Medication Non-adherence Is Associated With A Broad Range Of Adverse Outcomes In Patients With

Coronary Artery Disease

P. Michael Ho, MD, PhDP. Michael Ho, MD, PhD1-31-3, David J. Magid, MD, MPH, David J. Magid, MD, MPH2,32,3, Susan M. Shetterly, MS, Susan M. Shetterly, MS33, , Kari L. Olson, PharmD, BCPSKari L. Olson, PharmD, BCPS33, Thomas M. Maddox, MD, MSc, Thomas M. Maddox, MD, MSc1-31-3, Pamela N. , Pamela N.

Peterson, MD, MSPHPeterson, MD, MSPH2-42-4, Frederick A. Masoudi, MD, MSPH, Frederick A. Masoudi, MD, MSPH2-42-4

John S. Rumsfeld, MD, PhDJohn S. Rumsfeld, MD, PhD1-31-3

6.6. Denver VA Medical CenterDenver VA Medical Center7.7. University of Colorado Health Sciences CenterUniversity of Colorado Health Sciences Center8.8. Institute for Health Research, Kaiser Permanente of ColoradoInstitute for Health Research, Kaiser Permanente of Colorado9.9. Denver Health Medical CenterDenver Health Medical Center

Disclosure Information

DISCLOSURE INFORMATION: This work was supported by an American Heart Association Scientist Development Grant (0535086N)

Background and ObjectivesBackground and Objectives

Efficacy of β-blockers, ACE-inhibitors, and Efficacy of β-blockers, ACE-inhibitors, and statins demonstrated in clinical trialsstatins demonstrated in clinical trials

Gap between benefits demonstrated in clinical Gap between benefits demonstrated in clinical trials and effectiveness of medications in clinical trials and effectiveness of medications in clinical practicepractice

Objective: To evaluate the association between Objective: To evaluate the association between non-adherence to β-blockers, ACE-inhibitors, non-adherence to β-blockers, ACE-inhibitors, and statin medications with a broad range of CV and statin medications with a broad range of CV adverse outcomes adverse outcomes

MethodsMethods Setting: Integrated, nonprofit managed care organization Setting: Integrated, nonprofit managed care organization

in the Denver, Colorado metropolitan areain the Denver, Colorado metropolitan area Patients: 15,567 patients with coronary artery disease Patients: 15,567 patients with coronary artery disease Study design: Retrospective cohort studyStudy design: Retrospective cohort study

Median follow-up 4.1 yearsMedian follow-up 4.1 years Medication adherence: proportion of days covered for Medication adherence: proportion of days covered for

ββ-blockers, ACE-inhibitors, and statin medications-blockers, ACE-inhibitors, and statin medications Non-adherence defined as PDC<0.80Non-adherence defined as PDC<0.80

OutcomesOutcomes All-cause mortalityAll-cause mortality Cardiovascular mortalityCardiovascular mortality Cardiovascular hospitalization for AMI or heart failureCardiovascular hospitalization for AMI or heart failure Revascularization procedures including PCI or CABGRevascularization procedures including PCI or CABG

Baseline characteristicsBaseline characteristics

28-36%Depression

35-45%Diabetes

95%Hyperlipidemia

90%Hypertension

25%Cerebrovascular disease

28%Chronic obstructive pulmonary disease

33-48%Heart failure

42-49%Prior MI

50%Prior PCI

45-50%Prior CABG

20%Current smoker

30%Female gender

65Age (mean)

Rates of non-adherenceRates of non-adherence

0

5

10

15

20

25

30P

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on

-ad

he

ren

t

AC

E-

inh

ibit

ors

Sta

tin

s

B-

blo

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ers

Non-adherent patients were younger and more likely to have COPD and depression

n=10,021

n=13,596n=11,865

Non-adherence to cardioprotective Non-adherence to cardioprotective medications is associated with adverse medications is associated with adverse

outcomesoutcomes

0.5

All-cause mortalityn=1,889

CV mortalityn=372

CV Hospitalization*n=2,008

Coronary Revascularization#

n=2,117

B-blockersStatinsACE-inhibitors

Hazards Ratio1.0 2.0

*Hospitalization for AMI or heart failure#PCI or CABG

Non-adherence to H2 antagonists or Non-adherence to H2 antagonists or proton pump inhibitors not associated proton pump inhibitors not associated

with adverse outcomeswith adverse outcomes

1.14 (0.97-1.33)All-cause mortality

1.10 (0.78-1.57)CV mortality

1.02 (0.87-1.18)CV hospitalization

1.07 (0.92-1.23)Coronary revascularization

Hazard ratio (95% confidence interval)

Outcome

ConclusionsConclusions

1 in 4 patients were non-adherent 1 in 4 patients were non-adherent Non-adherence to cardioprotective medications Non-adherence to cardioprotective medications

associated with higher risk of adverse outcomes associated with higher risk of adverse outcomes Non-adherence to GI medications not Non-adherence to GI medications not

associated with adverse outcomesassociated with adverse outcomes Suggest lower risk associated with adherence due to Suggest lower risk associated with adherence due to

benefits of cardioprotective medications rather than benefits of cardioprotective medications rather than ‘healthy adherer’ effect‘healthy adherer’ effect

Expanding current quality of care measures to Expanding current quality of care measures to include the assessment of medication include the assessment of medication adherence may be an important quality metricadherence may be an important quality metric