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Rodríguez-Bernal CL, Sánchez-Saez F, Bejarano-Quisoboni D, Hurtado I, García-Sempere A, Peiró S, Sanfélix-Gimeno G. Assessing Concurrent Adherence to Combined Essential Medication and Clinical Outcomes in Patients With Acute Coronary Syndrome. A Population-Based, Real-World Study Using Group-Based Trajectory Models. Front Cardiovasc Med 2022; 9:863876. [PMID: 35694663 PMCID: PMC9174582 DOI: 10.3389/fcvm.2022.863876] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 03/21/2022] [Indexed: 12/02/2022] Open
Abstract
Aim Adherence to multiple medications recommended for secondary prevention of cardiovascular conditions represents a challenge. We aimed to identify patterns of concurrent adherence to combined therapy and assess their impact on clinical outcomes in a cohort of patients with acute coronary syndrome (ACS). Methods Population-based retrospective cohort of all patients discharged after hospitalization for ACS (2009–2011), prescribed ≥3 therapeutic groups within the first month. We assessed monthly concurrent adherence (≥24 days of medication out of 30) to ≥3 medications during the first year, and patterns were identified through group-based trajectory models. A composite clinical outcome during the second year was constructed. The association between adherence patterns and traditional refill adherence metrics [e.g., the proportion of days covered (PDC)], and outcomes were assessed through a multivariable Cox proportional hazards model. Results Among 15,797 patients discharged alive, 12,057 (76.32%) initiated treatment with ≥3 therapeutic groups after discharge. We identified seven adherence trajectories to ≥3 medications: Adherent (52.94% of patients); Early Gap (6.64%); Middle Gap (5.67%); Late Decline (10.93%); Occasional Users (5.45%); Early Decline (8.79%); Non-Adherent (9.58%). Compared to the Adherent group, patients belonging to Early Gap (HR:1.30, 95%CI 1.07;1.60), Late decline (hazards ratio (HR): 1.31, 95% CI 1.1; 1.56), and Non-Adherent trajectories (HR: 1.36, 95% CI 1.14; 1.63) had a greater risk of adverse clinical outcomes, which was also different to the risk ascertained through concurrent PDC < 80 (HR: 1.13, 95% CI 1.01; 1.27). Conclusion Overall, seven adherence trajectories to ≥3 drugs were identified, with three distinct adherence patterns being at higher risk of adverse outcomes. The identification of patterns of concurrent adherence, a more comprehensive approach than traditional measurements, may be useful to target interventions to improve adherence to multiple medications.
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Affiliation(s)
- Clara L. Rodríguez-Bernal
- Health Services Research Unit, The Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
- *Correspondence: Clara L. Rodríguez-Bernal
| | - Francisco Sánchez-Saez
- Health Services Research Unit, The Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - Daniel Bejarano-Quisoboni
- Health Services Research Unit, The Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), Valencia, Spain
| | - Isabel Hurtado
- Health Services Research Unit, The Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - Anibal García-Sempere
- Health Services Research Unit, The Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - Salvador Peiró
- Health Services Research Unit, The Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - Gabriel Sanfélix-Gimeno
- Health Services Research Unit, The Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
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Cram P, Hatfield LA, Bakx P, Banerjee A, Fu C, Gordon M, Heine R, Huang N, Ko D, Lix LM, Novack V, Pasea L, Qiu F, Stukel TA, de Groot CU, Yan L, Landon B. Variation in revascularisation use and outcomes of patients in hospital with acute myocardial infarction across six high income countries: cross sectional cohort study. BMJ 2022; 377:e069164. [PMID: 35508312 PMCID: PMC9066381 DOI: 10.1136/bmj-2021-069164] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To compare treatment and outcomes for patients admitted to hospital with a primary diagnosis of ST elevation or non-ST elevation myocardial infarction (STEMI or NSTEMI) in six high income countries with very different healthcare delivery systems. DESIGN Retrospective cross sectional cohort study. SETTING Patient level administrative data from the United States, Canada (Ontario and Manitoba), England, the Netherlands, Israel, and Taiwan. PARTICIPANTS Adults aged 66 years and older admitted to hospital with STEMI or NSTEMI between 1 January 2011 and 31 December 2017. OUTCOMES MEASURES The three categories of outcomes were coronary revascularisation (percutaneous coronary intervention or coronary artery bypass graft surgery), mortality, and efficiency (hospital length of stay and 30 day readmission). Rates were standardised to the age and sex distribution of the US acute myocardial infarction population in 2017. Outcomes were assessed separately for STEMI and NSTEMI. Performance was evaluated longitudinally (over time) and cross sectionally (between countries). RESULTS The total number of hospital admissions ranged from 19 043 in Israel to 1 064 099 in the US. Large differences were found between countries for all outcomes. For example, the proportion of patients admitted to hospital with STEMI who received percutaneous coronary intervention in hospital during 2017 ranged from 36.9% (England) to 78.6% (Canada; 71.8% in the US); use of percutaneous coronary intervention for STEMI increased in all countries between 2011 and 2017, with particularly large rises in Israel (48.4-65.9%) and Taiwan (49.4-70.2%). The proportion of patients with NSTEMI who underwent coronary artery bypass graft surgery within 90 days of admission during 2017 was lowest in the Netherlands (3.5%) and highest in the US (11.7%). Death within one year of admission for STEMI in 2017 ranged from 18.9% (Netherlands) to 27.8% (US) and 32.3% (Taiwan). Mean hospital length of stay in 2017 for STEMI was lowest in the Netherlands and the US (5.0 and 5.1 days) and highest in Taiwan (8.5 days); 30 day readmission for STEMI was lowest in Taiwan (11.7%) and the US (12.2%) and highest in England (23.1%). CONCLUSIONS In an analysis of myocardial infarction in six high income countries, all countries had areas of high performance, but no country excelled in all three domains. Our findings suggest that countries could learn from each other by using international comparisons of patient level nationally representative data.
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Affiliation(s)
- Peter Cram
- Department of Medicine, University of Texas Medical Branch, Galveston, TX, USA
- ICES, Toronto, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Laura A Hatfield
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Pieter Bakx
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, Netherlands
| | - Amitava Banerjee
- Institute of Health Informatics, University College London, London, UK
- Department of Cardiology, University College London Hospitals, London, UK
| | - Christina Fu
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Michal Gordon
- Clinical Research Center, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheba, Israel
| | - Renaud Heine
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, Netherlands
| | - Nicole Huang
- Institute of Hospital and Health Care Administration, National Yang-Ming Chiao Tung University, Taipei, Taiwan
| | - Dennis Ko
- ICES, Toronto, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Schulich Heart Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Lisa M Lix
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- George & Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, MB, Canada
| | - Victor Novack
- Clinical Research Center, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheba, Israel
| | - Laura Pasea
- Institute of Health Informatics, University College London, London, UK
| | | | - Therese A Stukel
- ICES, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Carin Uyl de Groot
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, Netherlands
| | - Lin Yan
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- George & Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, MB, Canada
| | - Bruce Landon
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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