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Hospital Variation in Adherence Rates to Secondary Prevention Medications and the Implications on Quality.

ABSTRACT: BACKGROUND:Medication adherence is important to improve the long-term outcomes after acute myocardial infarction (MI). We hypothesized that there is significant variation among US hospitals in terms of medication adherence after MI, and that patients treated at hospitals with higher medication adherence after MI will have better long-term cardiovascular outcomes. METHODS:We identified 19?704 Medicare patients discharged after acute MI from 347 US hospitals participating in the ACTION Registry-GWTG (Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines) from January 2, 2007, to October 1, 2010. Using linked Medicare Part D prescription filling data, medication adherence was defined as proportion of days covered >80% within 90 days after discharge. Cox proportional hazards modeling was used to compare 2-year major adverse cardiovascular events among hospitals with high, moderate, and low 90-day medication adherence. RESULTS:By 90 days after MI, overall rates of adherence to medications prescribed at discharge were 68% for ?-blockers, 63% for statins, 64% for angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and 72% for thienopyridines. Adherence to these medications up to 90 days varied significantly among hospitals: ?-blockers (proportion of days covered >80%; 59% to 75%), statins (55% to 69%), thienopyridines (64% to 77%), and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (57% to 69%). Compared with hospitals in the lowest quartile of 90-day composite medication adherence, hospitals with the highest adherence had lower unadjusted and adjusted 2-year major adverse cardiovascular event risk (27.5% versus 35.3%; adjusted hazard ratio, 0.88; 95% confidence interval, 0.80-0.96). High-adherence hospitals also had lower adjusted rates of death or readmission (hazard ratio, 0.90; 95% confidence interval, 0.85-0.96), whereas there was no difference in mortality after adjustment. CONCLUSIONS:Use of secondary prevention medications after discharge varies significantly among US hospitals and is inversely associated with 2-year outcomes. Hospitals may improve medication adherence after discharge and patient outcomes through better coordination of care between inpatient and outpatient settings.

SUBMITTER: Mathews R

PROVIDER: S-EPMC5953793 | biostudies-literature | 2018 May

REPOSITORIES: biostudies-literature

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Hospital Variation in Adherence Rates to Secondary Prevention Medications and the Implications on Quality.

Mathews Robin R Wang William W Kaltenbach Lisa A LA Thomas Laine L Shah Rashmee U RU Ali Murtuza M Peterson Eric D ED Wang Tracy Y TY

Circulation 20180131 20

<h4>Background</h4>Medication adherence is important to improve the long-term outcomes after acute myocardial infarction (MI). We hypothesized that there is significant variation among US hospitals in terms of medication adherence after MI, and that patients treated at hospitals with higher medication adherence after MI will have better long-term cardiovascular outcomes.<h4>Methods</h4>We identified 19 704 Medicare patients discharged after acute MI from 347 US hospitals participating in the ACT ...[more]

PMID: 29386204

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Project description:BackgroundAtherosclerotic cardiovascular disease (ASCVD) is the leading cause of mortality worldwide, with a prevalence of approximately 100 million patients. There is evidence that antiplatelet agents and antihypertensive medications could reduce the risk of new vascular events in this population; however, treatment adherence is very low. An SMS text messaging intervention was recently developed based on behavior change techniques to increase adherence to pharmacological treatment among patients with a history of ASCVD.ObjectiveThis study aims to evaluate the efficacy and safety of an SMS text messaging intervention to improve adherence to cardiovascular medications in patients with ASCVD.MethodsA randomized controlled clinical trial for patients with a prior diagnosis of cardiovascular events, such as acute myocardial infarction, unstable angina, cerebrovascular disease, or peripheral artery disease, in one center in Colombia was conducted. Patients randomized to the intervention arm were assigned to receive SMS text messages daily for the first 4 weeks, 5 SMS text messages on week 5, 3 SMS text messages each in weeks 6 and 7, and 1 SMS text message weekly from week 8 until week 52. In contrast, patients in the control arm received a monthly SMS text message reminding them of the next study appointment and the importance of the study, requesting information about changes in their phone number, and thanking them for participating in the study. The primary endpoint was the change in low-density lipoprotein cholesterol (LDL-C) levels, whereas the secondary endpoints were the changes in thromboxane B2 levels, heart rate, systolic and diastolic blood pressure, medication adherence, cardiac and noncardiac mortality, and hospitalization. Linear regression analyses and bivariate tests were performed.ResultsOf the 930 randomized patients, 805 (86.5%) completed follow-up and were analyzed for the primary endpoint. There was no evidence that the intervention changed the primary outcome (LDL-C levels; P=.41) or any of the secondary outcomes evaluated (all P>.05). There was also no evidence that the intervention was associated with adverse events.ConclusionsIn this study, there was no evidence that a behavior modification intervention delivered by SMS text messaging improved LDL-C levels, blood pressure levels, or adherence at 12 months. More research is needed to evaluate whether different SMS text messaging strategies, including personalized messages and different timings, are effective; future studies should include mixed methods to better understand why, for whom, and in which context (eg, health system or social environment) SMS text messaging interventions work (or not) to improve adherence in patients with ASCVD.Trial registrationClinicalTrials.gov NCT03098186; https://clinicaltrials.gov/ct2/show/NCT03098186.International registered report identifier (irrid)RR2-10.1136/bmjopen-2018-028017.

Project description:ObjectiveTo identify barriers and facilitators of medication adherence in patients with stroke along with their caregivers.DesignQualitative thematic analysis of posts about secondary prevention medications, informed by Perceptions and Practicalities Approach.SettingPosts written by the UK stroke survivors and their family members taking part in the online forum of the Stroke Association, between 2004 and 2011.Participants84 participants: 49 stroke survivors, 33 caregivers, 2 not stated, identified using the keywords 'taking medication', 'pills', 'size', 'side-effects', 'routine', 'blister' as well as secondary prevention medication terms.ResultsPerceptions reducing the motivation to adhere included dealing with medication side effects, questioning doctors' prescribing practices and negative publicity about medications, especially in regard to statins. Caregivers faced difficulties with ensuring medications were taken while respecting the patient's decisions not to take tablets. They struggled in their role as advocates of patient's needs with healthcare professionals. Not experiencing side effects, attributing importance to medications, positive personal experiences of taking tablets and obtaining modification of treatment to manage side effects were facilitators of adherence. Key practical barriers included difficulties with swallowing tablets, dealing with the burden of treatment and drug cost. Using medication storage devices, following routines and getting help with medications from caregivers were important facilitators of adherence.ConclusionsAn online stroke forum is a novel and valuable resource to investigate use of secondary prevention medications. Analysis of this forum highlighted significant barriers and facilitators of medication adherence faced by stroke survivors and their caregivers. Addressing perceptual and practical barriers highlighted here can inform the development of future interventions aimed at improving adherence to secondary prevention medication after stroke.

Project description:IntroductionAnti-platelet therapy, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, beta-blockers and statins are cost-effective in patients with atherosclerotic cardiovascular diseases (ASCVD) for reducing the risk of ASCVD events. Unfortunately, there is abundant evidence that adherence to these cardiovascular medications is far from ideal. A recent Cochrane review showed a potential beneficial effect of Short Message Service (SMS) interventions on adherence to medication in ASCVD patients.Methods and analysisThe txt2heart study is a pragmatic randomised single-blind controlled trial. The objective is to evaluate the efficacy and safety of an intervention with SMS messages delivered by mobile phones to improve adherence to cardiovascular medications in patients with ASCVD. The intervention consists of behavioural techniques delivered via SMS. The primary outcome is change in blood serum low-density lipoprotein cholesterol levels as an indicator of adherence to statins. Secondary outcomes will include systolic blood pressure as an indicator of adherence to blood-lowering therapies and heart rate as an indicator of adherence to beta-blockers, urine levels of 11-dehydrothromboxane B2, self-reported adherence to cardiovascular medications and rates of cardiovascular death or hospitalisation due to cardiovascular disease.Ethics and disseminationThe study will be performed in compliance with the protocol, regulatory requirements, Good Clinical Practice and ethical principles of the Declaration of Helsinki. The Ethics Committee of Fundación Cardiovascular de Colombia evaluated and approved the trial. The txt2heart Colombia trial aims to provide robust evidence to evaluate whether SMS messages delivered through mobile telephones change the behaviour of Colombian patients who have suffered a cardiovascular event. Trial results will be presented to the local health authorities, and if the intervention is effective and safe, we hope this strategy will be implemented quickly because of its low cost and wide-reaching impact on the population.Trial registration numberNCT03098186.

Project description:Background contextRepeat lumbar spine surgery is generally an undesirable outcome. Variation in repeat surgery rates may be because of patient characteristics, disease severity, or hospital- and surgeon-related factors. However, little is known about population-level variation in reoperation rates.PurposeTo examine hospital- and surgeon-level variation in reoperation rates after lumbar herniated disc surgery and to relate these to published benchmarks.Study design/settingRetrospective analysis of a discharge registry including all nonfederal hospitals in Washington State.MethodsWe identified adults who underwent an initial inpatient lumbar decompression for herniated disc from 1997 to 2007. We then performed generalized linear mixed-effect logistic regressions, controlling for patient characteristics and comorbidity, to examine the variation in reoperation rates within 90 days, 1 year, and 4 years.ResultsOur cohort included 29,529 patients with a mean age of 47.5 years, 61% privately insured, and 15% having any comorbidity. The age-, sex-, insurance-, and comorbidity-adjusted mean rate of reoperation among hospitals was 1.9% at 90 days (95% confidence interval [CI], 1.2-3.1), with a range from 1.1% to 3.4%; 6.4% at 1 year (95% CI, 3.9-10.6), with a range from 2.8% to 12.5%; and 13.8% at 4 years (95% CI, 8.8-19.8), with a range from 8.1% to 24.5%. The adjusted mean reoperation rates of surgeons were 1.9% at 90 days (95% CI, 1.4-2.4) with a range from 1.2% to 4.6%, 6.1% at 1 year (95% CI, 4.8-7.7) with a range from 4.3% to 10.5%, and 13.2% at 4 years (95% CI, 11.3-15.5) with a range from 10.0% to 19.3%. Multilevel random-effect models suggested that variation across surgeons was greater than that of hospitals and that this effect increased with long-term outcomes.ConclusionsEven after adjusting for patient demographics and comorbidity, we observed a large variation in reoperation rates across hospitals and surgeons after lumbar discectomy, a relatively simple spinal procedure. These findings suggest uncertainty about indications for repeat surgery, variations in perioperative care, or variations in quality of care.

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Hospital Variation in Adherence Rates to Secondary Prevention Medications and the Implications on Quality.

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Hospital Variation in Adherence Rates to Secondary Prevention Medications and the Implications on Quality.

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