation study of a multi-faceted intervention to improve clopidogrel adherence at 20 VA PCI sites that builds on our pilot work and leverages the VA's Cardiovascular Assessment Reporting and Tracking in the Cardiac Catheterization Laboratory (CART-CL), a uniform CATH lab procedure reporting tool at all VA CATH labs. The goal of the study is to improve clopidogrel adherence and to lower the risk of recurrent cardiovascular events following PCI for veterans.

OBJECTIVE(S):
The main objective of the study is to conduct a type I hybrid effectiveness/implementation study to test the effectiveness of a successfully-piloted, evidence-based, multi-faceted intervention to improve patient adherence to clopidogrel following percutaneous coronary intervention (PCI).

METHODS:
To achieve this objective, we developed the intervention based on the Chronic Care Model. The intervention also leverages clinical information systems to deliver team-based coordinated care to activated patients to improve clopidogrel adherence. This project will test a multi-faceted intervention to improve clopidogrel adherence after patients undergo stent implantation. The intervention will be tested at 5 sites in each roll-out phase and there will be 4 phases for a total of 20 sites. The intervention consists of 4 components: a) a reminder from CART-CL will be sent to the inpatient pharmacist prior to discharge that a patient has received a stent; b) the pharmacist will educate the patients on the importance of and adherence to clopidogrel following PCI, as well as bring clopidogrel to the patient's bedside prior to hospital discharge; c) interactive voice response (IVR) calls will be made to patients prior to the time of clopidogrel refill to remind patients and to facilitate refills during follow-up; and d) a Patient Aligned Care Team (PACT) member will contact patients who delay filling clopidogrel. We will also learn from each roll-out phase to understand barriers and facilitators to implementing the intervention at each site.

FINDINGS/RESULTS:
The project is still in the enrollment stage, with participants being enrolled at multiple sites. There are no findings to report at this time.

IMPACT:
Clopidogrel is a critical adjuvant therapy following percutaneous coronary intervention (PCI) and reduces the risk of stent thrombosis, myocardial infarction (MI) and mortality. By conducting the successfully-piloted evidence-based intervention we hope to improve clopidogrel initial fill post-PCI procedure and subsequent adherence in PCI patients and to lower the risk of recurrent cardiovascular events following PCI for veterans.

PUBLICATIONS:

Journal Articles

  1. McCreight MS, Lambert-Kerzner A, O'Donnell CI, Grunwald GK, Hebert P, Gillette M, Jneid H, Parashar A, Grossman PM, Helfrich C, Mavromatis K, Saket G, Ho PM. Improving anti-platelet therapy adherence in the Veterans Health Administration: A randomized multi-site hybrid effectiveness-implementation study protocol. Contemporary clinical trials. 2019 Feb 1; 77:104-110.
  2. Beste LA, Glorioso TJ, Ho PM, Au DH, Kirsh SR, Todd-Stenberg J, Chang MF, Dominitz JA, Barón AE, Ross D. Telemedicine Specialty Support Promotes Hepatitis C Treatment by Primary Care Providers in the Department of Veterans Affairs. The American journal of medicine. 2017 Apr 1; 130(4):432-438.e3.
  3. Doll JA, Tang F, Cresci S, Ho PM, Maddox TM, Spertus JA, Wang TY. Change in Angina Symptom Status After Acute Myocardial Infarction and Its Association With Readmission Risk: An Analysis of the Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status (TRIUMPH) Registry. Journal of the American Heart Association. 2016 Jun 13; 5(6).
Conference Presentations

  1. Fagan K, Haverhals LM, McCreight M, Lambert-Kerzner AC, Ho M. Reporting Balanced Findings on a National Veteran's Health Administration Initiative While Including Constructive Feedback. Poster session presented at: American Evaluation Association Annual Conference; 2014 Oct 15; Denver, CO.
  2. Fehling KB, Ho M. A Mixed Methods Approach to Evaluation of Four Transformational Initiatives Within the Veterans Health Administration, the Nation's Largest Integrated Delivery System. Poster session presented at: American Evaluation Association Annual Conference; 2014 Oct 15; Denver, CO.


DRA: Aging, Older Veterans' Health and Care, Cardiovascular Disease
DRE: Treatment - Observational
Keywords: none
MeSH Terms: none

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