Guideline-based management of acute coronary syndrome (ACS) is well established, yet some may challenge that strict implementation of guideline recommendations can limit the individualization of therapy. The use of all recommended medications following ACS places a high burden of responsibility and cost on patients, particularly when these medications have not been previously prescribed. Without close attention to avoiding non-adherence to these medications, the full benefits of the guideline recommendations will not be realized in many patients. Using a case example, we discuss how the recognition of adherence barriers can be an effective and efficient process for identifying patients at risk of non-adherence following ACS. For those identified as at risk, the World Health Organization's model of adherence barriers is explored as a potentially useful tool to assist with individualization of therapy and promotion of adherence.

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Background Despite continual improvements in the management of acute coronary syndromes, adherence to guideline-based medications remains suboptimal. We aim to improve adherence with guideline-based therapy following acute coronary syndrome using an existing service that is provided by specifically trained pharmacists, called a Home Medicines Review. We have made two minor adjustments to target the focus of the existing service including an acute coronary syndrome specific referral letter and a training package for the pharmacists providing the service. Methods/Design We will be conducting a randomized controlled trial to compare the directed home medicines review service to usual care following acute coronary syndromes. All patients aged 18 to 80 years and with a working diagnosis of acute coronary syndrome, who are admitted to two public, acute care hospitals, will be screened for enrolment into the trial. Exclusion criteria will include: not being discharged home, documented cognitive decline, non-Medicare eligibility, and presence of a terminal malignancy. Randomization concealment and sequence generation will occur through a centrally-monitored computer program. Patients randomized to the control group will receive usual post-discharge care. Patients randomized to receive the intervention will be offered usual post-discharge care and a directed home medicines review at two months post-discharge. The study endpoints will be six and twelve months post-discharge. The primary outcome will be the proportion of patients who are adherent to a complete, guideline-based medication regimen. Secondary outcomes will include hospital readmission rates, length of hospital stays, changes in quality of life, smoking cessation rates, cardiac rehabilitation completion rates, and mortality. Discussion As the trial is closely based on an existing service, any improvements observed should be highly translatable into regular practice. Possible limitations to the success of the trial intervention include general practitioner approval of the intervention, general practitioner acceptance of pharmacists' recommendations, and pharmacists' ability to make appropriate recommendations. A detailed monitoring process will detect any barriers to the success of the trial. Given that poor medication persistence following acute coronary syndrome is a worldwide problem, the findings of our study may have international implications for the care of this patient group. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12611000452998

Rationale, aims and objectives: To develop and evaluate a person-centered online education package to facilitate the delivery of a Home Medicines Review system following acute coronary syndromes (ACS).Methods: An education package of 5 online lectures, an assessment quiz and an evaluation questionnaire was developed to increase the skills and capacity of pharmacists. Course material was generated from a targeted appraisal of literature and reviewed by expert pharmacists. Kirkpatrick’s 4-level model for evaluating training programs was applied as an international standard for measuring the quality of the material developed. The evaluation questionnaire measured the dimension of reactions to the material and the assessment quiz measured the dimension of learning.Results: From a pool of 91 accredited pharmacists, 36 registered an interest in the education package and completed the online enrolment. Of those who enrolled, 27 completed the package. Twenty-two pharmacists passed the quiz on their first attempt and 3 passed on their second attempt. Analysis of the evaluation questionnaire consistently showed pharmacists’ reactions to the material were positive.Conclusion: In Australia, Home Medicines Reviews are endorsed by policy and reimbursed. Providing resources to increase the knowledge and confidence of pharmacists will potentially improve their ability to address specific issues with adherence and medication use following ACS.