PT  - JOURNAL ARTICLE
AU  - Amitava Banerjee
AU  - Shweta Khandelwal
AU  - Lavanya Nambiar
AU  - Malvika Saxena
AU  - Victoria Peck
AU  - Mohammed Moniruzzaman
AU  - Jose Rocha Faria Neto
AU  - Katherine Curi Quinto
AU  - Andrew Smyth
AU  - Darryl Leong
AU  - José Pablo Werba
TI  - Health system barriers and facilitators to medication adherence for the secondary prevention of cardiovascular disease: a systematic review
AID  - 10.1136/openhrt-2016-000438
DP  - 2016 Sep 01
TA  - Open Heart
PG  - e000438
VI  - 3
IP  - 2
4099  - http://openheart.bmj.com/content/3/2/e000438.short
4100  - http://openheart.bmj.com/content/3/2/e000438.full
SO  - Open Heart2016 Sep 01; 3
AB  - Background Secondary prevention is cost-effective for cardiovascular disease (CVD), but uptake is suboptimal. Understanding barriers and facilitators to adherence to secondary prevention for CVD at multiple health system levels may inform policy.Objectives To conduct a systematic review of barriers and facilitators to adherence/persistence to secondary CVD prevention medications at health system level.Methods Included studies reported effects of health system level factors on adherence/persistence to secondary prevention medications for CVD (coronary artery or cerebrovascular disease). Studies considered at least one of β blockers, statins, angiotensin–renin system blockers and aspirin. Relevant databases were searched from 1 January 1966 until 1 October 2015. Full texts were screened for inclusion by 2 independent reviewers.Results Of 2246 screened articles, 25 studies were included (12 trials, 11 cohort studies, 1 cross-sectional study and 1 case–control study) with 132 140 individuals overall (smallest n=30, largest n=63 301). 3 studies included upper middle-income countries, 1 included a low middle-income country and 21 (84%) included high-income countries (9 in the USA). Studies concerned established CVD (n=4), cerebrovascular disease (n=7) and coronary heart disease (n=14). Three studies considered persistence and adherence. Quantity and quality of evidence was limited for adherence, persistence and across drug classes. Studies were concerned with governance and delivery (n=19, including 4 trials of fixed-dose combination therapy, FDC), intellectual resources (n=1), human resources (n=1) and health system financing (n=4). Full prescription coverage, reduced copayments, FDC and counselling were facilitators associated with higher adherence.Conclusions High-quality evidence on health system barriers and facilitators to adherence to secondary prevention medications for CVD is lacking, especially for low-income settings. Full prescription coverage, reduced copayments, FDC and counselling may be effective in improving adherence and are priorities for further research.