Clopidogrel Prescriptions Not Being Filled Fast Enough, If at All

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Seven days after placement of a drug-eluting stent (DES), 1 in 5 patients do not fill their clopidogrel prescriptions, while 1 in 7 fail to do so within 3 months, according to data published online December 6, 2011, ahead of print in Circulation: Cardiovascular Quality and Outcomes. The study’s authors say hospitals and physicians can improve prescription adherence by focusing on certain at-risk patient groups.

In a retrospective analysis of data from 15,996 Medicare Part D enrollees who received a DES between April 2006 and September 2007, Gregory A. Roth, MD, MPH, of the University of Washington (Seattle, WA), and colleagues assessed the likelihood of filling a clopidogrel prescription within 7 and 90 days of discharge. They also looked at the relationship between prescription adherence and its association with acute myocardial infarction (AMI) hospitalization and death.

Prescription Adherence Too Low

The researchers determined that 19.7% of the study sample did not fill their prescriptions within 7 days of discharge, with 13.3% failing to do so by 3 months. The average time to fill the prescription overall was 2.8 ± 10.3 days.

Characteristics found to be most strongly associated with nonadherence at 90 days include:

• Dementia (20.2% less likely; 95% CI 10.4%-30.1%)
• Depression (10.7% less likely; 95% CI 6.9%-14.5%)
• Age greater than 84 years (10.6% less likely; 95% CI 8.6%-12.7%)
• Black race (6.6% less likely; 95% CI 4.2%-9.0%)
• Intermediate levels of medication cost share (5.2% less likely; 95% CI 2.9%-7.6%)
• Female sex (3.3% less likely; 95% CI 2.1%-4.5%)

However, patients originally hospitalized for an AMI had higher prescription adherence than those with no AMI (12.5% more likely to fill at 90 days; 95% CI 11.3%-13.6%).

Ultimately, failure to fill a clopidogrel prescription within 7 days of discharge was associated with a higher risk of death during days 8 to 90 (OR 2.44; 95% CI 1.76-3.38) but not with an increased risk of hospitalization for AMI.

Opportunities for Improvement

Because of the wide variety of variables associated with clopidogrel nonadherence, the authors state, “Overall, these findings suggest that expanded prescription coverage through the Medicare Part D benefit is not, by itself, sufficient to address barriers in effectively delivering clopidogrel to those who need it after PCI.”

Addressing each nonadherent patient group, the authors offer recommendations to both hospitals and physicians to better identify at-risk patients. First, as patients with dementia or depression were at the highest risk for not filling prescriptions, the authors say, “Cognitive function among older patients appears inversely related to ability to manage medications, which may explain why depression was also significantly associated with failure to fill a prescription.”

Dr. Roth told TCTMD in a telephone interview that many hospitals are beginning to employ a phone call system to follow-up with patients post-discharge.

“I think there are a lot of opportunities that need to be looked at around discharge planning within the hospital and then also systems to provide follow-up care,” he said. “Trying to measure how well quality improvement interventions like [phone calls] are implemented is a future opportunity with these kinds of data.”

To combat this “huge problem” of prescription nonadherence, Deepak L. Bhatt, MD, MPH, of Brigham and Women’s Hospital (Boston, MA), told TCTMD in a telephone interview that some hospitals, especially those within an integrated healthcare system, have implemented programs where the patient leaves the hospital with their medication, thereby bypassing the entire step of having to visit the pharmacy themselves. He also suggested utilizing the evolving electronic medical record system to alert physicians as to when patients are filling or not filling prescriptions.

Although the authors reported being somewhat unsure as to why black patients were more apt to not fill their prescriptions, they noted the possibility that clopidogrel is underprescribed for this patient group.

“Racial differences in both prescribing practices and medication adherence after placement of a DES should remain a focus of investigation and quality improvement efforts,” they state.

Lastly, for patients with AMI, the authors suggest both inpatient care by a cardiologist and predischarge medication counseling to increase adherence.

A Common Problem

Ultimately, Dr. Roth suggested 2 take-away points from this study. First, it is “common not to fill clopidogrel prescriptions after getting a drug-eluting stent,” more common than many physicians might think, he added. Second, this patient population is heterogeneous and both physicians and hospitals need to pay careful attention to patients who are at highest risk for nonadherence.

“All doctors work very hard with their patients to make sure that they understand the medications that they’re taking and that they adhere to them,” Dr. Roth said. “But there are limits as to what you can do as an individual provider and I think what our paper really highlights are future opportunities for system-level improvements in promoting adherence to these really essential medications like clopidogrel.”

Dr. Bhatt alluded to the larger problem of not merely ensuring that patients are filling their prescriptions, but also taking their medications correctly.

“If the issue is that the patient has some degree of dementia and that’s contributing to them not filling their prescription, the honest extrapolation would be that it’s probably also contributing to them not taking the medicine as well, or to taking it inappropriately,” he said, adding that this and other risk factors found in the paper are not modifiable.

Ultimately, it comes down to physicians being more alert to these issues, potentially calling on increased social support, if available, Dr. Bhatt concluded.

“Perhaps, as clinicians, we can be more aware if a patient has one of those predictors, such as dementia, to be especially sure that the prescription gets filled,” he said. “There’s no easy solution to this problem, and it’s a big problem. As a health care system, it would be very cost-effective to get patients who are prescribed medications, particularly patients who are at a high risk for complications, to further enhance their adherence. Then I think we would see large risk reductions.”

Study Details

Mean cohort age was 74.5 years, 50.3% were women, and 6.9% were black. Only a minority (26.1%) of DES placements occurred during an admission with a primary diagnosis of AMI. Comorbidities were common, with diabetes, chronic pulmonary disease, and congestive heart failure diagnosed in 30.4%, 13.2%, and 16.9% of individuals, respectively.

 

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Source:
Roth GA, Morden NE, Zhou WZ, et al. Clopidogrel use and early outcomes among older patients receiving a drug-eluting coronary artery stent. Circ Cardiovasc Qual Outcomes. 2011;Epub ahead of print.

 

 

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