Coronary artery disease
Predictors of Early Discontinuation of Evidence-Based Medicine After Acute Coronary Syndrome

https://doi.org/10.1016/j.amjcard.2009.03.013Get rights and content

Use of evidence-based medicine (EBM) improves outcomes after acute coronary syndromes (ACS), yet patients often discontinue prescribed therapies after discharge. Although such discontinuation is well documented, patients' reasons for medication discontinuation have not been reported. MAINTAIN is a longitudinal follow-up registry of CRUSADE/ACTION, which enrolled patients during an ACS hospitalization from January 2006 to September 2007. All discharge medications were obtained from hospital charts. Patients were interviewed by telephone 3 months after discharge to determine if EBM classes prescribed at discharge were continued (aspirin, clopidogrel, β blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and lipid-lowering medications). If discontinuation occurred, patients were asked if it was with provider knowledge/input or not (self-discontinuation). A multivariable logistic regression model was performed to identify factors associated with self-discontinuation of prescribed EBM. Of the 1,077 patients interviewed, 1,006 (93.4%) were discharged on aspirin, 816 (75.8%) on clopidogrel, 982 (91.2%) on β blockers, 745 (69.2%) on angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and 968 (89.9%) on lipid-lowering medications. At 3-month follow-up, 304 patients (28.2%) had discontinued ≥1 of these prescribed EBM classes. Although many reported provider involvement, most discontinuation (61.5%) was self-determined. Factors independently associated with self-discontinuation were no pharmacy coinsurance, increasing number of medications, not using reminder tools (e.g., pillbox), lower education, and dialysis. In conclusion, 1/3 of patients with ACS discontinue ≥1 of their prescribed EBMs within 3 months of hospital discharge, and most of this discontinuation is without provider involvement. Patient education, better prescription drug coverage, and reminder strategies may improve use of EBMs at 3 months after discharge from ACS admission.

Section snippets

Methods

MAINTAIN is a longitudinal follow-up study that enrolled high-risk patients with non–ST-segment elevation ACS from United States hospitals included in the CRUSADE quality improvement initiative or ACTION registry from January 2006 to September 2007. The CRUSADE QI initiative, started in November 2001, transitioned to the ACTION registry in January 2007. The ACTION registry is the combination of CRUSADE and the National Registry for Myocardial Infarction (http://www.ncdr.com). Inclusion criteria

Results

Of the 1,077 patients, 1,006 (93.4%) were discharged on aspirin, 816 (75.8%) on clopidogrel, 982 (91.2%) on β blocker, 745 (69.2%) on ACEI/ARB (663, 61.6%, on ACEI and 86, 8.0%, on ARB), and 968 (89.9%) on lipid-lowering medication (942, 87.5%, on statin and 188, 17.5%, on nonstatin). Figure 2 displays—for each class of EBM drug—the proportion of patients who were prescribed that class of drug at discharge and the proportion of those who were still taking or started (new prescription) that

Discussion

Three months after hospital discharge, 28% of patients with ACS had discontinued ≥1 of their prescribed EBM. Although some (38%) discontinued EBM with the advice and input of their providers, most (62%) self-discontinued. Self-discontinuation was associated with lack of prescription drug coverage, a larger number of medications prescribed at discharge, and no medication-reminder tools. In addition, patients on dialysis or with peripheral arterial disease were more likely to self-discontinue

Acknowledgment

We acknowledge Tina Harding and Khaula Baloch for their dedicated efforts to the leadership and co-ordination of the MAINTAIN initiative and the interviewing team (Nancy Clapp-Channing, Andrea Davis, Tatiana Metelova) and the data management team (Marian Jones-Richmond, Bob Sanderford, Allyson Drew, Laura Drew, Abigail Patterson, Jeannie Sands) for their tremendous work. We also express our gratitude and appreciation to the physicians and nurses participating in MAINTAIN.

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    MAINTAIN is funded by Bristol-Myers Squibb/Sanofi-Aventis Pharmaceuticals partnership and by Merck Schering-Plough Pharmaceutical.

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