Physician's Weekly Article - Enhancing Post-Discharge Contact After AMI

       Published studies have demonstrated that patients who suffer an acute myocardial infarction have poor adherence to medications after discharge, but efforts to improve post-discharge communication may enhance outcomes.

      There has been increasing recognition that broad adoption of established strategies may further reduce mortality rates in acute myocardial infarction (AMI). Many large-scale studies have been designed to improve rates of prescriptions for proven medications, and some of these efforts have achieved success. “Quality-of-care efforts are continuing to evolve,” explains Edward P. Havranek, MD. “These efforts are starting to focus more heavily on ensuring that AMI patients actually take medications that have been proven to reduce mortality once they have been prescribed.”

      Early outpatient follow-up of AMI patients after hospital discharge is recommended in published guidelines, and several evidence-based therapies—most notably ß-blockers and statins—are critical to improving long-term mortality rates. However, many AMI patients fail to adhere to these therapies, says Dr. Havranek. “Several years ago, only about two-thirds of patients who should have been receiving ß-blockers and/or statins to reduce their mortality risk were actually prescribed them. Since then, prescription rates for these medications are up considerably. That said, it’s estimated that between one-half and two-thirds of patients with this asymptomatic, chronic illness will stop taking these medications shortly after discharge. This is why efforts are needed to ensure that patients continue medication use and increase their chances for survival.”

      New Studies Assess Adherence to AMI Therapies

      The March 10, 2008 Archives of Internal Medicine featured two studies that assessed the care of AMI patients after discharge. The first, conducted by Stacie L. Daugherty, MD, MSPH, and colleagues, demonstrated that many AMI patients who were discharged from the hospital struggled to adhere to post-treatment drug regimens. “Patients who didn’t visit their primary care physician (PCP) within a month of their event were less likely to adhere to their prescribed AMI drug regimens when evaluated 6 months later than those who did meet their PCP within 30 days of the event,” Dr. Havranek says (Table 1). “This study demonstrates that proper transitions from hospitals to outpatient settings are crucial to sustaining long-term management. If the handoff from the hospital specialist to the PCP isn’t accomplished, there are long-term consequences to consider.”

      A second study from the March 10, 2008 Archives of Internal Medicine by David H. Smith, RPh, PhD, and colleagues assessed the impact of using a simple direct-to-patient intervention for AMI patients post-discharge. The intervention consisted of two mailings that were done 2 months apart from each other in which letters to patients described the importance of ß-blocker use. “In this study, the authors took the problem of poor adherence head on,” says Dr. Havranek. “They asked their patients how they could best craft messages that will help them adhere to their medications. It seems simple to ask patients what works best for them, but these efforts are important and sometimes forgotten. Addressing patients’ needs and concerns are critical aspects to decreasing AMI-related mortality.”

      Findings from Smith et al showed that AMI patients receiving the intervention of two mailed letters after hospital discharge had an average absolute increase of 4.3% of days covered with prescription drug therapy (in this case, ß-blockers) per month when compared with the control group (Table 2). “Although this was a modest effect,” Dr. Havranek notes, “these findings are important because medications like ß-blockers have been shown to reduce mortality by 20% to 30% after an AMI.”

      Continued Efforts Are Warranted

      Dr. Havranek notes that the intervention used in the study by Smith et al was simple and reproducible. “Other institutions—hospitals and primary care settings alike—throughout the country can adopt this intervention with little resistance. In fact, hospitals can go even further by developing programs in which patients are called 1 to 2 weeks after discharge. They can be asked if there are any questions or problems concerning their medications. Such programs could go miles toward reducing the problem of adherence drop offs shortly after hospital discharge.”

      The healthcare system continues to place a huge burden on primary care to treat AMI patients after discharge. Dr. Havranek says it is important to share adherence enhancement tools broadly so they can be more widely adopted. “Hospitals should try to partner with PCPs and pool their resources to develop programs aimed at increasing post-discharge adherence rates. When messages to patients come from their PCPs, they may be more likely to listen to them. Hospitals may need to get ‘buy in’ from PCPs to have their names on letters to patients and to get PCPs involved with such programs. The hope is this will lead to a more seamless transition of care that will ultimately improve long-term AMI mortality rates.”

      Edward P. Havranek, MD, has indicated to Physician’s Weekly that within the past 10 years (but not the last 2 years) he has worked as a consultant for Bristol-Myers Squibb and CV Therapeutics, as a paid speaker for Bristol-Myers Squibb, Merck, and Takeda, and has received grants/research aid from Bristol-Myers Squibb, Merck, and AstraZeneca.