Kamil F Faridi1, Eric D Peterson2, Lisa A McCoy2, Laine Thomas2, Jonathan Enriquez3, Tracy Y Wang2. 1. Department of Internal Medicine, Johns Hopkins Hospital, Baltimore, Maryland. 2. Duke Clinical Research Institute, Duke University Hospital, Durham, North Carolina. 3. Division of Cardiology, Department of Medicine, University of Missouri-Kansas City.
Abstract
IMPORTANCE: The use of evidence-based medication therapy in patients after acute myocardial infarction (AMI) improves long-term prognosis, yet the current rates of adherence are poor. OBJECTIVE: To determine whether earlier outpatient follow-up after AMI is associated with higher rates of medication adherence. DESIGN, SETTING, AND PARTICIPANTS: A retrospective analysis was conducted of 20 976 Medicare patients older than 65 years discharged alive after an AMI between January 2, 2007, and October 1, 2010, from 461 Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines hospitals in the United States. Patients were grouped based on the timing of first follow-up clinic visit within 1 week, 1 to 2 weeks, 2 to 6 weeks, or more than 6 weeks after hospital discharge. Data analysis was conducted from September 26, 2014, to April 22, 2015. MAIN OUTCOMES AND MEASURES: Medication adherence was defined as the proportion of days with more than 80% coverage using Medicare Part D prescription fill records and was examined at 90 days and 1 year after discharge for β-blockers, platelet P2Y12 receptor inhibitors, statins, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. RESULTS: Among 20 976 Medicare-insured patients discharged alive after acute MI, 10 381 (49.5%) were men; mean (SD) age was 75.8 (7.5) years. The median time to the first outpatient follow-up visit after hospital discharge was 14 days (interquartile range, 7-28 days). Overall, the first follow-up clinic visit occurred 1 week or less after discharge in 5542 (26.4%) patients, 1 to 2 weeks in 5246 (25.0%), 2 to 6 weeks in 6830 (32.6%), and more than 6 weeks in 3358 (16.0%) individuals. Rates of medication adherence for secondary prevention therapies ranged from 63.4% to 68.7% at 90 days and 54.4% to 63.5% at 1 year. Compared with patients with follow-up visits within 1 week, those with follow-up in 1 to 2 weeks and 2 to 6 weeks had no significant difference in medication adherence; however, patients with follow-up more than 6 weeks after discharge had lower adherence at both 90 days (56.8%-61.3% vs 64.7%-69.3%; P < .001) and 1 year (49.5%-57.7% vs 55.4%-64.1%; P < .001). Patients with delayed follow-up more than 6 weeks were more likely to reside in communities with lower household incomes and educational levels (both P < .001); however, their clinical characteristics were similar to those of patients with earlier follow-up. After adjusting for these differences, delayed follow-up of more than 6 weeks remained associated with lower medication adherence at 90 days (odds ratio [OR], 0.74 [95% CI, 0.70-0.78]) and 1 year (OR, 0.79 [95% CI, 0.73-0.85]) compared with follow-up of 6 weeks or less. CONCLUSIONS AND RELEVANCE: Delayed outpatient follow-up beyond the first 6 weeks after AMI is associated with worse short-term and long-term patient medication adherence. These data support the concept that medication adherence is modifiable via improved care transitions.
IMPORTANCE: The use of evidence-based medication therapy in patients after acute myocardial infarction (AMI) improves long-term prognosis, yet the current rates of adherence are poor. OBJECTIVE: To determine whether earlier outpatient follow-up after AMI is associated with higher rates of medication adherence. DESIGN, SETTING, AND PARTICIPANTS: A retrospective analysis was conducted of 20 976 Medicare patients older than 65 years discharged alive after an AMI between January 2, 2007, and October 1, 2010, from 461 Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines hospitals in the United States. Patients were grouped based on the timing of first follow-up clinic visit within 1 week, 1 to 2 weeks, 2 to 6 weeks, or more than 6 weeks after hospital discharge. Data analysis was conducted from September 26, 2014, to April 22, 2015. MAIN OUTCOMES AND MEASURES: Medication adherence was defined as the proportion of days with more than 80% coverage using Medicare Part D prescription fill records and was examined at 90 days and 1 year after discharge for β-blockers, platelet P2Y12 receptor inhibitors, statins, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. RESULTS: Among 20 976 Medicare-insured patients discharged alive after acute MI, 10 381 (49.5%) were men; mean (SD) age was 75.8 (7.5) years. The median time to the first outpatient follow-up visit after hospital discharge was 14 days (interquartile range, 7-28 days). Overall, the first follow-up clinic visit occurred 1 week or less after discharge in 5542 (26.4%) patients, 1 to 2 weeks in 5246 (25.0%), 2 to 6 weeks in 6830 (32.6%), and more than 6 weeks in 3358 (16.0%) individuals. Rates of medication adherence for secondary prevention therapies ranged from 63.4% to 68.7% at 90 days and 54.4% to 63.5% at 1 year. Compared with patients with follow-up visits within 1 week, those with follow-up in 1 to 2 weeks and 2 to 6 weeks had no significant difference in medication adherence; however, patients with follow-up more than 6 weeks after discharge had lower adherence at both 90 days (56.8%-61.3% vs 64.7%-69.3%; P < .001) and 1 year (49.5%-57.7% vs 55.4%-64.1%; P < .001). Patients with delayed follow-up more than 6 weeks were more likely to reside in communities with lower household incomes and educational levels (both P < .001); however, their clinical characteristics were similar to those of patients with earlier follow-up. After adjusting for these differences, delayed follow-up of more than 6 weeks remained associated with lower medication adherence at 90 days (odds ratio [OR], 0.74 [95% CI, 0.70-0.78]) and 1 year (OR, 0.79 [95% CI, 0.73-0.85]) compared with follow-up of 6 weeks or less. CONCLUSIONS AND RELEVANCE: Delayed outpatient follow-up beyond the first 6 weeks after AMI is associated with worse short-term and long-term patient medication adherence. These data support the concept that medication adherence is modifiable via improved care transitions.
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