Clinical Investigations

Effect of Exposure to Evidence-Based Pharmacotherapy on Outcomes After Acute Myocardial Infarction in Older Adults

  1. Ilene H. Zuckerman PharmD, PhD1,*,
  2. Xianghua Yin MD2,
  3. Gail B. Rattinger PharmD, PhD1,
  4. Stephen S. Gottlieb MD3,
  5. Linda Simoni-Wastila BSPharm, PhD1,
  6. Sarah A. Pierce PharmD4,
  7. Ting-Ying Huang BSPharm1,
  8. Rahul Shenolikar PhD5,
  9. Bruce Stuart PhD1

Article first published online: 24 SEP 2012

DOI: 10.1111/j.1532-5415.2012.04165.x

Issue

Journal of the American Geriatrics Society

Journal of the American Geriatrics Society

Volume 60, Issue 10, pages 1854–1861, October 2012

Additional Information

How to Cite

J Am Geriatr Soc 60:1854–1861, 2012.

Author Information

  1. 1

    Department of Pharmaceutical Health Services Research, School of Pharmacy, University of Maryland, Baltimore, Maryland

  2. 2

    Department of Epidemiology and Public Health, School of Medicine, University of Maryland, Baltimore, Maryland

  3. 3

    Division of Cardiology, Department of Medicine, School of Medicine, University of Maryland, Baltimore, Maryland

  4. 4

    Veterans Affairs Maryland HealthCare System, Baltimore, Maryland

  5. 5

    GlaxoSmithKline, Durham, North Carolina

*Address correspondence to Ilene H. Zuckerman, Department of Pharmaceutical Health Services Research, School of Pharmacy, University of Maryland, 220 Arch Street, 12th floor, Baltimore, MD 21201. E-mail: izuckerm@rx.umaryland.edu

Publication History

  1. Issue published online: 11 OCT 2012
  2. Article first published online: 24 SEP 2012

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Keywords:

  • myocardial infarction;
  • Medicare;
  • pharmacotherapy;
  • Medicare Part D;
  • secondary prevention

Objectives

To assess the effect of exposure to evidence-based medication after hospital discharge for Medicare beneficiaries with acute myocardial infarction (AMI).

Design

A discrete-time hazard model was used to estimate time to outcome associated with exposure to four drug classes (angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin-II receptor blockers (ARBs), beta-blockers (BBs), statins, and clopidogrel) used for post-AMI secondary prevention of cardiovascular events and mortality.

Setting

Medicare administrative data for a 5% random sample of beneficiaries.

Participants

Medicare beneficiaries (N = 9,538) hospitalized for an AMI between April 1, 2006, and December 31, 2007, who survived for at least 30 days after discharge. The cohort was followed until death or December 31, 2008.

Measurements

Time-varying exposure was measured as proportion of days covered (PDC) for each quarter during the follow-up period. PDC was classified into five categories (0–0.2, 0.2–0.4, 0.4–0.6, 0.6–0.8, 0.8–1.0). Outcomes were mortality and a composite outcome of death or post-AMI hospitalization.

Results

Over a median follow-up of 18 months, mean PDC rates ranged from 0.37 (clopidogrel) to 0.50 (statins). When comparing the highest versus lowest categories of exposure, the hazard of the composite outcome was significantly lower for all drug classes except BBs (statins, adjusted hazard ratio (aHR) = 0.71, ACEIs/ARBs, aHR = 0.81, clopidogrel, aHR = 0.85, BBs, aHR = 0.93). All four drug classes were significantly associated with reductions in mortality; the magnitude of effect for the mortality outcome was largest for statins and smallest for BBs. Age modified the effect of statins on mortality.

Conclusion

Use of evidence-based medications for secondary prevention after AMI is suboptimal in the Medicare population, and low exposure rates are associated with significantly higher risk for subsequent hospitalization and death.

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