Liu J, Wang W, Liu J, Wang Y, Qi Y, Sun J Y, Zhao D
Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Institute of Beijing Heart, Lungand Blood Vessel Diseases, Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing 100029, China.
Zhonghua Xin Xue Guan Bing Za Zhi. 2018 Feb 24;46(2):124-130. doi: 10.3760/cma.j.issn.0253-3758.2018.02.011.
To evaluate the impact of different intervention models on adherence to secondary prevention therapies in patients with acute coronary syndrome (ACS). This multi-center cross-sectional study collected data from 34 hospitals covering 22 provinces in China. Hospitals were randomly divided into four groups: control group(routine treatment and care), promotional calendar group (routine treatment and care plus giving propaganda desk calendar to patients), education group (routine treatment and care add patients education by nurses) and combined intervention group (promotional calendar and education).At least 90 patients with ACS were consecutively enrolled from each involved hospital from April 15, 2012 to June 30, 2013. To reduce the impact of uneven distribution of inter-group variables on the results, 1∶1∶1∶1 propensity score matching method was used. The drug usage for secondary prevention and prognosis wasobtainedat 6 months after hospital discharge. (1) A total of 3 391 patients were selected and 2 244 patients were included for the final analysisafter propensity score analysis. (2) At 6 months after discharge, the adherence rates of antiplatelet, statins, angiotensin converting enzyme inhibitor(ACEI)/angiotensin Ⅱ receptor blocker(ARB), β-blocker and the combination of 4 medications were similar between control group and promotional calendar group (all 0.016).The adherence rates of antiplatelet and statins were 97.0% (526/542) and 91.0% (493/542) in the education group, 3.7% and 5.5% higher than in the control group (both 0.016). The adherence rates of statins,ACEI/ARB and combined medication were 91.0% (496/545), 68.3% (372/545) and 53.2% (290/545) in the combined intervention group,significantly higher than in the control group (5.5%,8.3% and 9.6%, all 0.016). (3) Poisson regression analysis showed that the adherence of antiplatelet drugs in the education group was 3.4%(1.034, 95% 1.007-1.060,0.05) and 3.5%(1.035, 95% 1.007-1.063, 0.05) higher than in the control group and the promotional calendar group, and the statins adherence rate was 5.5%(1.055, 95% 1.012-1.101,0.05) higher than in the control group. The antiplatelet drug adherence rates in the combined intervention group were 3.0% (1.030, 95% 1.002-1.058,0.05) and 3.1% (1.031, 95% 1.003-1.060,0.05) higher than in the control group and the promotional calendar group, respectively, and statin adherence was 6.1% (1.061, 95% 1.017-1.107,0.01) higher than in the control group. The adherence rates of ACEI/ARB in combined intervention group were respectively 15.4%(1.154, 95% 1.057-1.259, 0.01),20.0%(1.200, 95% 1.096-1.314, 0.01) and 25.5%(1.255, 95% 1.142-1.380, 0.01) higher than in the control group, promotional calendar group and education group. The adherence rates of combined medication in combined intervention group were respectively 21.6%(1.216, 95% 1.079-1.371, 0.01),21.5%(1.215, 95% 1.077-1.371, 0.01) and 27.8%(1.278, 95% 1.126-1.450, 0.01) higher than in the control group, promotional calendar group and education group. (4) At 6 months after discharge, the control rates of blood pressure (<140/90 mmHg,1 mmHg=0.133 kPa) in the education group were significantly higher than in the control group and promotional calendar group (78.7% (398/506) vs. 70.2%(373/531) and 71.1% (354/498) , all 0.016),and the control rates of blood pressure in combined intervention group were higher than in the control group and promotional calendar group (78.2% (376/481) vs. 70.2%(373/531) and 71.1% (354/498) , all 0.016).The rehospitalization rates were 7.0% (39/561) in the promotional calendar group, and 7.6% (42/561) in the education group, both significantly higher than in the control group (3.8% (21/561), all 0.016).The rate of the low density lipoprotein cholesterol<2.07 mmol/L and the rate for all-cause mortality were similar among groups (all 0.016) . Post-discharge medication adherence in ACS patients can be enhanced by either promotional calendaror nurses education strategy, and the efficacy is better by nurse education as compared with promotional calendar, the combination of both methods can further increase the post-discharge medication adherence rates in ACS patients.
评估不同干预模式对急性冠状动脉综合征（ACS）患者二级预防治疗依从性的影响。这项多中心横断面研究收集了来自中国22个省34家医院的数据。医院被随机分为四组：对照组（常规治疗和护理）、宣传日历组（常规治疗和护理外加给患者发放宣传台历）、教育组（常规治疗和护理加护士对患者进行教育）和联合干预组（宣传日历和教育）。从2012年4月15日至2013年6月30日，每家参与研究的医院至少连续纳入90例ACS患者。为减少组间变量分布不均对结果的影响，采用1∶1∶1∶1倾向得分匹配法。在出院6个月后获取二级预防用药情况及预后。（1）共选取3391例患者，经倾向得分分析后，2244例患者纳入最终分析。（2）出院6个月时，对照组和宣传日历组的抗血小板药物、他汀类药物、血管紧张素转换酶抑制剂（ACEI）/血管紧张素Ⅱ受体阻滞剂（ARB）、β受体阻滞剂及4种药物联合应用的依从率相似（均P>0.016）。教育组抗血小板药物和他汀类药物的依从率分别为97.0%（526/542）和91.0%（493/542），比对照组分别高3.7%和5.5%（均P<0.016）。联合干预组他汀类药物、ACEI/ARB及联合用药的依从率分别为91.0%（496/545）、68.3%（372/545）和53.2%（290/545），显著高于对照组（分别高5.5%、8.3%和9.6%，均P<0.016）。（3）Poisson回归分析显示，教育组抗血小板药物的依从性比对照组和宣传日历组分别高3.4%（比值比1.034，95%置信区间1.007～1.060，P<0.05）和3.5%（比值比1.035，95%置信区间1.007～1.063，P<0.05），他汀类药物依从率比对照组高5.5%（比值比1.055，95%置信区间1.012～1.101，P<0.05）。联合干预组抗血小板药物的依从率比对照组和宣传日历组分别高3.0%（比值比1.030，95%置信区间1.002～1.058，P<0.05）和3.1%（比值比1.031，95%置信区间1.003～1.060，P<0.05），他汀类药物依从性比对照组高6.1%（比值比1.061，95%置信区间1.017～1.107，P<0.01）。联合干预组ACEI/ARB的依从率比对照组、宣传日历组和教育组分别高15.4%（比值比1.154，95%置信区间1.057～1.259，P<0.01）、20.0%（比值比1.200，95%置信区间1.096～1.314，P<0.01）和25.5%（比值比1.255，95%置信区间1.142～1.380，P<0.01）。联合干预组联合用药的依从率比对照组、宣传日历组和教育组分别高21.6%（比值比1.216，95%置信区间1.079～1.371，P<0.01）、21.5%（比值比1.215，95%置信区间1.077～1.371，P<0.01）和27.8%（比值比1.278，95%置信区间1.126～1.450，P<0.01）。（4）出院6个月时，教育组血压控制率（<140/90 mmHg，1 mmHg = 0.133 kPa）显著高于对照组和宣传日历组（78.7%（398/506） vs. 70.2%（373/531）和71.1%（354/498），均P<0.016），联合干预组血压控制率高于对照组和宣传日历组（78.2%（376/481） vs. 70.2%（373/531）和71.1%（354/498），均P<0.016）。宣传日历组再住院率为7.0%（39/561），教育组为7.6%（42/561），均显著高于对照组（3.8%（21/561），均P<0.016）。各组低密度脂蛋白胆固醇<2.07 mmol/L率及全因死亡率相似（均P>0.016）。宣传日历或护士教育策略均可提高ACS患者出院后用药依从性，护士教育的效果优于宣传日历，两种方法联合可进一步提高ACS患者出院后用药依从率。
