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Cardiovascular events are a leading cause of death among individuals with type 2 diabetes (T2D), and these patients also experience higher rates of hospital readmission following myocardial infarction (MI) or coronary revascularization procedures, both of which frequently fall under the umbrella of acute coronary syndrome (ACS). Guideline-directed medical therapy, including beta-blockers, ACE inhibitors/ARBs, statins, and SGLT2 inhibitors, is crucial for reducing these risks and improving outcomes.¹ However, medication adherence after ACS is often suboptimal, particularly among individuals with T2D.^2,3

Improving medication adherence after ACS is a critical priority for healthcare providers and systems, as non-adherence to guideline-directed medical therapy is associated with increased mortality and rehospitalization rates.⁴ This underscores the importance of identifying factors associated with non-adherence and developing targeted interventions to improve medication uptake and persistence in high-risk patients.

A new study published in JAMA Network Open,examines prescription fill rates for these essential medications among Medicare beneficiaries with T2D following ACS hospitalization, highlighting opportunities to improve care and reduce cardiovascular risk in this vulnerable population.¹

Missed opportunities for medication optimization

Researchers used Medicare claims data to identify 188,651 beneficiaries with T2D who were hospitalized for ACS between January 2017 through December 2020. The median age of patients was 73 years, 59.4% were men, and 81.3% were White. They examined prescription fill rates for five classes of guideline-recommended cardiovascular medications:

• Beta-blockers
• ACE inhibitors, ARBs or ARN inhibitors
• Statins or PCSK9 inhibitors
• P2Y12 inhibitors
• GLP-1RA or SGLT2 inhibitors

Data were collected in the 90 days before admission, during hospitalization (filled the day of discharge to 90 days after), and in the 90 days following ACS hospitalization (filled 91鈥�180 days after discharge).¹

Prescription fills for cardiovascular medications modestly increased between admission and discharge but generally decreased in the 91-180 days after discharge. The exception was SGLT2 inhibitors and GLP-1 receptor agonists, which showed small increases.¹

Restarts鈥攐r not

The most significant predictor of not taking cardiovascular medications after discharge was not having a prescription filled at discharge. Patients who had medications stopped at discharge rarely restarted them in the following months鈥攐nly 8.1% of patients taking an ACEI/ARB/ARNI at admission who had the medication stopped at discharge restarted it after discharge. Similar low restart rates were seen with other medication classes.¹

Additionally, a substantial proportion of patients never filled prescriptions for recommended medications at any point, with never-fill rates of: 

• 27.0% for ACEIs/ARBs/ARNIs
• 37.8% for 尾-blockers
• 27.5% for P2Y12 inhibitors
• 9.0% for statins/PCSK9 inhibitors
• 90.9% for SGLT2 inhibitors/GLP-1RAs.¹

While comorbidities played a smaller role, conditions like atrial fibrillation, kidney disease, and dementia were associated with decreased medication use for certain drug classes.¹

Limitations: Claims data and beyond

This study had several notable strengths, including its large sample size of 188,651 Medicare beneficiaries and its ability to track actual prescription fills rather than just prescriptions written. The researchers examined multiple time points (pre-admission, discharge, and post-discharge periods) and analyzed various cardiovascular medication classes, providing a comprehensive view of medication use patterns.¹ However, the study had important limitations that should be considered when interpreting the results. The researchers could only track prescription fills through Medicare Part D data, which does not necessarily reflect actual medication adherence, as filled prescriptions may not always be taken as prescribed. The study also could not capture medication titration information or fully account for valid clinical reasons why some patients may not have been eligible for certain medications due to contraindications or intolerances. Additionally, as with all observational research, there may have been unmeasured factors affecting medication prescription fill rates that were not captured in the analysis.¹

Improving adherence through targeted interventions

The findings from this study highlight the critical importance of the hospital discharge period as a key opportunity to optimize evidence-based medication use in patients with type 2 diabetes following MI or coronary revascularization. Since medication status at discharge was the strongest predictor of long-term medication use, clinicians should pay particular attention to initiating and/or continuing guideline-recommended therapies during this transition period. The study suggests that if medications are discontinued at discharge, patients are unlikely to restart them in the following months, emphasizing the need for careful consideration before stopping any evidence-based therapies.¹

The research also reveals concerning gaps in the use of recommended cardiovascular medications in this high-risk population, with substantial proportions of patients never filling prescriptions for key drug classes. Of particular note were the very low utilization rates of SGLT2 inhibitors and GLP-1 receptor agonists (90.9% never-fill rate), despite growing evidence supporting their cardiovascular benefits in patients with type 2 diabetes. These findings suggest a need for healthcare systems to develop more robust strategies to ensure patients receive and fill prescriptions for guideline-recommended medications. Special attention may be needed for certain patient populations, as the study identified lower prescription fill rates among Black patients and those with specific comorbidities such as atrial fibrillation, kidney disease, and dementia. Implementation science research is needed to develop effective strategies to improve the use of these evidence-based medications across all patient populations.¹

Published: December 27, 2024