1. Mailers and telephone reminders together significantly increased the likelihood of completing cardiac rehabilitation at 12 months among individuals who have experienced a myocardial infarction.
Evidence Rating Level: 2 (Good)
Secondary prevention following a myocardial infarction (MI) is important to reduce subsequent morbidity and mortality. Though recommended drug regimens and cardiac rehabilitation have been shown to be effective forms of secondary prevention, non-adherence is notoriously common, and around half of patients discontinue therapy by 12 months following their MI. This pragmatic, three-arm, single-blinded randomized controlled trial involved 2,632 participants from 9 cardiac centers in Ontario, Canada, randomized 1:1:1. 878 participants (M [SD] age = 66.8 [12.6] years, 71.3% male) receiving mail-out reminders and 878 participants (M [SD] age = 65.9 [12.1] years, 71.3% male) receiving mail-out reminders plus telephone calls were compared with 876 participants (M [SD] age = 66.8 [12.5] years, 71.2% male) receiving usual care for adherence to recommended pharmacotherapy as well as attendance at and completion of cardiac rehabilitation. Primary outcomes were adherence to recommended drugs as measured on an ordinal scale and completion of cardiac rehabilitation, both assessed at 12 months post-MI. No significant difference in medication adherence was observed among participants in either intervention arm compared with usual care. However, patients receiving mail-out reminders plus telephone calls had significantly greater odds of fully completing cardiac rehabilitation when compared with those receiving usual care (OR 1.55, 95% CI 1.18 to 2.03, p = 0.007). These findings were consistent on the absolute scale (adjusted risk difference 9.4%, 95% CI 3.5% to 15.4%). Patients who received only mail-out reminders had a higher, but statistically insignificant, rate of cardiac rehabilitation completion (OR 1.19, 95% CI 0.95 to 1.50, p = 0.34), with findings again being consistent on the absolute scale (adjusted risk difference 3.7%, 95% CI -1.0% to 8.4%). Overall, this trial showed that an educational intervention delivered by mail and telephone to post-MI patients can be a cost-effective route to significantly increase adherence to cardiac rehabilitation but not to medication.
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