Optimised heart failure medication in hospital-to-home transitions: An adherence burden for patients?

Abstract

When patients are hospitalised for heart failure (HF), doctors review and optimise their pharmacotherapy at subsequent care transitions. Studies show that patients, many of whom are old and frail, have adherence rates of only 40%-60%. Few communication studies have examined the burden of optimisation on patients as their regimens evolve. Focusing on prescription changes over multiple care transitions, we aimed to: (1) identify how many changes patients received, (2) characterise the support provided in discharge letters, and (3) assess patients' implementation of changes at home. We conducted an exploratory, observational cohort study with prospective longitudinal data collection. We recruited 23 older HF patients in Norway, collecting observational data (medical records, discharge letters, interviews, photographs) from their hospital visits (admission, discharge), general practitioner visit, and their homes. We inductively developed a systematic analytical procedure to identify prescription changes and to assess the quality of doctors' written information about patients' medication management at home. Doctors made a median of six prescription changes per patient (range 2-19) over a median timespan of 25 days, usually leading to more medications. Of the discharge letters patients received, 26% provided clear instructions about all changes and explanations of the benefit. While all patients reported adherence, home visits revealed 17% had discrepancies indicating non-adherence, and 61% dispensed medications from original pharmacy packaging with outdated dosing instructions. To adhere to their optimised pharmacotherapy, HF patients needed to implement many incremental changes. Doctors' discharge letters were often unclear or lacked information about the changes. To enhance patients' ability to adhere to treatment, clinicians may consider: (i) improving the quality of discharge letters, including clarifying medication labels (ii) providing updated instructions for old medication packages, (iii) normalising and providing safety-net support for non-adherence to HF regimens. Further research is needed to test these actions.