Denver, CO - Two new studies show that nonadherence to medication is common among recent MI patients and in those with diabetes, resulting in higher mortality. Nonadherence in the MI study resulted in an almost fourfold increase in the death rate in the first year after hospital discharge, while the diabetes sufferers had almost a twofold increase in mortality following noncompliance.

Both studies are led by Dr P Michael Ho (Denver Veterans Affairs Medical Center, CO) and colleagues and reported in the September 25, 2006 issue of the Archives of Internal Medicine [1,2]. Ho told heartwire that the fact that people are not taking their medications is underappreciated: "As doctors, we assume that once we've written the prescription, the patient will take the medication. We need to first recognize the problem before we can begin to treat it."

In an accompanying editorial [3], Dr Patrick J O'Connor (HealthPartners Research Foundation, Minneapolis, MN) says medication nonadherence "is very expensive, sometimes lethal, and depressingly common." He also discusses another report in the same issue that finds physician behavior contributes to the problem "in a major way" and appraises two new approaches to try to improve compliance.

Ho et al explain that the impact of stopping therapy early after MI remains unknown in community-based populations. So they decided to study 1521 patients in the Prospective Registry Evaluating Myocardial Infarction: Event and Recovery (PREMIER) study and assessed their use of aspirin, beta blockers, and statins one month after MI hospitalization, as well as recording 12-month all-cause mortality.

Of the patients, 184 discontinued all three medications after one month (around one in eight of the participants), 56 discontinued two medications, and 272 stopped using one medication (one in five); 1009 continued taking all three.

Those who stopped taking medication had significantly increased mortality during the subsequent 11 months (hazard ratio 3.81 in multivariable survival analysis) compared with those who continued to take any one medication. Older people and those who lacked a complete high school education were most likely to discontinue medication.

"These findings highlight the need to improve the care of patients in the transition from the hospital setting to outpatient care to ensure that patients continue to take medications that have demonstrated a mortality benefit," the researchers state.

Perhaps patients get an information overload on discharge, and the first visit is a good opportunity to reemphasize things.

Ho adds that the first physician visit after hospital discharge is a golden opportunity. "It is incumbent on doctors to ask their patients if they are taking their medications. Perhaps patients get an information overload on discharge, and the first visit is a good opportunity to reemphasize things."

He added that getting the patient's family involved is always helpful: "In my experience in a VA medical center, I like it if the wife turns up, as I don't always get the full information from the patient."

In the diabetes study, Ho et al looked retrospectively at 11 532 patients with diabetes mellitus in a managed-care organization and assessed adherence as the proportion of days covered for filled prescriptions of oral hypoglycemics, antihypertensives, and statins. The primary outcomes were all-cause hospitalization and all-cause mortality between January 2004 and April 2005.

They found a similar rate of noncompliance to the MI study, with one in five patients failing to take their therapies. Nonadherent patients were younger and had fewer comorbidities compared with adherent patients.

After multivariate adjustment, nonadherence remained significantly associated with increased all-cause hospitalization (odds ratio 1.58; p<0.001) and increased all-cause mortality (OR 1.81; p<0.001).

Ho et al say: "The assessment of medication nonadherence should be incorporated into routine clinical practice. Interventions are urgently needed to increase medication adherence so that patients can realize the full benefit of prescribed therapies."

Ho told heartwire that the profile of patients who were noncompliant in this study differed from that of patients who did not adhere to their medications in the MI study. "This highlights the fact that there are multiple reasons why people stop taking their medication, and we need to educate all patients about this, rather than concentrating on any one particular group."