At least a quarter of patients who have suffered a stroke stop taking one or more of their prescribed stroke prevention medications within the first three months after being hospitalized – when the chance of having another stroke is highest – according to a new study by researchers at Wake Forest University Baptist Medical Center and colleagues.
Each year, there are an estimated 180,000 recurrent strokes in the United States. The study identified several modifiable factors that are associated with stroke survivors’ compliance in taking medication that can help prevent recurrent stroke. Researchers hope those factors will prove effective targets for improving compliance.
The paper appears online this week in the Archives of Neurology, one of the JAMA/Archives journals, and is scheduled to appear in the journal’s December print issue.
“There is very little known about how stroke patients feel about their medications and all of the complicated reasons that people may or may not stay on those medications,” said Cheryl D. Bushnell, M.D., M.H.S., an associate professor of neurology at Wake Forest Baptist and lead author on the study. “Physicians can prescribe all of the right medications, but if patients don’t take them, they’re not receiving the benefits of prevention.”
So, Bushnell and colleagues, including researchers at Duke Clinical Research Institute, designed a study similar to those done to investigate medication compliance in patients with coronary artery disease. They looked at compliance issues from the patients’ perspective, as well as system and provider issues, such as what type of doctor the patients saw, what kind of follow-up care they had and the patients’ understanding of their medications and why they were taking them.
The researchers studied 2,598 patients from the Adherence Evaluation After Ischemic Stroke–Longitudinal (AVAIL) Registry to evaluate how many stroke patients continued taking their prescribed medications to prevent a second stroke three months after their discharge from the hospital. The chance of a second stroke, the authors noted, is greatest during the first three months after the initial attack.
The authors found that about 75 percent of those studied had continued with their full regimen of medications – usually including an aspirin or other type of blood thinner, blood pressure medication and cholesterol lowering medication – three months after discharge. But they also found that nearly 20 percent of patients had stopped taking one or more of their prescribed medications, while 3.5 percent of patients weren’t taking any of their medications at three months.
“This is actually much better than what we would expect based on our clinical experience,” Bushnell said. “It’s surprising at how high the compliance rate was. As physicians, we often see a lot more patients stopping their medicine on their own or having it stopped by a physician, so we think this may have been a best-case scenario, but it’s still concerning. That’s a lot of people at high risk of having a second stroke who are not doing everything they can to prevent it.” Bushnell explained that the participating hospitals were all involved in quality improvement activities for stroke care, so they were highly motivated to have good stroke outcomes. It is possible that the patients at these hospitals were seen for their follow-up appointments by the same doctor who prescribed the medications at discharge, unlike many hospitals where follow-up care is handled by the patient’s normal doctor.
Researchers learned from the study that multiple factors were associated with persistence in continuing secondary medication regimens, including the presence of cardiovascular disease and risk factors prior to stroke, having insurance, having a better quality of life, being prescribed fewer discharge medications and having an understanding of why these medications were prescribed and how to refill them. Additionally, increasing age, lesser stroke disability and fewer financial hardships were also associated with persistence in continuing medication regimens.
Bushnell also explained that many times, patients aren’t discontinuing their medications on their own, but rather their doctors may be discontinuing them.
“I think that a lot of patients will tell their doctors that the medication doesn’t agree with them or they can’t take it for some other reason and the doctor takes them off of it,” Bushnell said. “Many doctors try to limit the number of medications a patient has to take, especially when a lot of the same medicines can be used to treat both stroke and coronary disease.”
In fact, patients who had a diagnosis of coronary disease or some other chronic disease before their stroke and were accustomed to taking daily medications to treat that condition were more likely to continue taking their new medications after stroke, the study showed.
“Patients who are taken off-guard by a stroke, and are given a lot of new medications and a new diagnosis, can get a little overwhelmed and the result can be discontinuation of one or more medications,” she said. “But we learned that patients who actually understand why they are being prescribed each new medication and how to go about refilling their prescriptions are more compliant. This is a really important teaching moment. We, as doctors, need to make sure we are giving patients more specific information upon discharge. We need to explain things in more detail, such as, ‘This blood pressure medication we’re asking you to take isn’t just for lowering your blood pressure, it’s for preventing another stroke.’
“This study has really changed the way I interact with my patients,” Bushnell added. “I’ve started asking the sometimes uncomfortable questions about whether they can afford their medications and if they’re taking them. If they aren’t, I’m asking why. My passion is to try to prevent recurrent stroke and to understand the patients’ and caregivers’ perspectives and the barriers and areas we can intervene in to make sure that people have the knowledge and resources to keep taking their medicines. Hopefully, we as providers can improve patients’ medication compliance through better communication and by being aware of the factors associated with medication discontinuation.”
The researchers’ next study will reveal the compliance results one year after hospital discharge.
This study was conceived and designed by the AVAIL team, researchers at Duke Clinical Research Institute, the project executive committee and an American Heart Association representative. The AVAIL analyses were also supported in part by a grant from the Agency for Healthcare Research and Quality.