The Importance of Discharge Medications
When I look back at my career, there are certain patients that stood out. Notably, these patients were “repeat customers” who would return periodically with in-stent restenosis or progressed disease. I would wonder why some patients never seemed to require additional treatments while others routinely came back… After conversing with these repeat patients, a common thread emerged. Many of them did not continue with their medications after discharge, resulting in an advancement of their disease.
Evidence-based testing has proven the importance of post-procedural care after coronary revascularization. Considerations include lifestyle modifications that incorporate a comprehensive cardiac rehabilitation program and patient-specific discharge medications to prevent lesion restenosis. When choosing post-discharge medications, there are many factors to consider. Did the patient undergo percutaneous coronary intervention, (PCI), STENT placement, or coronary artery bypass grafts (CABG)? Does the patient have atrial fibrillation or diabetes? Is the patient on medication for high blood pressure and cholesterol, and how are these factors being managed?
Typically, restenosis rates post coronary intervention occur within 6-12 months, while the progression of existing and new lesions may occur 1 year or more after revascularization. Restenosis within 6-12 months is normally instigated by in-stent thrombosis, therefore, dual antiplatelet therapy (DAPT) is highly recommended as a preventative measure. The progression of disease beyond a year is mostly due to the buildup of atherosclerosis-related, high-risk factors such as elevated cholesterol, diabetes, and saphenous vein graph degeneration. The industry standards and recommended best practices are to address later occurrences with risk factor modification through cardiac rehabilitation and pharmacological control of high blood pressure and diabetes as well as aggressive lipid-lowering statins for elevated cholesterol.
Addressing Discharge Medication Non-Compliance
The importance of adherence to prescribed discharge medications is widely known, yet there is a high propensity of noncompliance amongst cardiac patients due to several factors. The most common of these include a lack of understanding of post-procedural instructions, breakdown in professional communication, inadequate follow-up care, and patient inability to purchase medications. Often, patients receive their discharge instructions while they are still recovering from sedation. If there is a family member or caregiver present, they may be feeling overwhelmed and may not remember or understand the instructions. Sometimes there are language barriers to overcome. Detailed written instructions for the patient and caregivers to refer to post-discharge are vital. Frequently, the post-discharge documentation is not performed by the invasive cardiologist, but by an intensivist, or physician’s assistant. The most common failure in this process is that the medications are prescribed, but not documented properly in the patient’s chart, leading to a breakdown in follow-up care. Creating electronic hard-stops in the charting system that do not allow the person who is documenting to continue until they have addressed the discharge medications can be a very successful solution. Another simpler solution is to keep an algorithm for reference.
Finally, effective follow-up care is essential for the patient’s long-term outcomes. Findings from a single center retrospective analysis revealed that “More than one-third of patients did not fill all new discharge medications within 30 days after cardiac revascularization; almost 1 in 10 did not fill any of their discharge medications”. The study attributed this non-initiation of discharge medications to a lower number of discharge medications and shorter hospital stays. Implementation of programs like “Meds-to-beds” that include pharmacist involvement, counseling services, follow-up phone calls, health literacy, and socioeconomic considerations have proven to be effective in increasing adherence to discharge medications.
There is no question regarding the importance of discharge medications in positive long-term patient outcomes. The challenge is to identify existing barriers to care and to create and implement solutions. A comprehensive quality program is essential in determining the root cause of noncompliance to discharge medications and the establishment of effective resolutions. Corazon has the services to help through Accreditation, Consulting, or Program Audits, resulting in better patient care and ultimately, longer, and more meaningful lives for our patients. Isn’t that why we are all in this business in the first place?
Author: Joyce Froetschel
2021 Acc/AHA/SCAI Guideline for Coronary Artery Revascularization, Jennifer S. Lawton, MD, FAHA, Chair, Jacqueline E. Tamis-Holland, MD, FAHA, FACC, FSCAI, Vice Chair, Sripal Bangalore, MD, MHA, FACC, FAHA, FSCAI, et. al., Journal of the American College of Cardiology, 2021 By the American College of Cardiology Foundation and The American heart Association Inc., ISSN 0735-1097, https://doi.org/10.1016/j.jacc.2021.09.006.
Popma JJ, Sawyer M, Selwyn AP, Kinlay S. Lipid-Lowering Therapy after coronary revascularization. Am J Cardiol. 2000 Aug 24;86(4B0:18H-28H. https://doi.org/10.1016/s0002-9149(00)01096-1 PMID: 11021252.
Medaglio D, Glasgow J, Zhang Z, Elliott D. Non-initiation of Discharge Medication After Revascularization. J Manag Care Spec Pharm, 2020 Mar;26(3):305-310. https://doi.org/10.18553/jmcp.2020.26.3.305. PMID: 32105182.