Each year in the United States, about 1 million Americans are hospitalized for acute myocardial infarction (AMI), and nearly half of these individuals are expected to have a recurrent major adverse cardiovascular event. According to current guidelines, secondary prevention strategies for patients with AMI include treatment with aspirin, β-blockers, statins, platelet P2Y12 receptor inhibitors, and ACE inhibitors or angiotensin receptor blockers. These therapies have been shown to provide long-term survival benefits for those who have suffered an AMI, but studies indicate that adherence to prescribed drug regimens following an AMI is often low. This can result in higher risks for mortality and hospital readmission.

“Hospital readmissions following AMI are an important challenge in healthcare, and many of these individuals are readmitted early after they’re discharged,” says Tracy Y. Wang, MD, MHS, MSc. In recent years, greater attention has been paid to finding strategies that can increase the likelihood of earlier outpatient follow-up after AMI patients are hospitalized. Early follow-up may help prevent adverse events.

Studies indicate that up many AMI patients who are readmitted to the hospital have not had an outpatient physician visit prior to their readmission. “Early follow-up is now incorporated into provider payment models and national quality improvement guidelines,” Dr. Wang says, “but it’s unknown if the timing of outpatient follow-up of AMI patients is associated with better medication adherence.”

Taking a Closer Look

For a study published in JAMA Cardiology, Dr. Wang and colleagues conducted a retrospective analysis of more than 20,000 Medicare-aged patients who were discharged after an AMI to see if the timing of outpatient follow-up was associated with better medication adherence. Patients were grouped based on the timing of their first follow-up clinic visit within 1 week, 1 to 2 weeks, 2 to 6 weeks, or more than 6 weeks after being discharged from the hospital. Medication adherence was defined as the proportion of days with more than 80% coverage using Medicare Part D prescription fill records.

Results of the study showed that only 26% of patients had a first follow-up clinic visit within 1 week after being discharged with an AMI. “About one-quarter of patients in the study had their first follow-up visit in 1 to 2 weeks, and approximately one-third had it in 2 to 6 weeks,” says Dr. Wang. In addition, 16% had such a visit more than 6 weeks after their hospitalization. Rates of medication adherence for secondary prevention therapies ranged broadly when assessed at 90 days and 1 year (Figure below).

Wang figure

When compared with patients who had a follow-up visit within 1 week, those who had their visit in 1 to 2 weeks and 2 to 6 weeks had no significant differences in medication adherence. However, patients who had their first follow-up visit more than 6 weeks after being discharged had lower secondary prevention medication adherence rates. “Several factors were associated with delaying an initial follow-up visit by more than 6 weeks, including living in a community with lower household incomes and residing in areas where educational levels were lower,” Dr. Wang says.

The analysis also showed that patients who had later follow-up times were more likely to be transferred from another hospital than were patients who had earlier follow-up times. Lower adherence for patients with follow-up of more than 6 weeks after discharge was seen for all medication classes included in the study. Importantly, the investigation revealed that medication adherence could be modifiable by improving care transitions following hospital discharges for AMI. Specifically, patients who attended their first follow-up appointment within 6 weeks of discharge had better medication adherence.

Important Implications

Findings of the study are especially important in the context of efforts being made to improve the quality of care of patients with AMI, according to Dr. Wang. “Adherence to evidence-based therapies during index hospitalizations among patients with AMI has improved dramatically due to the development and implementation of performance measures and quality improvement programs,” she says. “However, adherence to secondary prevention treatments does not appear to have improved in tandem with primary prevention therapies. A greater focus on medication adherence is needed to improve patient outcomes.”

Scheduling follow-up within 6 weeks of hospital discharge, with a cardiologist or even a primary care physician, may help improve medication adherence, according to Dr. Wang. “We need to identify risk factors for patients delaying follow-up after their AMI and then develop interventions that can help these individuals improve adherence to medication regimens,” she says. Such strategies may include requiring patients to sign discharge contracts in which they acknowledge the need for follow-up visits with primary care physicians and cardiologists. “For patients living in lower socioeconomic areas, greater attention is needed to ensure timely follow-up care both before and after they are discharged from the hospital,” adds Dr. Wang.

References

Faridi KF, Peterson ED, McCoy LA, Thomas L, Enriquez J, Wang TY. Timing of first postdischarge follow-up and medication adherence after acute myocardial infarction. JAMA Cardiol. 2016;1:147-155. Available at: http://cardiology.jamanetwork.com/article.aspx?articleid=2505212.

Hess CN, Shah BR, Peng SA, Thomas L, RoeMT, Peterson ED. Association of early physician follow-up and 30-day readmission after non–ST-segment-elevation myocardial infarction among older patients. Circulation. 2013;128:1206-1213.

Daugherty SL, Ho PM, Spertus JA, et al. Association of early follow-up after acute myocardial infarction with higher rates of medication use. Arch Intern Med. 2008;168:485-491.