University of Groningen
Medication use for acute coronary syndrome in Vietnam
Nguyen, Thang
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Nguyen, T. (2018). Medication use for acute coronary syndrome in Vietnam. University of Groningen.
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Chapter 8
165
General discussion
Summary of results
This thesis addresses two stages of the medicine use process in acute coronary syndrome (ACS): the first part focusing on physician adherence to prescribing guidelines and the second part focusing on patient adherence to treatment.
In general, the cross‑sectional study showed that physicians strictly adhered to prescribing guideline‑recommended medications [antiplatelet agents, angiotensin‑ converting enzyme inhibitors or an angiotensin II receptor blockers (ACEIs/ARBs), and statins] for patients with ACS, but adherence was suboptimal for beta‑blockers and clopi‑ dogrel loading doses. Patients who underwent percutaneous intervention (PCI) were more likely to receive these medications (Chapter 2). In the cohort study, we found that about half of the patients were prescribed all medications according to guidelines. In about one‑third of patients, major cardiovascular outcomes occurred within the first six months after hospital discharge. A 29% reduction in major cardiovascular outcomes was seen in the first six months after discharge for patients who received medications according to guidelines compared to those who did not. Prior heart failure, renal insufficiency or not receiving PCI also signifi‑ cantly increased the risk of major cardiovascular outcomes (Chapter 3). Our systematic literature review showed that interventions to enhance prescribing guideline‑recommended medications for patients with ischemic heart diseases (IHDs) were of organizational or professional nature. The interventions significantly improved prescribing of statins/lipid lowering agents and target blood pressure but not for other medications (antiplatelet agents, beta blockers, and ACEIs/ARBs) and patient health outcomes (Chapter 4).
We translated and cross‑culturally adapted the Brief Illness Perception Questionnaire (BIPQ),1 the Belief about Medicines Questionnaire (BMQ),2 and the Eight‑item Morisky
Medication Adherence Scale (MMAS‑8)3 into Vietnamese. Our findings suggested that
the Vietnamese version of these questionnaires were reliable tools for assessing percep‑ tion of illness, beliefs about medicines, and medication adherence in patients with ACS in Vietnam (Chapter 5). Over three‑quarters of the patients with ACS in Vietnam were adherent to taking cardioprotective medications in the first six months after discharge. The proportion of adherence remained stable during the six months. Most frequently reported reasons for non‑adherence were missing/forgetting taking medicine, not complying with medical visits, and finding it hassling to stick to treatment. Patients who perceived that ACS had serious consequences, who believed stronger in the necessity of prescribed medica‑ tions, and who were adherent at one or three months after discharge were more likely to be adherent to taking cardioprotective medications at six months. Patients who perceived they had personal control of ACS or believed that physicians overused medicines were less likely to be adherent (Chapter 6). In our randomized controlled trial (RCT), we found that our intervention comprising pharmacist‑led medication counselling and tailoring, patient education, and providing medication aids enhanced the proportion of adherent patients
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by over 13% in the first three months after discharge, but there was no statistically signifi‑ cant improvement on the change in quality of life from baseline and mortality or readmis‑ sion to hospital over the 3 months of the study (Chapter 7).
Strengths and weaknesses
As far as we are aware, limited work has been done to elucidate the two main stages of the medicine use process in treatment for patients with ACS in Vietnam. We believe that our studies are unique to explore the process and give valuable insights for clinical practice and research. Despite recommendations issued in both international and national guidelines for management of ACS, prescribing and taking the guideline‑recommended medications in Asia or resource‑limited countries remain suboptimal.4–6 Exploratory of physicians’
behaviors in prescribing and patients’ behaviors in taking medicine are the new and necces‑ sary area in treatment for ACS and also other NCDs in Vietnam. Furthermore, we translated and cross‑cultural adapted all questionnaires following the well‑known guideline on trans‑ lation and adaptation7,8 before using them for measurements of patients’ outcomes in this
thesis (Chapter 5). Studies in this thesis were conducted and reported followed validated and widely used guidelines for suitable designs including the Strengthening The Reporting of OBservational Studies in Epidemiology (STROBE) statement9 for the cross‑sectional and
prospective cohort and observational studies (Chapter 2, Chapter 3, and Chapter 6); the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta‑ Analyses (PRISMA) statement10 for the systematic
review and meta‑analysis (Chapter 4); and the CONsolidated Standards of Reporting Trials (CONSORT) statement11 for the RCT (Chapter 7).
Some issues need to be considered in this thesis. First, we collected data from paper medical records because of unavailability of electronic medical records in the study hospitals Lack of databases for electronic medical record systems is a typical situation of the health‑ care system in LMICs including Vietnam.12,13 Paper medical records are probably difficult
to read and understand due to the physician’s illegible penmanship. These records are not always readily accessible to researchers. We had to retrieve them from archives and read them to collect data. This was a time‑consuming process and required more personnel to collect paper files and extract data. In the absence of databases suitable to study medication use, prospective studies were set up to explore the research questions of this thesis (obser‑ vational and cohort studies). We trained researchers to gather data using predefined data collection forms which had been piloted and modified in order to improve the accuracy of data collection. Second, we measured patient adherence using the MMAS‑8 which might be biased by inaccurate patient recall or patient giving socially desirable responses. Patient’s psychological state can also impact the response.14 Nevertheless, the scale has been proven
167
General discussion
and patients’ health outcomes.15,16 We also assessed the cognitive status of all participants
before inclusion. The questionnaire might be one of the most economically feasible tools for measuring medication adherence in Vietnam, a lower middle‑income country rather than other methods such as Medication Event Monitoring System (MEMS) caps or pharmacy refill data which have often been described as more accurate.5,6 Third, reasons of death or
hospital readmission were based on interviews of patients or their relatives. We could not assess specific causes of mortality. Furthermore, we could not assess reasons for readmis‑ sions as patients were readmitted to a number of different hospitals. It was outside the scope of our study to collect data from all of these hospitals. Finally, we conducted the studies in selected hospitals in two urban regions of Vietnam, this potentially limited the generaliz‑ ability our findings to other regions, especially rural regions.
Implications for clinical practice & further research
We found that in‑hospital guideline adherence was associated with a significant reduction in six‑month major cardiovascular outcomes of patients with ACS in Vietnam. Prescribing according to guidelines was suboptimal in clinical practice. The data support the need for improving physician adherence to guidelines and affirm the importance of evidence‑based medicine in Vietnam. However, findings of our systematic review showed that 11 out of 13 RCTs came from North America and Europe, only two from Brazil and Taiwan, and there were limited improvements from the implemented interventions (organizational, profes‑ sional, or both). Financial and regulatory strategies could be tested.17–19 These could beintegrated in large quality improvement programs20–22 with close cooperation of all healthcare
professionals. In practice, any intervention needs to fit the local context and local barriers to change should be addressed. Known barriers include lack of awareness and familiarity with the guideline as well as physician attitudes, such as lack of agreement, self‑efficacy (physician believes that he/she cannot perform guideline recommendation), outcome expectancy (physician believes that performance of guideline recommendation will not lead to desired outcome), and motivation (inertia of previous practice). Furthermore, external barriers including patient, guideline, or environmental factors can affect the physician’s ability to execute recommendations.23 Further work is needed to determine the barriers
to physician adherence to guidelines in the Vietnamese context. Such knowledge can help policy makers, health care professionals and researchers design effective interventions to change physician practice.
Although, most patients do fit the recommendations in guidelines, guidelines are suggestions for care, not rules. “One size does not fit all”, there is always individual patients who should be managed specifically. The reasons for individual care include biologic differences in drug metabolism, immune response, or genetic endowment; the presence of comorbid conditions; available resources determined by the social and economic
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environment of medicine at the local level; and patient preferences.24,25 In our findings,
there were certain proportions of patients do not fit the guidelines. Further studies on such patients should be done. In addition, guidelines are usually based upon the best available research evidence and practice experience, but evidence‑based medicine is sometimes over‑ reliant on the reliability of clinical trials and systematic reviews. Limitations of clinical trials and systematic reviews are due to: unrepresentativeness of trial patients in terms of age, therapy, and comorbidity; over‑reliance on statistical as opposed to clinical significance; and misleading results due to reporting bias, inappropriate pooling of small trials, effect of changes in disease mortality, and prognosis over time.26 Patients who are treated in practice
are possibly different from those included in research.
Our findings suggest that patient adherence to taking cardioprotective medications was relatively high, but still suboptimal. Little is known to what extent physicians assess medication adherence in patients and discuss this with them. Physicians should be encour‑ aged to identify patients’ behaviors and associated factors of non‑adherence and promote adherence to prescribed medications. Pharmacists, in addition to medication dispensing, can provide medication education and disease management for patients to improve medication adherence to achieve desired therapeutic outcomes.27 The role of pharmacists
in Vietnam has been expanding from dispensing medications to providing services about medication management to support rational use of medicine.28 With an increasing number
of patients needing long‑term use of secondary prevention medications for treatment of chronic diseases, the pharmacist should become an essential partner for other health‑ care professionals and patients to make optimal use of available resources and to achieve expected therapeutic outcomes. Our findings showed that pharmacists could enhance patient adherence to taking cardioprotective medications in the first three months after discharge. Previous systematic reviews have shown significant benefits of pharmacist‑led interventions in IHDs 27,29 and in CVDs.30,31 It encourages a closer cooperation of physicians
with clinical pharmacists in order to improve long‑term outcomes of patients with CVDs. Future studies should evaluate the effect of the intervention with more counseling sessions during the long‑term follow‑up and could focus on low adherence patients. Research should also address aspects of shared decision‑making between health professionals and patients, a concept which has been emerging in high‑income countries might improve medication adherence.32–34 However, patient involvement in decision‑making is probably the forgotten
area in LMICs.35,36
This thesis has focused on two main stages of the medicine use process for patients with IHDs, stages of dispensing and follow‑up treatment should be considered in future work for this patient group. The total impact of the poor quality of all stages of the process on patient health outcomes is probably an interesting research question. Furthermore, results of this thesis may encourage similar research of these stages in separately or as a whole carried out for other CVDs or NCDs in Vietnam.
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General discussion
Vietnam is facing a high burden of IHDs as well as other CVDs and NCDs.37–39 The
Vietnamese version of the BIPQ, BMQ, and MMAS‑8 can be applied as reliable tools for assessing illness perception, beliefs about medicines, and medication adherence of patients with IHDs. These instruments could be also considered for other NCDs. More studies are needed to validate the psychometric properties of these questionnaires in patients with different chronic conditions in different clinical settings. Our study confirms the necessity of the process of translation and cross‑cultural adaptation of a questionnaire before using them. Further work investigating patient self‑reporting plus another method may be more comprehensive in measuring patient adherence as different aspects of patient adherence can be measured.
A majority of global deaths due to CVDs occur o in LMICs.40 Survivors from an
ACS are at increased risk of recurrent infarctions and death, but adherence to prescribing and medicine taking remains suboptimal in clinical practice in LMICs.41,42 Guideline and
medication adherence have been shown to reduce both morbidity and mortality in patients with IHDs.43–45 We hope that our results trigger research on prescribing and medication
taking in other NCDs and prompt policy makers and healthcare professionals in Vietnam and similar LMICs to evaluate their systems to improve the medication use process.
Conclusions
This thesis provides insight into pharmacological management for patients with ACS in Vietnam. In general, the extent of physician adherence to prescribing guidelines and patient adherence to taking cardioprotective medications was relatively high, but still far from optimal. While we have shown that the pharmacist can support patients in improving adherence, more work investigating how to improve physician adherence to prescribing guidelines is needed.
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