November 27, 2013 - A targeted effort to help high-risk heart failure patients stay on their medications did improve adherence to drug regimens, but had surprisingly little effect lowering hospital readmission rates, according to a study at Duke Medicine.
The findings, presented last week at the American Heart Association’s Scientific Sessions meeting in Dallas, suggest that medication management is just one of many issues facing patients most at risk for their conditions to worsen.
“We found that we could solve much of the problem around medication adherence, but that is not the whole issue,” said Bradi B. Granger, RN, Ph.D., director of the Heart Center Nursing Research Program at Duke. “This illuminates the opportunities we have to help patients in a much broader way, redesigning care to confront some of the issues that keep the most vulnerable patients from regaining their health.”
Increasingly, hospitals face financial penalties from the Medicare and Medicaid insurance programs if patients are readmitted within 30 days. To reduce readmissions, hospitals are working to coordinate better and more intensive follow-up care in outpatient settings. Making sure patients take their medications has been a key component.
Granger and colleagues reported the findings from a study at Duke called CHIME, for Chronic Heart Failure Intervention to Improve Medication Adherence. The study was designed to learn why patients skip their medications, and test whether a nursing intervention could improve compliance.
Granger said 86 heart failure patients at high risk for poor medication adherence were randomly assigned to one of two groups: those who were periodically contacted and coached by nurses about taking their medications, and those who were contacted on the same schedule but did not receive the coaching.
As part of the intervention, nurses asked the patients about their symptoms, what triggered their symptoms and how they typically responded. Many of the patients said they quit taking their medications when symptoms persisted, believing the drugs were ineffective. They also reported that they primarily headed to the hospital emergency department when symptoms escalated, often leading to higher admission rates.
With coaching from the nurses at three, six and 12 months, patients in the intervention were tutored about managing their symptoms, taking their pills on schedule, and developing an action plan for addressing their symptoms. They were encouraged to use doctors’ offices and clinics rather than the emergency department.
The approach was successful, Granger reported. Patients who received the intervention were four times as likely to adhere to their medication regimens as the comparison group.
“We were able to dramatically improve medication compliance, and that was the primary end-point of the study,” Granger said.
But when the researchers looked at the hospital readmission rate, they found that readmissions were not significantly different between the two groups.
"We were surprised by this, and it’s leading us to dig into what is going on,” Granger said. “Our next area of study will focus on the complex factors that affect the patient experience and lead to the avoidable use of emergency health care resources. We thought it was medication adherence in large part, but it might be that many of the same social and economic factors causing health disparities may also contribute significantly to high resource use."