Untangling the relationship between medication adherence and post–myocardial infarction outcomes: Medication adherence and clinical outcomes

doi:10.1016/j.ahj.2013.09.014

American Heart Journal

Volume 167, Issue 1, January 2014, Pages 51-58.e5

https://doi.org/10.1016/j.ahj.2013.09.014 Get rights and content

Background

Patients who adhere to medications experience better outcomes than their nonadherent counterparts. However, these observations may be confounded by patient behaviors. The level of adherence necessary for patients to derive benefit and whether adherence to all agents is important for diseases that require multiple drugs remain unclear. This study quantifies the relationship between medication adherence and post–myocardial infarction (MI) adverse coronary events.

Methods

This is a secondary analysis of the randomized MI FREEE trial. Patients who received full prescription coverage were classified as adherent (proportion of days covered ≥80%) or not based upon achieved adherence in the 6 months after randomization. First major vascular event or revascularization rates were compared using multivariable Cox models adjusting for comorbidity and health-seeking behavior.

Results

Compared with patients randomized to usual care, full coverage patients adherent to statin, β-blocker, or angiotensin-converting enzyme inhibitor/angiotensin receptor blocker were significantly less likely to experience the study's primary outcome (hazard ratio [HR] range 0.64-0.81). In contrast, nonadherent patients derived no benefit (HR range 0.98-1.04, P ≤ .01 for the difference in HRs between adherent and nonadherent patients). Partially adherent patients had no reduction in clinical outcomes for any of the drugs evaluated, although their achieved adherence was higher than that among controls.

Conclusion

Achieving high levels of adherence to each and all guideline-recommended post-MI secondary prevention medication is associated with improved event-free survival. Lower levels of adherence appear less protective.

Section snippets

Methods

The study population was derived from MI FREEE—a randomized policy study evaluating the impact of copayments for β-blocker, statin, angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB) prescribed to patients discharged from hospital after MI. Full details of the trial have previously been published.⁹ To evaluate the impact of adherence on clinical outcomes, we restricted the cohort to patients who had filled a prescription for at least one of the study

Results

The proportion of patients in the full and usual coverage groups who were fully and nonadherent to the study medications is presented in online Appendix A (top panel). Table I shows the baseline characteristics of all patients randomized to the full and usual coverage arms, stratified by study medication and achieved adherence. Age, gender, comorbidity scores, and copayment were similar across groups. Nonadherent patients in the full coverage cohort were slightly less likely to have used

Discussion

The broad use of secondary prevention medications in patients after MI has made substantial contributions to reductions in cardiovascular mortality.¹⁸ However, the benefits of these therapies¹⁹ are limited by patient adherence to treatment.20., 21. Although the role of consistent long-term medication use is appreciated by clinicians and policymakers, its actual impact on clinical outcomes and the level of drug use required to derive benefit have required further clarification. We evaluated the

Acknowledgements

This work was supported by unrestricted research grants from Aetna and CVS Caremark to Brigham and Women's Hospital. Troyen Brennan and Olga Matlin are employees of CVS Caremark. Lonny Reisman and Michele Toscano are employees of Aetna.

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Clinical InvestigationOutcomes, Health Policy, and Managed CareUntangling the relationship between medication adherence and post–myocardial infarction outcomes: Medication adherence and clinical outcomes

Background

Methods

Results

Conclusion

Section snippets

Methods

Results

Discussion

Acknowledgements

J Am Coll Cardiol

J Clin Epidemiol

J Am Coll Cardiol

Am J Cardiol

A blueprint for pharmacy benefit managers to increase value

Am J Manag Care

Effect of the Women's Health Initiative on osteoporosis therapy and expenditure in Medicaid

J Bone Miner Res

Medication adherence leads to lower health care use and costs despite increased drug spending

Health Aff

Adherence to lipid-lowering therapy and the use of preventive health services: an investigation of the healthy user effect

Am J Epidemiol

Relationship between adherence to evidence-based pharmacotherapy and long-term mortality after acute myocardial infarction

JAMA

Statin adherence and risk of accidents: a cautionary tale

Circulation

The implications of therapeutic complexity on adherence to cardiovascular medications

Arch Intern Med

Full coverage for preventive medications after myocardial infarction

N Engl J Med

Clinical Investigation
Outcomes, Health Policy, and Managed Care
Untangling the relationship between medication adherence and post–myocardial infarction outcomes: Medication adherence and clinical outcomes