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Fang Study: Significant Race, Gender Gaps in Adherence among Elderly Heart-Attack Survivors

A month after a heart attack, elderly patients of different races and genders are about equally likely to be on medications that reduce the risk of another heart attack and other potentially life-threatening cardiovascular problems.

Within one year, however, the odds that a patient is still taking the medications as prescribed vary significantly depending on race and gender, and black and Hispanic women are the least likely to adhere to their regimens.

Those are some of the findings from a study led by researchers at the UNC Eshelman School of Pharmacy, who examined prescription records for more than 85,000 Medicare Part D beneficiaries who were hospitalized for a heart attack in 2008 and survived at least thirty days after discharge. The results, published online December 10 in the journal Circulation, showed that although there is little racial and gender disparity in getting the patients started on evidence-based preventive medications, keeping them on those medications long-term is a different story. (See an infographic of the disparity)

The findings suggest that while national initiatives have been effective in encouraging clinicians to prescribe preventive medications for heart-attack patients at the time of discharge, more needs to be done to help patients stay on those medications, says Gang Fang, PharmD, MS, PhD, the study’s senior author and principal investigator.

“Adherence is a two-dimensional behavior: The physician has to prescribe the medication, and the patient has to fill the prescription,” says Fang, an assistant professor in the School’s Division of Pharmaceutical Outcomes and Policy.

“The policy implication from our study is that we should now put a lot of emphasis on helping patients, especially minority groups, understand the importance of these medications and help them improve their long-term adherence to get the greatest benefits.”

Studies have shown that lower adherence to evidence-based medications leads to worse cardiovascular outcomes, Fang says. He says the three medications examined in the study need to be taken long-term, so disparity in adherence could lead to disparity in patient outcomes such as death, heart attack, stroke, and other cardiovascular problems.

Julie Lauffenburger, PharmD, first author on the paper and a graduate student in DPOP, says the findings also suggest a need for different interventions for different groups.

“Some adherence interventions in the past have focused on a blanket approach to emphasizing adherence even though patient demographic subgroups may have different needs and perceptions about medication use,” she says. “These results suggest that more targeted interventions need to be considered, especially for adherence after heart attacks.”

Racial Minorities, Women Have Worse Adherence

The researchers found worse adherence among racial minorities. Using white men as the reference group for comparisons, the study found that

  • black and Hispanic women were the least likely to be filling their prescriptions as prescribed in the year after discharge,
  • black and Hispanic patients had the lowest likelihood of adherence to beta-blockers and statins, and
  • black patients had the lowest likelihood of adherence to ACEIs/ARBs.

The study also found that women, who have worse outcomes than men after heart attacks, had worse adherence within each race group, especially in blacks and Hispanics. The researchers say one possible explanation is a difference in men and women’s beliefs on the severity of their heart attacks and the benefits from the medications.

“In clinical practice we’ve observed that females tend to not have as severe chest pains as men,” Fang says. “That raises the question: Is it because of this difference that the importance of taking these medications is not sufficiently emphasized, either from the patient side or the clinician side, because the benefits and risks might not be perceived to be as great as in men?”

A Complex Picture of Adherence

The findings raise a number of other questions about what might influence adherence, Fang says. For example, the study revealed different levels of adherence to each of the three medications within a race and gender group. White women, for instance, were more adherent to statins but less adherent to ACEIs/ARBs and beta-blockers.

“There is no clinical evidence that says one of these drugs is more important than the others,” Fang says. “So this brings up a very interesting question about how clinicians and patients perceive benefits from each of the drugs.”

The researchers also adjusted their results to control for out-of-pocket medication costs and whether the patients had a follow-up visit with a primary-care physician or a cardiologist. They did not find a significant connection between those factors and the racial and gender gaps in adherence.

“This paints a more complex picture about adherence,” Fang says. “It’s not just how much you pay for medications or whether you visit a primary-care physician or cardiologist after discharge. There are a lot more complex issues. For instance, it could be whom you see — the quality of the providers’ care and services.”

The study was supported by funding from the American Heart Association National Clinical Research Program. Other authors were Jennifer Robinson, MD, MPH, a professor at the University of Iowa College of Public Health, and Christine Oramasionwu, PharmD, PhD, an assistant professor in DPOP.