Mailed Reminders to Heart Attack Patients Improve Compliance With Beta-Blocker Medication Regimen

Problem Addressed

• A leading cause of death and high costs: More than 1 million Americans have a heart attack (also known as an acute myocardial infarction or acute MI) each year. In 2006, CHD is estimated to have accounted for more than $140 billion in direct and indirect health care costs.²
• Patients at high risk of recurrent heart attacks: Patients who have had at least one acute MI are at high risk of recurrent heart attacks and death. One study that compared survival of MI male patients with that of healthy male patients over several years found a dismal 34 percent survival rate among MI patients, compared to a 72 percent survival rate among men without CHD.³
• Medications available to prevent repeat heart attacks: Practice guidelines recommend that patients who survive a heart attack receive treatment with a beta-blocker, a lipid-lowering agent, an ACE inhibitor or angiotensin receptor blocker (ARB), and aspirin, unless contraindications for these drugs exist.⁴ Taken in combination, these drugs have been estimated to reduce the risk of CHD-related death by 80 percent (as compared to a placebo).⁵
• Low compliance rates lead to increased risks and costs: More than 90 percent of patients discharged from hospitals following a heart attack are prescribed beta-blockers, but only about half of them still use the drugs 2 years later.⁶ High costs, the complexity of treatment regimens, side effects, poor provider-patient relationships, and difficulties accessing physicians or pharmacies all contribute to this lack of compliance.¹ Researchers estimate that heart attack patients who discontinue beta-blockers are twice as likely to die in the following year.⁶ In addition, health care costs are higher among those who do not comply with their medication regimen, due primarily to increased complications and readmissions. 

Description of the Innovative Activity

• First letter, including wallet card: The first letter includes a list of brand names so patients recognize their beta-blocker medications, reminders about the importance of taking the drug, answers to a list of frequently asked questions (FAQs), and a wallet card designed to aid patient-physician communication during subsequent physician visits. The letter features answers to FAQs about beta-blockers, including a discussion of side effects and the importance of adherence to long-term survival.
  • Wallet card designed to aid patient-physician communication: A small card, designed to be folded and placed in the patient's wallet, encourages the patient to discuss beta-blocker treatment with the physician at the next appointment, and to address any side effects that could be interfering with adherence. The card also provides the patients with prompts (i.e., questions to ask the provider, such as: "Why do I need to take the beta-blocker for life? Should I be taking a daily aspirin, a statin to lower cholesterol, and/or an ACE inhibitor?)
• Second letter, featuring wallet card and brochure: The second mailing, which arrives 2 months after the first, delivers the same messages, with an emphasis on the importance of treatment compliance. The mailing contains a followup letter, the same wallet card, and a brochure that cites the recommendations of the American Heart Association and the American College of Cardiology that heart attack patients stay on beta-blocker medication for life.

References/Related Articles

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Results

• Higher compliance with beta-blocker treatment regimen: Approximately 65 percent of those who received the mailings achieved an 80 percent or higher medication compliance rate, compared to only 59 percent of those in the control group. There was little or no variation in results across regions, gender, or race.
• No drop in compliance with other cardiac drugs: Drug compliance for other cardiac medications, including ACE inhibitors and ARBs, rose by 17 percent in the intervention group, which suggests that the increased beta-blocker compliance did not come at the expense of reduced adherence to other medications.
• No data on health outcomes: The study did not track the program's impact on health outcomes, such as number of cardiac events.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Evaluating options for boosting compliance: HMO Research Network CERT investigators conducted research in an effort to find a simple, low-cost, direct-to-patient intervention that could boost compliance and be easily replicated by health plans and providers across the country. 
• Focus groups on roadblocks to compliance and ways to overcome them: Researchers convened focus groups made up of recent MI patients who had been dispensed a beta-blocker prescription. The participants identified the barriers and challenges to compliance, including concerns about side effects, forgetting to refill the prescription, and interruptions in their medication routines. To help overcome these barriers, focus group members suggested that the following informational content be included in any message about the importance of compliance:
  • An explanation of why the drug is important in MI treatment
  • A discussion of the risks of not taking the drug
  • Information about side effects
• Crafting the appropriate language and reading level: The focus groups suggested that patients want letters that are personalized and written so that anyone, regardless of educational level, can easily understand them.
• Determining who would send the letter: While focus group participants suggested that patients would be more likely to open and read the letter if it came directly from the patient’s physician, the study lacked the resources to do this. As a result, the decision was made to have the letters come from the administrator of the local health plan.
• Tracking medication compliance during the study: Electronically stored patient data, including membership files, inpatient and ambulatory visits, and pharmacy data, were monitored during the study so that gaps in medication compliance could be identified. Data on how often patients refilled their beta-blocker prescriptions, derived from pharmacy records, allowed the researchers to determine how many days patients took the drug as prescribed during the 9-month study period.

Resources Used and Skills Needed

• Staffing/systems: While the initiative does not require additional staffing once it is up and running, staff time is needed to develop the program. Information technology programmers or data analysts need to develop systems to identify patients or health plan members who have been recently hospitalized for acute MI. Staff, including graphic artists, are needed to design and customize the letters, wallet cards, and brochures for the target audience. Translators may also be required, depending on the target audience. Systems to track prescription refill rates should be developed in order to assess the effectiveness of the intervention on compliance.
• Costs: The cost of each mailing, including postage, printing, the effort of analysts to pull data, and graphic artist time to format the materials, range from $5 to $10 per patient, depending on the number of letters and brochures printed. These cost estimates do not include focus groups or clinical expertise, which may be required if organizations wish to create original content instead of using the available sample content for free.

Funding Sources

Agency for Healthcare Research and Quality

Tools and Other Resources

Getting Started with This Innovation

• Identify a program champion: One person needs to take charge of the program, including: determining the criteria for which patients will receive the mailings; overseeing the writing and printing of all materials; and working with information system staff to set up systems to identify patient names and addresses and evaluate program effectiveness. 
• Use focus groups to customize the text for targeted patients: While the letters, brochures, and wallet card used by HMO Research Network Investigators are available for use by any organization (see http://www.kpchr.org/public/support/ami/ami.aspx), there may be a need to customize the materials to the target audience. A focus group made up of representative patients can be an effective way to accomplish this task as participants can review the materials and suggest changes or translations to maximize their effectiveness.
• Consider having materials come from the patient’s provider: The focus group participants suggested that any correspondence come from the patient’s primary care provider. While the researchers were unable to do this, individual practices or health plans may be able to customize the reminder letter templates and/or preprint brochures and wallet cards so that they are identified as coming from the provider.

Sustaining This Innovation

• Consider adapting systems to automatically print materials for target patients: Information technology specialists aligned with individual practices or health plans may be able to develop systems that automatically trigger the printing and addressing of reminder letters to appropriate patients, thus reducing required staff time.
• Consider tracking noncompliance and intervening as needed: Given the potential for improved health outcomes and cost savings from enhanced beta-blocker compliance, would-be adopters should investigate whether MI patients’ medication compliance can be tracked, and work with providers to follow up with patients who are not refilling beta-blocker prescriptions as recommended. These patients can be targeted to receive additional mailings or followup calls.
• Integrate reminder letters into ongoing care processes: The reminder letters should become part of the ongoing care process for patients with cardiac disease. In addition to sending reminders shortly after a patient is discharged from the hospital, additional reminders can be sent out once or twice a year, possibly in conjunction with a patient's semiannual or annual visit to the physician. Software "prompts" may be helpful in facilitating these mailings.  
• Take advantage of economies of scale if possible: Due to economies of scale in programming and printing, per-patient costs can be reduced if the program targets a significant number of patients.

Additional Considerations and Lessons

• Consider combining mailings with other interventions: Researchers believe that more dramatic improvements in beta-blocker treatment compliance could be achieved if this type of intervention is combined with other initiatives, such as providing low-cost or free beta-blockers to low-income, uninsured individuals, and/or encouraging patients to schedule and attend followup visits with clinicians during the critical 2-month period after an individual is hospitalized for an acute MI. 
• Provide physicians with copies of letters: Giving doctors copies of the reminder mailings helps them respond to patients' questions, and reminds them to reinforce the value of treatment compliance during office visits.

Use By Other Organizations