**5.5 Cost reduction and financial aid**

Current evidence suggests that reducing medication costs improves patient adherence and clinical outcomes. A trial randomized 10,102 hospitalized patients with acute MI to a group of copayment vouchers for P2Y12 inhibitors or no vouchers. At 1 year, patient adherence was reported to be higher in the intervention group than in the control group (aOR 1.19, 95% CI 1.02–1.40), but no significant difference was observed in MACEs (aHR 1.07, 95% CI 0.93–1.25) [94]. Another positive result was found in the MI FREEE trial randomized 5855 hospitalized patients with AMI to full prescription coverage vs. usual coverage for BBs, statins, and ACEIs/ARBs over about 1 year. Adherence rates were increased in the full-coverage group compared with the usual coverage group by 5.6% for ACEI/ARBs (95% CI 3.4–7.7), by 4.4% for BBs (95% CI 2.3–6.5), by 6.2% for statins (95% CI 3.9–8.5), and by 5.4% for all three medication groups (95% CI 3.6–7.2). A significant reduction was observed in total MACEs in the full-coverage group (HR 0.89, 95% CI 0.90–0.99; *P* = 0.03) was observed, despite no significant differences in the first MACEs (HR 0.93; 95% CI 0.82–1.04; *P* = 0.21) [95].

Cost reduction strategies using either copayment reduction or financial incentives have shown modest changes in medication adherence, although further research is needed to determine the sustainability of these interventions. Another possible cost reduction solution is replacing brand-name medications with well-proven, equally effective, and less costly generic ones. In a study of over 300,000 privately insured adults aged ≥18, generic drug therapy improved adherence [96].

#### **5.6 Healthcare team**

Community health workers (e.g. community pharmacists) often regularly interact with patients and provide access, education, and support regarding medication use. Enhanced community health workers' involvement has been explored to improve medication adherence. Recent systematic reviews evaluating community health worker-led

intervention demonstrate improvement in adherence and reduction in secondary ASCVD (97% intervention vs. 92% control; OR 2.62, 95%CI 1.32–5.19) [79].

Pharmacist-led consultations improved medication adherence in CVD patients compared with usual care (4.5% difference, 95% CI 0.8–8.2, *P* = 0.017) [77]. Another standardized counseling intervention by pharmacists at hospital discharge of ACS patients showed (1) an increased medication adherence at 1 year (11.9% non-counseling receivers vs. 18.4% counseling receivers, *P* = 0.19) and (2) decreased cardiovascular readmission and all-cause mortality (17.6% intervention vs. 22.3% usual care, *P* = 0.42; and 3.4% intervention vs. 4.2% usual care, *P* > 0.99, respectively) [97].

The healthcare team plays an important role in patients' adherence by identifying medication nonadherence and adherence barriers and providing interventions that address these barriers. One of the consistent features of successful interventions has been regular follow-up with the healthcare team [98].

#### **5.7 Fixed-dose therapy (polypill)**

The relationship between polypill therapy and CVD outcomes was studied enormously, and most studies found positive findings. A systematic review and meta-analysis of eight studies involving 25,584 patients demonstrated that the use of polypills (1) significantly enhanced drug adherence (RR 1.31, 95% CI 1.11–1.55, (2) significantly reduced CVD risk factors (hypertension) and the risk of all-cause mortality (RR 0.90, 95% CI 0.81–1.00, *P* < 0.05) and MACEs (RR 0.85, 95% CI 0.70–1.02, *P* > 0.05) [99]. Another systematic review indicated that polypills improved adherence and reduced secondary ASCVD (86% intervention vs. 65% control, OR 1.33, 95%CI 1.26–1.41) [79]. A meta-analysis demonstrated significant improvement in adherence with the use of polypill of two or more antihypertensive drugs (OR 1.21, 95% CI 1.03–1.43, *P* = 0.02), but beneficial trends in BP and adverse effects [100]. Challenges can explain this in matching patients to a specific polypill and adjusting the dose of a component in a polypill.

In summary, since nonadherence factors are patient-specific, personalized interventions are required to enhance the impact of an intervention to improve medication adherence in CVD [98]. Evidence demonstrated that simple strategies requiring low healthcare resources such as simplifying the regimen, organizing medications in pillboxes, obtaining family and social support, using motivational interviewing, and educating patients on the importance of medication adherence appear cost-effective.

## **6. Conclusions**

Adherence to cardiovascular medication reduces substantial morbidity and mortality and reduces healthcare costs. Despite these advantages, medication nonadherence remains common due to multiple barriers from patients, providers, and system levels. Various interventions have been tested to overcome these barriers, and most of them have illustrated positive findings. A combination of interventions is more likely to be effective as several factors simultaneously influence adherence. The heterogeneity of effect within each intervention may result from the inappropriate matching of intervention and factors influencing adherence. Thus, after identifying medication nonadherence, clinicians should consider potential factor(s) influencing adherence to select intervention(s) targeting the identified factor(s).

*Medication Adherence in Cardiovascular Diseases DOI: http://dx.doi.org/10.5772/intechopen.108181*
