scholarly journals Chronic polytherapy after myocardial infarction: the trade-off between hospital and community-based providers in determining adherence to medication

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Mirko Di Martino ◽  
Michela Alagna ◽  
Adele Lallo ◽  
Kendall Jamieson Gilmore ◽  
Paolo Francesconi ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Medication Adherence ◽  
Geographic Variation ◽  
Best Practice ◽  
Multilevel Models ◽  
Medication Possession Ratio ◽  
Coronary Intervention ◽  
Community Based ◽  
Optimal Care ◽  
Adherence To Medication

Abstract Background The benefits of chronic polytherapy in reducing readmissions and death after myocardial infarction (MI) have been clearly shown. However, real-world evidence shows poor medication adherence and large geographic variation, suggesting critical issues in access to optimal care. Our objectives were to measure adherence to polytherapy, to compare the amount of variation attributable to hospitals of discharge and to community-based providers, and to identify determinants of adherence to medications. Methods This is a population-based study. Data were obtained from the information systems of the Lazio and Tuscany Regions, Italy (9.5 million inhabitants). Patients hospitalized with incident MI in 2010–2014 were analyzed. The outcome measure was medication adherence, defined as a Medication Possession Ratio (MPR) ≥ 0.75 for at least 3 of the following drugs: antiplatelets, β-blockers, ACEI/ARBs, statins. A 2-year cohort-study was performed. Cross-classified multilevel models were applied to analyze geographic variation. The variance components attributable to hospitals of discharge and community-based providers were expressed as Median Odds Ratio (MOR). Results A total of 32,962 patients were enrolled. About 63% of patients in the Lazio cohort and 59% of the Tuscan cohort were adherent to chronic polytherapy. Women and patients aged 85 years and over were most at risk of non-adherence. In both regions, adherence was higher for patients discharged from cardiology wards (Lazio: OR = 1.58, p < 0.001, Tuscany: OR = 1.59, p < 0.001) and for patients with a percutaneous coronary intervention during the index admission. Relevant variation between community-based providers was observed, though when the hospital of discharge was included as a cross-classified level, in both Lazio and Tuscany regions the variation attributable to hospitals of discharge was the only significant component (Lazio: MOR = 1.30, p = 0.001; Tuscany: MOR = 1.31, p = 0.001). Conclusion Adherence to best practice treatments after MI is not consistent with clinical guidelines, and varies between patient groups as well as within and between regions. The variation attributable to providers is affected by the hospital of discharge, up to two years from the acute episode. This variation is likely to be attributable to hospital discharge processes, and could be reduced through appropriate policy levers.

scholarly journals Difference in Medication Adherence Between Patients Prescribed a 30‐Day Versus 90‐Day Supply After Acute Myocardial Infarction

2021 ◽  
Vol 10 (1) ◽  
Author(s):  
Jennifer A. Rymer ◽  
Eileen Fonseca ◽  
Durgesh D. Bhandary ◽  
Deepa Kumar ◽  
Naeem D. Khan ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Medication Adherence ◽  
Angiotensin Converting Enzyme ◽  
Enzyme Inhibitors ◽  
Angiotensin Receptor Blockers ◽  
Coronary Intervention ◽  
Angiotensin Converting Enzyme Inhibitors ◽  
Evidence Based ◽  
Converting Enzyme ◽  
Converting Enzyme Inhibitors

Background Evidence‐based medication adherence rates after a myocardial infarction are low. We hypothesized that 90‐day prescriptions are underused and may lead to higher evidence‐based medication adherence compared with 30‐day fills. Methods and Results We examined patients with myocardial infarction treated with percutaneous coronary intervention between 2011 and 2015 in the National Cardiovascular Data Registry. Linking to Symphony Health pharmacy data, we described the prevalence of patients filling 30‐day versus 90‐day prescriptions of statins, β‐blockers, angiotensin‐converting enzyme inhibitors/angiotensin receptor blockers, and P2Y 12 inhibitors after discharge. We compared 12‐month medication adherence rates by evidence‐based medication class and prescription days' supply and rates of medication switches and dosing changes. Among 353 259 patients with myocardial infarction treated with percutaneous coronary intervention, 90‐day evidence‐based medication fill rates were low: 13.0% (statins), 12.3% (β‐blockers), 14.6% (angiotensin‐converting enzyme inhibitors/angiotensin receptor blockers), and 9.7% (P2Y 12 inhibitors). Patients filling 90‐day prescriptions were more likely older (median 69 versus 62 years) with a history of prior myocardial infarction (25.0% versus 17.9%) or percutaneous coronary intervention (30.3% versus 19.5%; P <0.01 for all) than patients filling 30‐day prescriptions. The 12‐month adherence rates were higher for patients who filled 90‐day versus 30‐day supplies: statins, 83.1% versus 75.3%; β‐blockers, 72.7% versus 62.9%; angiotensin‐converting enzyme inhibitors/angiotensin receptor blockers, 71.1% versus 60.9%; and P2Y 12 inhibitors, 78.5% versus 66.6% ( P <0.01 for all). Medication switches and dosing changes within 12 months were infrequent for patients filling 30‐day prescriptions—14.7% and 0.3% for 30‐day P2Y 12 inhibitor fills versus 6.3% and 0.2% for 90‐day fills, respectively. Conclusions Patients who filled 90‐day prescriptions had higher adherence and infrequent medication changes within 1 year after discharge. Ninety‐day prescription strategies should be encouraged to improve post–myocardial infarction medication adherence.

Abstract 20678: A Systematic Review of World-Wide Characteristics and Management of Patients With ST-Segment Elevation Myocardial Infarction

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Yang Zhan ◽  
Thao Huynh
Keyword(s):  
Myocardial Infarction ◽  
Beta Blockers ◽  
Coronary Intervention ◽  
Optimal Care ◽  
St Segment Elevation ◽  
P2y12 Inhibitors ◽  
Variation In Care ◽  
St Segment ◽  
Remedial Actions ◽  
Door To Balloon

Background: Management of ST elevation myocardial infarction (STEMI) has made tremendous progresses during the last decades. However, it remains uncertain whether all STEMI patients are receiving optimal care and whether variation in care has any impact on their outcomes. We aim to characterize the contemporary global characteristics, managements, and outcomes of STEMI patients. Methods and Results: We searched EMBASE/MedLINE Ovid for observational data of patients with STEMI. We identified 17 studies enrolling 112 772 patients in 20 countries during the last 5 years (2008-2013). The median age ranged from 54 to 66 years with 13%-33% females. Twelve percent to 39% of patients presented in Killip heart failure class 2-4. In-hospital use of aspirin (ASA), P2Y12 inhibitor/thienopyridines, and systemic anticoagulation was 90-99%, 77-97%, and 61-100% respectively. Reperfusion was provided for 63%-97% of patients. Fibrinolysis was used in 0.7%-66% with a door-to-needle (D2N) time of 28-65 minutes; 12%-74% with D2N <30minutes. Primary percutaneous coronary intervention was performed for 17%-97% with a door-to-balloon (D2B) time of 40-125 minutes; 40%-94% had D2B <90 minutes. Emergency cardiac surgery was performed in 0.4%-8% of patients. Discharge prescriptions included ASA, thienopyridines/P2Y12 inhibitors, beta-blockers, and statins in 85%-99%, 77%-97%, 54%-83%, and 64%-95% respectively. In-hospital outcomes included death (2%-10%), recurrent myocardial infarction (0.4%-5%), stroke (0.2%-1.6%), major bleeding (0.3%-7%). The median hospital stay ranged from 4-6 days. Conclusion: Despite recent progresses in STEMI care, there remains marked heterogeneity in STEMI care and outcomes worldwide that warrants further attention. Identification of gaps to STEMI care and remedial actions may improve the global outcomes of STEMI patients.

scholarly journals Community-Based Physical Rehabilitation After Percutaneous Coronary Intervention for Acute Myocardial Infarction

2021 ◽  
Vol 48 (2) ◽  
Author(s):  
Meiling Xiao ◽  
Yinjun Li ◽  
Xiaodan Guan
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Percutaneous Coronary Intervention ◽  
Coronary Intervention ◽  
Left Ventricular ◽  
Physical Rehabilitation ◽  
Left Ventricular Ejection ◽  
Community Based ◽  
Ventricular Ejection Fraction ◽  
Percutaneous Coronary

To determine whether a community-based physical rehabilitation program could improve the prognosis of patients who had undergone percutaneous coronary intervention after acute myocardial infarction, we randomly divided 164 consecutive patients into 2 groups of 82 patients. Patients in the rehabilitation group underwent 3 months of supervised exercise training, then 9 months of community-based, self-managed exercise; patients in the control group received conventional treatment. The primary endpoint was major adverse cardiac events (MACE) during the follow-up period (25 ± 15.4 mo); secondary endpoints included left ventricular ejection fraction, 6-minute walk distance, and laboratory values at 12-month follow-up. During the study period, the incidence of MACE was significantly lower in the rehabilitation group (13.4% vs 24.4%; P &lt;0.01). Cox proportional hazards regression analysis indicated a significantly lower risk of MACE in the rehabilitation group (hazard ratio=0.56; 95% CI, 0.37–0.82; P=0.01). At 12 months, left ventricular ejection fraction and 6-minute walk distance in the rehabilitation group were significantly greater than those in the control group (both P &lt;0.01), and laboratory values also improved. These findings suggest that community-based physical rehabilitation significantly reduced MACE risk and improved cardiac function and physical stamina in patients who underwent percutaneous coronary intervention after acute myocardial infarction.

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