Keywords

Clopidogrel, Medically uninsured persons, Myocardial infarction

Abstract

The Joint Commission in a joint effort with the Centers of Medicare and Medicaid Services (CMS) has established certain "core measures" by which hospital performance is measured. One of these is the measure for patients with ST-elevation myocardial infarction (STEMI) recommending percutaneous coronary intervention within 90 minutes of presentation to the Emergency Department in institutions that are able to provide this service. This recommendation does not take into account the long-term use of clopidogrel that is recommended by the American College of Cardiology and American Heart Association for patients that are treated with coronary stents. The purpose of this study was to evaluate outcomes of providing a short course of clopidogrel versus a prescription alone for clopidogrel to uninsured patients experiencing STEMI who were treated with a bare metal stent. After conducting a cost-benefit analysis, a policy was approved that provided uninsured STEMI patients with clopidogrel at discharge rather than a prescription. A social worker evaluated patients to determine if they met criteria and arranged for medication delivery to the patient’s bedside. A retrospective chart review for all patients who presented to the Emergency Department during two different time frames (before and after policy implementation) was conducted to evaluate if providing clopidogrel decreased readmissions. Data were collected on over a 15-month period of time before and after the clopidogrel policy implementation to allow for evaluation of 90-day readmissions with repeat STEMI. Data were analyzed using chi-square cross tabulation and T-test for independent samples. A total of 201 charts were reviewed: 100 from the pre-intervention group and 101 from the post-intervention group. Demographic characteristics of age, gender and insurance status iv were not statistically different between groups. The mean age for the control group was 59.1 (+ 13.8) years and 58.9 (+ 13.6) years for the intervention group. Twenty percent of the patients were uninsured. Five uninsured patients were readmitted with STEMI prior to the intervention compared to two patients in the intervention group (p = .191). The admissions for the preintervention patients occurred in the first 30 days after discharge compared to 31-60 days in the post-intervention group. All of the patients who were readmitted were assessed to be noncompliant with treatment. Additionally, a transition to increased use of bare metal stents in STEMI patients from 23.1% pre-intervention to 67.4% post-intervention was noted (p < .001). Although no differences were found in readmission rates, fewer readmissions for STEMI were noted after the intervention. The small number of patients who were readmitted with STEMI likely accounted for this finding, and additional monitoring of readmission rates is warranted. Despite provision of the clopidogrel, adherence remains an issue and needs to be addressed. During the intervention, physicians were encouraged to consider the financial and social resources of individual STEMI patients presenting to the Emergency Department to help identify patients that would be less likely to adhere to antiplatelet therapy. In those believed to be at high risk for non-adherence, primarily due to inability to purchase the relatively expensive medication clopidogrel, many physicians chose to insert bare metal stents rather than drugeluting stents to take advantage of the shorter course of clopidogrel required post procedure. Provision of a 30-day course of clopidogrel and aspirin was a major part of this effort to decrease recurrent myocardial infarction in this at-risk population. A few patients eligible for the clopidogrel were not provided the medication if they were admitted to a nursing unit where staff members were not familiar with the policy; revisions to the policy to ensure medication is provided to all eligible patients will be made. Providing clopidogrel to patients who experience v STEMI may improve adherence and thereby decrease readmissions as a result of repeat STEMI due to subacute thrombus formation. Patients who experience STEMI continue to be vulnerable after STEMI. Programs that provide medication to patients should be expanded within this facility and to other hospital systems to encompass all patients who are treated for STEMI. Multi-disciplinary collaboration is necessary in developing and implementing a program that will address care for this.

Notes

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Graduation Date

2011

Semester

Spring

Advisor

Sole, Mary Lou

Degree

Doctor of Nursing Practice (D.N.P.)

College

College of Nursing

Department

Nursing

Degree Program

Nursing Practice

Format

application/pdf

Identifier

CFE0003940

URL

http://purl.fcla.edu/fcla/etd/CFE0003940

Language

English

Length of Campus-only Access

None

Access Status

Doctoral Dissertation (Open Access)

Subjects

Dissertations, Academic -- Nursing, Nursing -- Dissertations, Academic

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Nursing Commons

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