The Ups and Downs of Statin Adherence Around Acute MI Hospitalization
Hospitalization for acute MI can serve as a spark to increase adherence to statins in some Medicare beneficiaries, but also as a turning point associated with a decline in adherence for others, a new analysis shows.
Overall, though, the percentage of patients who were not adherent to statins increased after acute MI hospitalization (from 36.4% to 43.4%), with a similar trend of declining adherence seen in those hospitalized for pneumonia and in those who were not admitted to the hospital, Ian Kronish, MD (Columbia University Medical Center, New York, NY), and colleagues report.
The study, published online May 24, 2016, ahead of print in Circulation: Cardiovascular Quality and Outcomes, “supports the hypothesis that a hospitalization for [acute MI] can act as teachable moment that promotes adherence to treatments prescribed to prevent recurrent events,” the authors write.
“In contrast, patients who were adherent to statins before hospitalization for [acute MI] or pneumonia were more likely to become nonadherent after discharge compared with patients with no hospitalizations,” they add. “This suggests that a hospitalization, irrespective of the reason, can also have an adverse impact on medication adherence.”
The Good and the Bad
Prior research has shown that nonadherence to statins is common among patients who have been hospitalized for acute MI, and poor adherence to the preventive medications has been tied to higher risks of cardiovascular events, death, and readmissions and higher healthcare costs, according to the authors.
To explore patterns of adherence and nonadherence around acute MI hospitalization, Kronish and colleagues looked at administrative claims data from a 5% random sample of Medicare beneficiaries. The analysis included 6,618 patients hospitalized for acute MI between 2007 and 2011, 11,471 hospitalized for pneumonia during the same time period, and 158,099 who were not hospitalized in either 2010 or 2011. All patients were taking statins.
The Take Home To boost adherence, “there is a role for simplifying the regimen, triaging these patients, [and] involving social services in the transition of care,” Sameer Bansilal says.
The percentage of patients who were nonadherent to statins—defined as having a proportion of days covered < 80% according to statin prescription fills—increased from before to after hospitalization for patients with acute MI and pneumonia and from 2010 to 2011 for those who were not hospitalized.
Among patients who were not adherent to statins before acute MI hospitalization, 37.7% became compliant after discharge. These patients were more likely to become adherent compared with patients with pneumonia (adjusted RR 1.70; 95% CI 1.57-1.84) and nonhospitalized patients (adjusted RR 1.79; 95% CI 1.68-1.90).
Among patients adherent to statins before hospitalization for acute MI, 32.6% became nonadherent after discharge. These patients were less likely to become nonadherent compared with patients with pneumonia (adjusted RR 0.93; 95% CI 0.88-0.98) but more likely to become nonadherent compared with patients who were not hospitalized (adjusted RR 1.41; 95% CI 1.35-1.48).
Focus on High-Risk Patients
Risk factors associated with a lower likelihood of moving from nonadherence to adherence after an acute MI hospitalization included pre-existing coronary heart disease or diabetes and a low level of initial adherence (proportion of days covered < 50%). Factors tied to a greater risk of moving from adherence to nonadherence included older age, diabetes, depression, and dementia.
“These findings are consistent with evidence showing that disjointed transitions in care from hospital to home can produce medication reconciliation errors that put patients, especially those from vulnerable groups, at risk for medication nonadherence,” the authors write. “These findings also support the posthospital syndrome hypothesis that the hospitalization, in itself, impairs patients’ ability to adhere to medications after discharge.”
Speaking with TCTMD, Kronish said there can be a bias on the part of physicians in that they assume their patients are taking their medications as prescribed. The first step toward improving medication adherence after acute MI hospitalization is establishing good patient-provider communication “where you can make patients feel comfortable telling you if they actually are not taking their medications,” he said.
Other areas that can potentially be tapped to boost adherence are electronic records of prescription ordering, which can be used to alert physicians if patients are not refilling in a timely fashion, and communication during the transition from hospital to home, which can often be confusing, Kronish said.
And finally, he said, greater attention should be paid to patient factors beyond cardiovascular health. “Paying attention to [patients’] whole cardiovascular and emotional health may lead to greater awareness of emotional symptoms like depression or posttraumatic symptoms that can then be intervened on, and maybe that could help the adherence as well,” he said.
Commenting on the study for TCTMD, Sameer Bansilal, MD (Mount Sinai Hospital, New York, NY), said there is a need to focus on the types of high-risk patients identified in the study—those with coronary disease, depression, diabetes, or dementia, for example—to boost adherence.
Also, reducing the complexity of treatment regimens and getting medications to patients at the bedside before discharge could be strategies to improve compliance, he said.
“There are some very crystal clear messages beyond the whole teachable moment,” Bansilal said. “I think there is a role for simplifying the regimen, triaging these patients, [and] involving social services in the transition of care.”
- Kronish IM, Ross JS, Zhao H, et al. The impact of hospitalization for acute myocardial infarction on adherence to statins among older adults. Circ Cardiovasc Qual Outcomes. 2016;Epub ahead of print.
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- Kronish reports receiving support from the National Institutes of Health.
- Bansilal reports no relevant conflicts of interest.