Marya J. Cohen, MD, MPH

In the outpatient setting, medication adherence (defined as percentage of prescribed medication doses taken by a patient during a specific time period) ranges between 40% and 80% for chronic conditions.1 During acute care hospitalization, changes are often made to patients' medication regimens, which can be confusing and contribute to nonadherence, medication errors, and harmful adverse events.2 Indeed, it is estimated that almost half of patients encounter a medication error after discharge, and approximately 12%17% experience an adverse drug event after returning home.36 It is likely that some of these adverse events may be the result of medication nonadherence.7 Improved patientprovider communication, systems to reconcile prehospitalization and posthospitalization medications, as well as development of mechanisms to enhance adherence, may prevent many of these errors and have become new targets for quality improvement.4, 8 Although postdischarge medication adherence is a crucial target for avoiding adverse events and rehospitalization, few studies have focused on understanding its incidence and predictors, in particular, patient demographic factors such as age and insurance status.911

In addition, few studies have looked at general and posthospital adherence in a population where health literacy is measured, an important area because medication changes during hospitalization may be particularly confusing for patients with low health literacy.11, 12 Health literacy is defined as the degree to which an individual has the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.13 Prior outpatient research shows that low health literacy is associated with poor patient understanding of the medication regimen and instructions for medication use, which may contribute to postdischarge medication nonadherence.14, 15 Understanding the factors associated with postdischarge medication adherence could help refine interventions that are oriented toward improving transitions in care, patient safety, and reducing unnecessary rehospitalization.

We report here on factors associated with postdischarge medication adherence using data from the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL‐CVD) study.16

METHODS

RESULTS

Table 1 shows descriptive baseline patient characteristics of study sample (responders) as well as nonresponders at 30 days. For the responders, the mean age of the 646 patients was 61.2 years, 94.7% were insured, and 19.3% had inadequate or marginal health literacy. Patients were prescribed an average of 8 preadmission medications. Most patients (92.3%) had a regular PCP prior to admission. Nonresponders had nonsignificant trends towards having lower health literacy, medication understanding, and baseline medication adherence.

The average postdischarge adherence score was 95% (standard deviation [SD] = 10.2%), and less than 10% of patients had an adherence score of less than 85%; overall the distribution was left‐skewed. Table 2 illustrates crude and adjusted parameter estimates for variables in the model. Table 3 shows significant findings in the fully adjusted model, which used multiple imputation techniques to account for missing data.

Intervention arm was of borderline statistical significance in predicting postdischarge adherence (P = 0.052), and so was removed from the final model. Study site, age, insurance, and baseline adherence were the only significant independent predictors of postdischarge adherence in the fully adjusted model (Table 3). For example, for every 10‐year increase in age, patients had, on average, an adjusted 1% absolute increase in their adherence score (95% confidence interval [CI] 0.4% to 2.0%). For every 1‐point increase in baseline medication adherence (based on the Morisky scale), there was a 1.6% absolute increase in medication adherence (95% CI 0.8% to 2.4%). In unadjusted analyses, patients with Medicaid were less adherent with medications after discharge than were patients with private insurance. This difference became nonsignificant in adjusted analyses, but when analyses were repeated using multiple imputation techniques, the results again became statistically significantMedicaid insurance was associated with a 4.5% absolute decrease in postdischarge adherence compared with private insurance (95% CI 7.6% to 1.4%). Study site (specifically, Brigham and Women's Hospital) was also a significant predictor of greater postdischarge medication adherence. Years of education was a significant predictor of adherence in unadjusted analyses, but was not an independent predictor when adjusted for other factors. When baseline adherence was removed from the multiple imputation model, there were no changes in which factors were significant predictors of adherence.

DISCUSSION

In this study, we found that low baseline adherence, younger age, Medicaid insurance, and study site were significant predictors of lower 30‐day medication adherence. Of particular interest is our finding regarding baseline adherence, a simple measure to obtain on hospitalized patients. It is notable that in our study, education was not an independent significant predictor of postdischarge adherence, even when baseline adherence was removed from the model. The same is true for medication understanding, cognitive function, and health literacy.

Older patients appeared more adherent with medications in the month after hospital discharge, perhaps reflecting increased interaction with the healthcare system (appointments, number of physician interactions), a greater belief in the importance of chronic medication management, or a higher level of experience with managing medications. A similar relationship between age and adherence has been shown in outpatient studies of patients with hypertension, diabetes, and other chronic diseases.2427

Medicaid patients may be less likely to remain adherent because of the plan's limited coverage of medications relative to patients' ability to pay. For example, Medicaid in Tennessee covers the first 5 generic medications at no cost to the patient but has co‐payments for additional medications and for brand name drugs. Medicaid in Massachusetts has co‐payments of $1 to $3 for each medication. Alternatively, Medicaid insurance may be a marker for other patient characteristics associated with low adherence for which we were not fully able to adjust.

Site differences were also notable in this study; these differences could have been due to differences in insurance coverage in Tennessee versus Massachusetts (which has near‐universal coverage), differences in types of insurance (eg, fewer patients at Brigham and Women's Hospital had Medicaid than at Vanderbilt), cultural and geographic differences between the 2 locations, or other differences in transitional care between the 2 sites.

This study corroborates previous literature on medication adherence (specifically unintentional nonadherence) in the outpatient setting,4, 811 for example, on the association of younger age with low adherence in certain populations. On the other hand, it may contrast with previous literature which has sometimes shown a relationship between patient education or health literacy and medication adherence.14, 15, 2835 However, previous studies have not focused on the transition from inpatient to outpatient settings. Perhaps intensive medication education in the hospital, even under usual care, mitigates the effects of these factors on postdischarge adherence. Finally, baseline adherence seems to correlate with postdischarge adherence, a finding which makes intuitive sense and has been previously reported for specific medications.36

There are several limitations to this study. Although large, the study was performed at only 2 clinical sites where most patients were white and fairly well‐educated, perhaps because patients admitted to a tertiary care center with ACS or ADHF are more affluent than general medical inpatients as a whole; this may limit generalizability. Postdischarge medication adherence might have been higher than in other patient populations given the nature of the population, possible loss‐to‐follow‐up bias, and the fact that half of the subjects received an intervention designed to improve medication management after discharge; such low rates of nonadherence in our study may have reduced our ability to detect important predictors in our models. In addition, the period of follow‐up was 30 days, thus limiting our findings to short‐term postdischarge medication adherence. Postdischarge medication adherence was based on patient self‐report, which not only assumed that the patient was still managing his/her own medications after discharge, but may also be susceptible to both recall and social acceptability bias, which might overestimate our adherence scores, again limiting our ability to detect important predictors of nonadherence. However, other studies have shown a good correlation between self‐reported medication adherence and other more objective measures,37, 38 and recall was only for 7 days, a measure used previously in the literature39, 40 and one designed to reduce recall bias. Systematic underreporting in certain patient populations is less likely but possible.

In the future, research should focus on targeting patients who have low baseline adherence to evaluate the effects of various interventions on postdischarge medication outcomes. Repeating the study in a population with a high prevalence of low health literacy might be illuminating, given that previous studies have shown that patients with low health literacy have less ability to identify their medications and have less refill adherence.29, 30

In conclusion, in patients hospitalized with cardiovascular disease, predictors of lower postdischarge adherence include younger age, Medicaid insurance, and low baseline adherence. It may be prudent to assess baseline adherence and insurance type in hospitalized patients in order to identify those who may benefit from additional assistance to improve medication adherence and medication safety during transitions in care.

In the outpatient setting, medication adherence (defined as percentage of prescribed medication doses taken by a patient during a specific time period) ranges between 40% and 80% for chronic conditions.1 During acute care hospitalization, changes are often made to patients' medication regimens, which can be confusing and contribute to nonadherence, medication errors, and harmful adverse events.2 Indeed, it is estimated that almost half of patients encounter a medication error after discharge, and approximately 12%17% experience an adverse drug event after returning home.36 It is likely that some of these adverse events may be the result of medication nonadherence.7 Improved patientprovider communication, systems to reconcile prehospitalization and posthospitalization medications, as well as development of mechanisms to enhance adherence, may prevent many of these errors and have become new targets for quality improvement.4, 8 Although postdischarge medication adherence is a crucial target for avoiding adverse events and rehospitalization, few studies have focused on understanding its incidence and predictors, in particular, patient demographic factors such as age and insurance status.911

In addition, few studies have looked at general and posthospital adherence in a population where health literacy is measured, an important area because medication changes during hospitalization may be particularly confusing for patients with low health literacy.11, 12 Health literacy is defined as the degree to which an individual has the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.13 Prior outpatient research shows that low health literacy is associated with poor patient understanding of the medication regimen and instructions for medication use, which may contribute to postdischarge medication nonadherence.14, 15 Understanding the factors associated with postdischarge medication adherence could help refine interventions that are oriented toward improving transitions in care, patient safety, and reducing unnecessary rehospitalization.

We report here on factors associated with postdischarge medication adherence using data from the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL‐CVD) study.16

METHODS

RESULTS

Table 1 shows descriptive baseline patient characteristics of study sample (responders) as well as nonresponders at 30 days. For the responders, the mean age of the 646 patients was 61.2 years, 94.7% were insured, and 19.3% had inadequate or marginal health literacy. Patients were prescribed an average of 8 preadmission medications. Most patients (92.3%) had a regular PCP prior to admission. Nonresponders had nonsignificant trends towards having lower health literacy, medication understanding, and baseline medication adherence.

The average postdischarge adherence score was 95% (standard deviation [SD] = 10.2%), and less than 10% of patients had an adherence score of less than 85%; overall the distribution was left‐skewed. Table 2 illustrates crude and adjusted parameter estimates for variables in the model. Table 3 shows significant findings in the fully adjusted model, which used multiple imputation techniques to account for missing data.

Intervention arm was of borderline statistical significance in predicting postdischarge adherence (P = 0.052), and so was removed from the final model. Study site, age, insurance, and baseline adherence were the only significant independent predictors of postdischarge adherence in the fully adjusted model (Table 3). For example, for every 10‐year increase in age, patients had, on average, an adjusted 1% absolute increase in their adherence score (95% confidence interval [CI] 0.4% to 2.0%). For every 1‐point increase in baseline medication adherence (based on the Morisky scale), there was a 1.6% absolute increase in medication adherence (95% CI 0.8% to 2.4%). In unadjusted analyses, patients with Medicaid were less adherent with medications after discharge than were patients with private insurance. This difference became nonsignificant in adjusted analyses, but when analyses were repeated using multiple imputation techniques, the results again became statistically significantMedicaid insurance was associated with a 4.5% absolute decrease in postdischarge adherence compared with private insurance (95% CI 7.6% to 1.4%). Study site (specifically, Brigham and Women's Hospital) was also a significant predictor of greater postdischarge medication adherence. Years of education was a significant predictor of adherence in unadjusted analyses, but was not an independent predictor when adjusted for other factors. When baseline adherence was removed from the multiple imputation model, there were no changes in which factors were significant predictors of adherence.

DISCUSSION

In this study, we found that low baseline adherence, younger age, Medicaid insurance, and study site were significant predictors of lower 30‐day medication adherence. Of particular interest is our finding regarding baseline adherence, a simple measure to obtain on hospitalized patients. It is notable that in our study, education was not an independent significant predictor of postdischarge adherence, even when baseline adherence was removed from the model. The same is true for medication understanding, cognitive function, and health literacy.

Older patients appeared more adherent with medications in the month after hospital discharge, perhaps reflecting increased interaction with the healthcare system (appointments, number of physician interactions), a greater belief in the importance of chronic medication management, or a higher level of experience with managing medications. A similar relationship between age and adherence has been shown in outpatient studies of patients with hypertension, diabetes, and other chronic diseases.2427

Medicaid patients may be less likely to remain adherent because of the plan's limited coverage of medications relative to patients' ability to pay. For example, Medicaid in Tennessee covers the first 5 generic medications at no cost to the patient but has co‐payments for additional medications and for brand name drugs. Medicaid in Massachusetts has co‐payments of $1 to $3 for each medication. Alternatively, Medicaid insurance may be a marker for other patient characteristics associated with low adherence for which we were not fully able to adjust.

Site differences were also notable in this study; these differences could have been due to differences in insurance coverage in Tennessee versus Massachusetts (which has near‐universal coverage), differences in types of insurance (eg, fewer patients at Brigham and Women's Hospital had Medicaid than at Vanderbilt), cultural and geographic differences between the 2 locations, or other differences in transitional care between the 2 sites.

This study corroborates previous literature on medication adherence (specifically unintentional nonadherence) in the outpatient setting,4, 811 for example, on the association of younger age with low adherence in certain populations. On the other hand, it may contrast with previous literature which has sometimes shown a relationship between patient education or health literacy and medication adherence.14, 15, 2835 However, previous studies have not focused on the transition from inpatient to outpatient settings. Perhaps intensive medication education in the hospital, even under usual care, mitigates the effects of these factors on postdischarge adherence. Finally, baseline adherence seems to correlate with postdischarge adherence, a finding which makes intuitive sense and has been previously reported for specific medications.36

There are several limitations to this study. Although large, the study was performed at only 2 clinical sites where most patients were white and fairly well‐educated, perhaps because patients admitted to a tertiary care center with ACS or ADHF are more affluent than general medical inpatients as a whole; this may limit generalizability. Postdischarge medication adherence might have been higher than in other patient populations given the nature of the population, possible loss‐to‐follow‐up bias, and the fact that half of the subjects received an intervention designed to improve medication management after discharge; such low rates of nonadherence in our study may have reduced our ability to detect important predictors in our models. In addition, the period of follow‐up was 30 days, thus limiting our findings to short‐term postdischarge medication adherence. Postdischarge medication adherence was based on patient self‐report, which not only assumed that the patient was still managing his/her own medications after discharge, but may also be susceptible to both recall and social acceptability bias, which might overestimate our adherence scores, again limiting our ability to detect important predictors of nonadherence. However, other studies have shown a good correlation between self‐reported medication adherence and other more objective measures,37, 38 and recall was only for 7 days, a measure used previously in the literature39, 40 and one designed to reduce recall bias. Systematic underreporting in certain patient populations is less likely but possible.

In the future, research should focus on targeting patients who have low baseline adherence to evaluate the effects of various interventions on postdischarge medication outcomes. Repeating the study in a population with a high prevalence of low health literacy might be illuminating, given that previous studies have shown that patients with low health literacy have less ability to identify their medications and have less refill adherence.29, 30

In conclusion, in patients hospitalized with cardiovascular disease, predictors of lower postdischarge adherence include younger age, Medicaid insurance, and low baseline adherence. It may be prudent to assess baseline adherence and insurance type in hospitalized patients in order to identify those who may benefit from additional assistance to improve medication adherence and medication safety during transitions in care.

In the outpatient setting, medication adherence (defined as percentage of prescribed medication doses taken by a patient during a specific time period) ranges between 40% and 80% for chronic conditions.1 During acute care hospitalization, changes are often made to patients' medication regimens, which can be confusing and contribute to nonadherence, medication errors, and harmful adverse events.2 Indeed, it is estimated that almost half of patients encounter a medication error after discharge, and approximately 12%17% experience an adverse drug event after returning home.36 It is likely that some of these adverse events may be the result of medication nonadherence.7 Improved patientprovider communication, systems to reconcile prehospitalization and posthospitalization medications, as well as development of mechanisms to enhance adherence, may prevent many of these errors and have become new targets for quality improvement.4, 8 Although postdischarge medication adherence is a crucial target for avoiding adverse events and rehospitalization, few studies have focused on understanding its incidence and predictors, in particular, patient demographic factors such as age and insurance status.911

In addition, few studies have looked at general and posthospital adherence in a population where health literacy is measured, an important area because medication changes during hospitalization may be particularly confusing for patients with low health literacy.11, 12 Health literacy is defined as the degree to which an individual has the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.13 Prior outpatient research shows that low health literacy is associated with poor patient understanding of the medication regimen and instructions for medication use, which may contribute to postdischarge medication nonadherence.14, 15 Understanding the factors associated with postdischarge medication adherence could help refine interventions that are oriented toward improving transitions in care, patient safety, and reducing unnecessary rehospitalization.

We report here on factors associated with postdischarge medication adherence using data from the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL‐CVD) study.16

METHODS

RESULTS

Table 1 shows descriptive baseline patient characteristics of study sample (responders) as well as nonresponders at 30 days. For the responders, the mean age of the 646 patients was 61.2 years, 94.7% were insured, and 19.3% had inadequate or marginal health literacy. Patients were prescribed an average of 8 preadmission medications. Most patients (92.3%) had a regular PCP prior to admission. Nonresponders had nonsignificant trends towards having lower health literacy, medication understanding, and baseline medication adherence.

The average postdischarge adherence score was 95% (standard deviation [SD] = 10.2%), and less than 10% of patients had an adherence score of less than 85%; overall the distribution was left‐skewed. Table 2 illustrates crude and adjusted parameter estimates for variables in the model. Table 3 shows significant findings in the fully adjusted model, which used multiple imputation techniques to account for missing data.

Intervention arm was of borderline statistical significance in predicting postdischarge adherence (P = 0.052), and so was removed from the final model. Study site, age, insurance, and baseline adherence were the only significant independent predictors of postdischarge adherence in the fully adjusted model (Table 3). For example, for every 10‐year increase in age, patients had, on average, an adjusted 1% absolute increase in their adherence score (95% confidence interval [CI] 0.4% to 2.0%). For every 1‐point increase in baseline medication adherence (based on the Morisky scale), there was a 1.6% absolute increase in medication adherence (95% CI 0.8% to 2.4%). In unadjusted analyses, patients with Medicaid were less adherent with medications after discharge than were patients with private insurance. This difference became nonsignificant in adjusted analyses, but when analyses were repeated using multiple imputation techniques, the results again became statistically significantMedicaid insurance was associated with a 4.5% absolute decrease in postdischarge adherence compared with private insurance (95% CI 7.6% to 1.4%). Study site (specifically, Brigham and Women's Hospital) was also a significant predictor of greater postdischarge medication adherence. Years of education was a significant predictor of adherence in unadjusted analyses, but was not an independent predictor when adjusted for other factors. When baseline adherence was removed from the multiple imputation model, there were no changes in which factors were significant predictors of adherence.

DISCUSSION

In this study, we found that low baseline adherence, younger age, Medicaid insurance, and study site were significant predictors of lower 30‐day medication adherence. Of particular interest is our finding regarding baseline adherence, a simple measure to obtain on hospitalized patients. It is notable that in our study, education was not an independent significant predictor of postdischarge adherence, even when baseline adherence was removed from the model. The same is true for medication understanding, cognitive function, and health literacy.

Older patients appeared more adherent with medications in the month after hospital discharge, perhaps reflecting increased interaction with the healthcare system (appointments, number of physician interactions), a greater belief in the importance of chronic medication management, or a higher level of experience with managing medications. A similar relationship between age and adherence has been shown in outpatient studies of patients with hypertension, diabetes, and other chronic diseases.2427

Medicaid patients may be less likely to remain adherent because of the plan's limited coverage of medications relative to patients' ability to pay. For example, Medicaid in Tennessee covers the first 5 generic medications at no cost to the patient but has co‐payments for additional medications and for brand name drugs. Medicaid in Massachusetts has co‐payments of $1 to $3 for each medication. Alternatively, Medicaid insurance may be a marker for other patient characteristics associated with low adherence for which we were not fully able to adjust.

Site differences were also notable in this study; these differences could have been due to differences in insurance coverage in Tennessee versus Massachusetts (which has near‐universal coverage), differences in types of insurance (eg, fewer patients at Brigham and Women's Hospital had Medicaid than at Vanderbilt), cultural and geographic differences between the 2 locations, or other differences in transitional care between the 2 sites.

This study corroborates previous literature on medication adherence (specifically unintentional nonadherence) in the outpatient setting,4, 811 for example, on the association of younger age with low adherence in certain populations. On the other hand, it may contrast with previous literature which has sometimes shown a relationship between patient education or health literacy and medication adherence.14, 15, 2835 However, previous studies have not focused on the transition from inpatient to outpatient settings. Perhaps intensive medication education in the hospital, even under usual care, mitigates the effects of these factors on postdischarge adherence. Finally, baseline adherence seems to correlate with postdischarge adherence, a finding which makes intuitive sense and has been previously reported for specific medications.36

There are several limitations to this study. Although large, the study was performed at only 2 clinical sites where most patients were white and fairly well‐educated, perhaps because patients admitted to a tertiary care center with ACS or ADHF are more affluent than general medical inpatients as a whole; this may limit generalizability. Postdischarge medication adherence might have been higher than in other patient populations given the nature of the population, possible loss‐to‐follow‐up bias, and the fact that half of the subjects received an intervention designed to improve medication management after discharge; such low rates of nonadherence in our study may have reduced our ability to detect important predictors in our models. In addition, the period of follow‐up was 30 days, thus limiting our findings to short‐term postdischarge medication adherence. Postdischarge medication adherence was based on patient self‐report, which not only assumed that the patient was still managing his/her own medications after discharge, but may also be susceptible to both recall and social acceptability bias, which might overestimate our adherence scores, again limiting our ability to detect important predictors of nonadherence. However, other studies have shown a good correlation between self‐reported medication adherence and other more objective measures,37, 38 and recall was only for 7 days, a measure used previously in the literature39, 40 and one designed to reduce recall bias. Systematic underreporting in certain patient populations is less likely but possible.

In the future, research should focus on targeting patients who have low baseline adherence to evaluate the effects of various interventions on postdischarge medication outcomes. Repeating the study in a population with a high prevalence of low health literacy might be illuminating, given that previous studies have shown that patients with low health literacy have less ability to identify their medications and have less refill adherence.29, 30

In conclusion, in patients hospitalized with cardiovascular disease, predictors of lower postdischarge adherence include younger age, Medicaid insurance, and low baseline adherence. It may be prudent to assess baseline adherence and insurance type in hospitalized patients in order to identify those who may benefit from additional assistance to improve medication adherence and medication safety during transitions in care.