Changes in Adherence to Evidence-Based Medications in the First Year After Initial Hospitalization for Heart Failure

Abstract

Background-The use of evidence-based medications in patients with heart failure has increased over the past 10 years.We aimed to determine whether adherence to these medications has also increased during this time. Methods and Results-A retrospective cohort was created using administrative databases from the province of Saskatchewan, Canada. Subjects discharged alive from their first hospitalization for heart failure between 1994 and 2003 were eligible. Those filling a prescription for a ␤-blocker (BB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB) within 6 months of discharge were followed for 1 year after the initial prescription. Of 8805 eligible patients, 67% of BB users (941/1414) and 74% of ACEI/ARB users (4441/5991) exhibited optimal adherence at 1 year (defined as Ն80% adherence calculated from pharmacy refill records). When grouped by year of initial heart failure hospitalization, the proportion of optimally adherent patients improved from 54% to 75% with BB and from 67% to 80% with ACEI/ARBs between 1994/1995 and 2002/2003 (P for trend Ͻ0.001 for both). Mean 1-year adherence improved from 71% to 83% for BB and 80% to 88% for ACEI/ARBs. After adjustment using multivariable logistic regression, subjects discharged in 2003 were significantly more likely to exhibit optimal adherence to a BB (odds ratio, 2.04; 95% CI, 1.21 to 3.44) or an ACEI/ARB (odds ratio, 1.65; 95% CI, 1.30 to 2.08) than those prescribed therapy in 1994/1995. Conclusions-One-year adherence to BB and ACEI/ARB is improving over time in patients discharged after first heart failure hospitalization. Patients taking multiple cardiac medications were not any less likely to exhibit optimal adherence than patients taking only 1 medication. (Circ Cardiovasc Qual Outcomes. 2009;2:228-235.)

The Pharmacist Role in Predicting and Improving Medication Adherence in Heart Failure Patients

“…6,23 Smaller cohort studies in U.S. patients had similar findings regarding race, where minority or nonwhite race were significant predictors for nonadherence. 8,21 Other interesting findings from large cohort studies with follow-up ranging from 1 to 5 years in the United States, 6,23,32 Canada, 29 and European countries 22,27 identified those with more severe HF, 27 a greater a reduction in quality of life. [8][9][10][11][12][13][14] Furthermore, the Candesartan in Heart Failure Assessment of Reduction in Mortality and Morbidity (CHARM) study demonstrated that increased adherence to HF medications was associated with a 35% reduction in mortality (hazard ratio [HR] = 0.65, 95% confidence interval [CI] = 0.57-0.75, P < 0.0001).…”

“…6,8,10,12,[21][22][23][24][25][26][27][28][29][30][31][32] Table 1 may assist the health care provider in recognizing predictors that may impact adherence to HF medications. Table 2 depicts a summary of the studies identifying predictors of decreased 6,8,10,[21][22][23][24][25][26]28,29,32 and increased 8,12,22,[26][27][28]30,31 HF medication adherence. Large, observational cohort studies extracting adherence and demographic data from health insurance claims databases or HF registries with 2 to 4 years of follow-up data from the United States found some similar significant predictors for nonadherence, including male gender or nonwhite race.…”

“…The review also included studies that did not measure medication adherence, but which measured mortality or hospital admission/readmission outcomes. number of concomitant illnesses, 22 living alone, 22 no health insurance, 6 higher medication copays, 32 or hospitalization within 6 months of their initial HF admission 29 as significant predictors for nonadherence to HF medications. Two smaller observational studies that followed patients for 3 to 6 months found that twice daily dosing of medication increased the likelihood of nonadherence to HF medications.…”

“…10,25 Some of these large cohort studies were in agreement that prior use of the same class of HF medication was a significant predictor for improved medication adherence. 23,27,29 Interestingly, 2 of these large cohort studies found that concomitant use of at least 3 cardiac medications was a significant predictor for medication adherence. 27,29 Smaller observational studies that measured medication adherence over a 6-to 9-month period with the ability to administer surveys to patients found that reading ability, 8 measured by a reading score assigned after patients complete a medication skills assessment survey, and health literacy, 30 measured by using the reading component of the Short Test of Functional Health Literacy in Adults, were positive predictors for adherence.…”

“…Wu et al (2012) conducted a series of studies in HF patients to determine factors affecting event-free survival, factors defined as ED visits for symptoms of decompensated HF, HF or cardiac hospitalizations, and all-cause mortality. 31 The studies found that those who were not married (P = 0.044), 31 Lapses in attention 24 Excessive daytime sleepiness with or without mild cognitive decline 24,25 Advanced age (≥ 65 years) 29 …”