Medication Adherence Suffers With Delayed Follow-up After Acute MI
Patients who are discharged after an acute MI and do not see their doctor within 6 weeks are less likely to adhere to evidence-based medications for secondary prevention than patients with more timely follow-up, a retrospective analysis shows. And that could have important clinical implications, as poor compliance with medication regimens has been associated with adverse outcomes, readmissions, and higher costs.
“There has been increasing focus on ensuring patients get early follow-up post-MI,” senior author Tracy Wang, MD (Duke Clinical Research Institute, Durham, NC), told TCTMD in an email, adding that there have been questions about how early is early enough and what swift follow-up actually accomplishes.
“In this study, we chose to study this from a very concrete endpoint of medication adherence,” she continued. “We thought medication adherence was an important metric primarily because it has a strong impact on downstream patient outcomes (risk of recurrence), but also because it has been introduced as a metric for care quality and value-based payments.”
Contrary to what was expected, there was not a dose-response relationship between the timing of posdischarge visits and the likelihood of patients adhering to medications, with a threshold observed at 6 weeks, she pointed out.
“However, across the board, one-third of patients had suboptimal adherence even as early as 90 days post-MI and across all medication classes,” Wang said. “What this suggests is that adherence behavior can be modified, we just need to figure out how to most effectively optimize this. Early clinic follow-up is one mechanism, but perhaps we don’t need to stress out about defining this as 1 week or 2 weeks postdischarge. We need to be creative about incentivizing adherence in patients who cannot or will not follow up within 6 weeks, particularly those with socioeconomic barriers to follow-up.”
Commenting on the study for TCTMD, Sameer Bansilal, MD (Mount Sinai Hospital, New York, NY), said that beyond aiming for early follow-up, there are multiple approaches to improving the transition of care or enhancing medication adherence.
Giving patients a bag of their medications at the bedside before discharge takes the guesswork out of filling prescriptions and makes the process clearer, Bansilal said. Another possible approach is the use of polypills to make it easier for patients to take all of their medications. That strategy will be evaluated in the SECURE trial, for which Bansilal serves on the executive committee. And finally, he said, technological advancements—pill bottles equipped with cellular technology and camera-based apps that ensure patients are taking their medications, for example—may play a role in enhancing adherence.
“All the medications listed in this paper together could bring about a nearly 80% reduction in cardiovascular events,” Bansilal said. “I think papers like this . . . buffer the fact there is a huge missed opportunity and there is a need for multiple strategies to be implemented and researched for us to truly impact cardiovascular care in a meaningful way.”
The findings were published online March 23, 2016, ahead of print in JAMA Cardiology by lead author Kamil Faridi, MD (Johns Hopkins Hospital, Baltimore, MD), Wang, and colleagues.
Delays May Make Poor Adherence Even Worse
Although studies have shown that timely follow-up after discharge is associated with a lower risk of readmission, no information is available on whether the timing of outpatient follow-up is related to medication adherence, according to the researchers. “We hypothesized that earlier follow-up with a healthcare professional may increase adherence owing to more timely clinical assessment, medication review, adverse effect monitoring, dose adjustment, patient education, and refilling of prescriptions,” they write.
They explored the issue by looking at data on 20,976 patients older than 65 who were discharged alive after an acute MI between January 2, 2007, and October 1, 2010, from 461 hospitals participating in the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry-Get With the Guidelines program. The analysis also drew on linked Medicare Part D prescription fill data for beta-blockers, P2Y12 inhibitors, statins, and ACE inhibitors/angiotensin receptor blockers.
The median time to the first outpatient visit was 14 days. About one-quarter of patients (26.4%) had their first visit within 1 week, 25.0% in 1 to 2 weeks, 32.6% in 2 to 6 weeks, and 16.0% beyond 6 weeks.
Medication adherence—defined as the proportion of days with more than 80% coverage using the prescription fill data—ranged from 63.4% to 68.7% at 90 days and 54.4% to 63.5% at 1 year. Adherence at both time points was similar among patients who had their first visit within 6 weeks after discharge, but was significantly lower in those who did not have a visit until after 6 weeks.
The main differences between patients with timely versus delayed visits were seen in socioeconomic status, with patients who took more than 6 weeks to have their first visit more likely live in areas with lower household incomes, home values, and educational levels. After multivariate adjustment, having a follow-up visit more than 6 weeks after discharge remained associated with lower medication adherence at 90 days (OR 0.74; 95% CI 0.70-0.78) and 1 year (OR 0.79; 95% CI 0.73-0.85), a finding consistent across medication classes.
Importance of Cardiologist Contact
About half of patients in the study (47.7%) had their first outpatient visit with a cardiologist, and within this subset, there was no difference in medication adherence based on how long it took for that visit to occur. That suggests that scheduling a first follow-up visit with a cardiologist may be one strategy to improve medication adherence, the researchers say.
“Cardiologists may be more likely to switch medication formulation or dose in response to patient-reported adverse effects instead of discontinuing evidence-based medications,” they write, adding, too, that “patients seeing a cardiologist may be more motivated to adhere to cardioprotective medications when reminded of their recent [acute MI].”
Bansilal said that it is important for that first postdischarge visit to be with a cardiologist, especially for patients who have undergone PCI. What it comes down to, he said, is that cardiologists have more time than primary care physicians to talk about lifestyle factors, medication adherence, and other issues related to secondary prevention after an MI.
“I think 50% of the battle is education, and that’s where the cardiologists have the onus and are best suited at that first visit to make a huge impact,” he said.
Postdischarge Adherence Remains Low
The authors note that there have been recent efforts to improve the care of acute MI patients, including clinical performance measures and quality improvement programs developed by the American College of Cardiology and American Heart Association.
“As a result of these efforts, adherence to evidence-based therapies during the index hospitalization among patients with [acute MI] has reached near-perfect levels,” they note, adding that the success has shifted attention to postdischarge secondary prevention.
Studies show that adherence after leaving the hospital improved between the 1990s and 2003, but “our study suggests that rates of long-term medication adherence have not improved recently,” Faridi and colleagues write.
Although early visits appear to
be helpful in boosting adherence, other interventions may be useful as well,
they say. “Strategies that have been demonstrated to improve
outcomes in patients after [acute MI] include patient involvement with
transitions of care, discharge contracts, inclusion of inpatient and outpatient
care, and care that involves primary care physicians and cardiologists,” they
write. They add that a focus should be placed on patients with lower
socioeconomic status, who are at risk for delays in follow-up and poor
Faridi KF, Peterson ED, McCoy LA, et al. Timing of first postdischarge follow-up and medication adherence after acute myocardial infarction. JAMA Cardiol. 2016;Epub ahead of print.
- The data linkage used in the study was supported by a grant from the Agency for Healthcare Research and Quality.
- Wang reports receiving research grant support from Eli Lilly, Daiichi Sankyo, AstraZeneca, Bristol-Myers Squibb, Boston Scientific, Gilead, GlaxoSmithKline, and Regeneron and paid consulting services Eli Lilly, AstraZeneca, and Premier.
- Faridi and Bansilal report no relevant conflicts of interest.