March 2001

From University of Michigan Health System

U-M patients take their medicine

Research suggests U-M discharge program educates, empowers patients

Orlando, Fla. - For patients with heart conditions, medication can mean the difference between running a mile and racing to the emergency room.

Studies have shown that beta-blockers, aspirin, lipid-lowering agents and other medications decrease patient morbidity and mortality after heart attacks and episodes of unstable angina.

But few data exist to show whether people with these heart problems continue to take their medications after hospital discharge.

Researchers at the University of Michigan Health System studied how well U-M patients who had suffered heart attacks or unstable angina complied with their doctors' recommendations about medications after leaving the hospital. Results suggest that U-M's approach to patient education at discharge is having a favorable effect. The research was presented today at the annual Scientific Session of the American College of Cardiology.

"Very little information is known about whether patients continue to take their post-heart attack or angina medications six months after discharge from the hospital," says Eva Kline-Rogers, nurse practitioner and cardiovascular outcomes research coordinator, U-M Health System, and the study's principal investigator. "This is one of the only reports that's ever been published that examines whether patients are maintaining their medications. It suggests that the program used at U-M to educate patients about their conditions and the need for medications is very effective."

Researchers followed 409 patients with acute coronary syndromes. Of those patients, 113 had ST-segment elevation myocardial infarctions or severe heart attacks causing significant heart damage; 108 had non ST-segment elevation myocardial infarctions, which are generally less severe and produce less significant heart damage; and 188 had unstable angina. Angina is a severe, squeezing pain in the chest caused by reduced oxygen to the heart from poor blood supply.

Just before these patients were discharged, each heart attack patient went through U-M's discharge program. The program includes a form, which has been used at U-M for more than four years, and is now one facet of a nationwide study called the GAP Initiative - Guidelines Applied in Practice Initiative. GAP is sponsored by the American Association of Cardiology and led by principal investigator Kim Eagle, M.D., chief of cardiology and co-director of the Cardiovascular Center at the U-M Health System.

The discharge form ensures that patients understand they have had a heart attack, what that means, what medications should be taken and why. Medications may include aspirin, ACE inhibitors, beta-blockers and lipid-lowering agents. If the patient smokes or has a high-fat diet, the form indicates that the patient has been counseled to stop smoking and has been counseled by a nutritionist to follow a heart-healthy diet. Both the patient and the doctor or nurse sign the form once all of the patient's questions are answered.

Although the form does not address unstable angina, patients with that condition were discharged using a similar process.

Six months after discharge, the researchers made at least five attempts to reach all heart attack and unstable angina patients. They were asked various questions including what medications they were currently taking.

"Although we know there's still room to improve, we were pleasantly surprised," Kline-Rogers says. "Because of the discharge procedures, our compliance rate with key treatments is high at discharge. This study shows that our compliance rate remains high six months after discharge. That's vitally important because we know that these therapies reduce mortality and morbidity over the long-term in patients who've suffered acute coronary syndromes."

Before discharge, physicians evaluated appropriate therapies for all patients and individualized follow-up medications that may, or may not, have included aspirin, beta-blockers, ACE inhibitors and lipid-lowering agents.

For patients in the study with ST-segment elevation myocardial infarction, doctors recommended that 97.2 percent take aspirin. At six months, 90.3 percent of patients still were taking aspirin. Beta-blockers: 85.8 percent at discharge, 81.1 percent at follow up. ACE inhibitors: 72.6 percent, 59.4 percent. (The fall in ACE inhibitor use may reflect the observation that 10 percent or more patients develop a dry, irritating cough that leads to discontinuation of the medication.) Lipid-lowering agents: 67.3 percent, 71.7 percent.

The follow-up results for patients with non ST-segment elevation myocardial infarction and unstable angina were similarly impressive.

Kline-Rogers points out that the results were not corrected for contraindications - when patients were recommended not to take a medication because of the their medical histories or medical conditions.

"This study suggests that patient education and empowerment, along with direct communication with the patient's primary physician at the time of discharge, as well as a focus on goals for long-term management improves patients' compliance with strategies that prolong life," Kline-Rogers says.

U-M researchers are continuing this project and, in future studies, hope to determine the factors that affect medication compliance, as well as interventions that may improve compliance.

Other researchers on the project were: Kim Eagle, M.D., chief, U-M Department of Cardiology, co-director of the U-M Cardiovascular Center; Rajendra H. Mehta, U-M clinical assistant professor of cardiology; Akhil Gulati, U-M Heart Care Program, Obli C. M. Mani, research fellow, U-M Department of Internal Medicine; Deepak Venkat, U-M Heart Care Program; Jeanna V. Cooper, research associate, U-M Department of Internal Medicine; Gwen E. Kearly, clinical nurse supervisor; Elizabeth Nolan, clinical nurse specialist; Robert J. Cody, U-M professor of internal medicine; and Steven R. Erickson, assistant professor, U-M College of Pharmacy.











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