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Improving Medication Adherence through Graphically Enhanced Interventions in Coronary Heart Disease (IMAGE-CHD): A Randomized Controlled Trial



Up to 50 % of patients do not take medications as prescribed. Interventions to improve adherence are needed, with an understanding of which patients benefit most.


To test the effect of two low-literacy interventions on medication adherence.


Randomized controlled trial, 2 × 2 factorial design.


Adults with coronary heart disease in an inner-city primary care clinic.


For 1 year, patients received usual care, refill reminder postcards, illustrated daily medication schedules, or both interventions.

Main Measures

The primary outcome was cardiovascular medication refill adherence, assessed by the cumulative medication gap (CMG). Patients with CMG < 0.20 were considered adherent. We assessed the effect of the interventions overall and, post-hoc, in subgroups of interest.

Key Results

Most of the 435 participants were elderly (mean age = 63.7 years), African-American (91 %), and read below the 9th-grade level (78 %). Among the 420 subjects (97 %) for whom CMG could be calculated, 138 (32.9 %) had CMG < 0.20 during follow-up and were considered adherent. Overall, adherence did not differ significantly across treatments: 31.2 % in usual care, 28.3 % with mailed refill reminders, 34.2 % with illustrated medication schedules, and 36.9 % with both interventions. In post-hoc analyses, illustrated medication schedules led to significantly greater odds of adherence among patients who at baseline had more than eight medications (OR = 2.2; 95 % CI, 1.21 to 4.04) or low self-efficacy for managing medications (OR = 2.15; 95 % CI, 1.11 to 4.16); a trend was present among patients who reported non-adherence at baseline (OR = 1.89; 95 % CI, 0.99 to 3.60).


The interventions did not improve adherence overall. Illustrated medication schedules may improve adherence among patients with low self-efficacy, polypharmacy, or baseline non-adherence, though this requires confirmation.

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We wish to thank Jessica Praska, PharmD, and Akilah Strawder, PharmD, for their assistance in intervention delivery. We thank Junling Ren for her assistance in outcome assessment, as well as Courtney Cawthon, MPH, and Abby Myers for their help with manuscript preparation.

This research was supported by a grant from the American Heart Association.

Prior Presentation

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    Kripalani S, Robertson RS, Schmotzer B, Jacobson TA. Improving Medication Adherence through Graphically Enhanced interventions in Coronary Heart Disease: The IMAGE-CHD Study. J Gen Intern Med 2007; 21(S1):151. Poster at American Heart Association grantee symposium 2006. Oral abstract at SGIM 2007.

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    Kripalani S Jacobson TA. Illustrated medication schedules improve medication adherence in at-risk patients with coronary heart disease. J Gen Intern Med 2010; 25(S3):S301. Oral abstract at SGIM 2010.

Conflict of Interest

Dr. Kripalani serves as a consultant to and holds equity in PictureRx, LLC, which makes patient education tools to improve medication management. PictureRx did not provide materials or funding for this study. The terms of this arrangement were reviewed and approved by Emory University and Vanderbilt University in accordance with their conflict of interest policies. Dr. Kripalani also has served as a consultant to Pfizer, Inc. Dr. Jacobson and Mr. Schmotzer have no relevant conflicts of interest to report. The statistical analysis was performed independently by Mr. Schmotzer, who was not affiliated with or compensated by PictureRx.

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Corresponding author

Correspondence to Sunil Kripalani MD, MSc.

Additional information

Figure 1 was published previously in Kripalani et al. Development of an illustrated medication schedule as a low-literacy patient education tool. Pt Educ Counsel 2007; 66:386-77. Emory University retained the copyright to this figure.

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Kripalani, S., Schmotzer, B. & Jacobson, T.A. Improving Medication Adherence through Graphically Enhanced Interventions in Coronary Heart Disease (IMAGE-CHD): A Randomized Controlled Trial. J GEN INTERN MED 27, 1609–1617 (2012).

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  • coronary heart disease
  • medical adherence
  • medication management