Tomás Villanueva, DO, MBA, FACPE, SFHM

Prehospitalization and Hospitalization

Prehospitalization and hospitalization are critical times for the patient with ACS: decisions not only affect the inpatient course but lay the groundwork for care after discharge. For ACS in particular, early identification and understanding of a patient's risk for further ischemic events is critical to determining the therapeutic course, and evidence shows that timely intervention decreases morbidity and mortality.7, 8 Notably, the evaluation and risk stratification of patients with ACS are hospitalist core competencies (Table 1); the initiation of a beta blocker and antiplatelet therapy are considered by the Center for Medicare and Medicaid Services (CMS) to be core measures by which to measure the quality of hospital care. The hospitalist may provide oversight and assure that care is coordinated and patients are assessed and triaged in a timely manner according to recommended guidelines.

Information‐gathering and evaluation begins in the emergency department (ED)9 (Table 2) and continues after admission9 (Table 3), when the hospitalist may need to seek additional medical and medication history to inform risk assessment. In fact, risk assessment should continue throughout the hospital stay as additional diagnostic information is acquired and consultations are provided. Medication reconciliation started during prehospitalization may be complicated by the lack of a reliable source of medication history and should be reevaluated 24 hours after the patient is admitted. Contact with the PCP is appropriate during the hospital stay, with the hospitalist apprising the PCP of diagnoses, interventions, and major clinical events during hospitalization. The PCP may offer valuable insight about issues related to discharge planning.

Discharge planning ideally begins soon after admission in order to adequately address issues which may complicate recovery. Medication reconciliation continues during discharge planning, and CMS core measures still apply relative to the use of beta blockers and antiplatelet therapies. Confirming the accuracy of the patient's medication history during hospitalization is an important step in medication reconciliation to ensure that therapies are appropriate and to avoid discrepancies in discharge medications.

A particular challenge of ACS care is the extensive amount of complex information which must be shared quickly and accurately with all stakeholders. The risk of miscommunication is real, but systems and tools are available to lower this risk. At this juncture, technology‐based resources can be especially useful for obtaining and organizing information. Standardized order entry programs or order sets are a reliable method that clinicians can use to meet quality standards during the patient's hospitalization and are highly recommended for patient safety. The SHM ACS Transitions Workgroup has also developed an adaptable multidisciplinary tracking tool that can be used to monitor a patient with ACS through the anticipated transitions in care. This tool tracks key pieces of clinical information throughout the hospital stay and facilitates communication between clinicians. The tool is detailed to include quality measures such as the CMS core measures and can serve as documentation to measure compliance.10 The tracking tool and examples of order sets for patients with ACS are available from the SHM in the Clinical Tools section of the ACS Quality Improvement (QI) Resource Room available at: http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_ACS/ACS_Home.cfm.

Discharge and Postdischarge

Discharge is one of the most crucial transitions in care, with potential impact on patient outcomes postdischarge, including readmission. In the past decade, initiatives to improve the discharge process, particularly discharge summaries,11 have yielded standards and tools to improve the process. Current standards for a safe discharge12, 13 are summarized in Table 4. Generally, standards address the need for delivery of a written discharge summary to the clinician who is assuming care after discharge; educating patients about their diagnosis, hospital course, and future medical needs; medication reconciliation; and, arrangement of postdischarge services such as follow‐up appointments. Additionally, the SHM has developed a discharge checklist14 (Table 5) and a template15 for the discharge summary, each to facilitate communication between stakeholders. The discharge summary is an obvious target for QI, as it is the most common vehicle for sharing patient information with the PCP and other healthcare providers. Essential elements of a discharge summary are content (Is key information captured?); format (Is content clear, concise, and accurate?); and delivery (Does the discharge summary reach the right people in a timely manner?).

Evidence indicates that the danger for patients at discharge is often related to medication reconciliation, adverse drug events (ADEs), and pending test results or testing needed after hospitalization.6 Errors affect a sizable proportion of patients, with 49% of patients in 1 study subject to at least 1 medical error within 2 months of discharge. This error was directly attributed to discontinuity during the transition from hospitalist care to the affiliated PCP practice. Errors were related to discharge medications, test results, or lack of PCP follow‐up on testing recommended by the inpatient provider (a work‐up error). Patients with a work‐up error were 6 times more likely to be rehospitalized in the 3 months following the first outpatient visit.16 Another study found that 41% of discharged patients had inhospital test results return after they were discharged and that PCPs were often unaware of these results. In some of these cases, test results required action, sometimes urgently.17

Most adverse events after discharge appear to be ADEs, with up to two‐thirds identified as preventable or ameliorable.1820 In a general medical population, Forster et al.20 found that ADEs resulted in significant injury in 71% of patients, serious injury in 13%, and life‐threatening injury in 16%. ADEs also resulted in 27% of patients requiring emergency care or readmission. Anticoagulants and cardiovascular medications were ranked high among medications associated with an ADE; failure to monitor medications was the most common cause of a preventable or ameliorable ADE, suggesting that ACS patients may be particularly at risk for an ADE following discharge. Patients had good recall of general drug information provided at discharge; patients who could not recall receiving specific information about ADEs were more likely to have an ADE. This is an area of opportunity for the hospitalist to improve patient safety during the transition to primary care. It is also of special concern for patients with ACS, given the complexity of medication regimens and the potential for serious drug reactions.

The risk of adverse events after discharge is higher in certain populations such as the elderly. Project BOOST (Better Outcomes for Older adults through Safe Transitions) is a QI initiative to improve patient care during discharge.21 BOOST aims to reduce 30‐day readmission rates for general medicine patients (especially older adults), improve patient satisfaction, improve communication between the institution and the PCP, identify high‐risk patients and mitigate risk, and improve patient and family education with a focus on patient‐specific risk factors.

BOOST uses a multidisciplinary 7P Screening tool to identify high‐risk patients, specifically through discharge planning and risk stratification.21 Seven areas are assessed: Problem medications, Punk (depression), Principal diagnosis, Polypharmacy, Poor health literacy, Patient support, and Prior hospitalization. For each, specific interventions are recommended to lower the risk of untoward events. 7P Screening applies to patients with ACS and can be an important step in identifying concerns at discharge, with the goals of promoting recovery and reducing the risk of readmission. The BOOST tool also includes a Universal Patient Discharge List reflective of those proposed by Project RED (Re‐Engineered Discharge) and the SHM. However, BOOST suggests additional steps to enhance communication: multidisciplinary rounds at discharge, direct communication with the PCP before discharge, phone contact with the patient or caregiver within 3 days of discharge, and phone numbers for hospital personnel familiar with the patient if the patient is unable to reach the PCP about an issue before the patient's first scheduled follow‐up visit. These steps recognize the value of direct communication between the hospitalist, the patient, and the PCP.

Impact of the Hospitalist on Long‐Term Outcomes

Evidenced‐based guidelines stress the need for aggressive modification of risk factors and treatment with antiplatelet, antihypertensive, and lipid‐lowering agents started during hospitalization and continued long‐term as part of secondary prevention strategies.7, 8 There is a missed opportunity for improving patient outcomes after ACS,26, 27 shown by the underuse of guideline‐recommended therapies (antiplatelet therapies such as clopidogrel and aspirin, beta blockers, angiotensin‐converting enzyme [ACE] inhibitors, and statins).28 More than one‐half of patients stopped evidence‐based medications without input from their providers, partly attributed to patients' perception that medication was not needed.26, 27, 29 In another study, 1 in 6 patients who received a DES delayed filling their antiplatelet prescription following discharge (median, 3 days; range, 1‐23 days). Patients who delayed filling the prescription were at increased risk of death or MI compared with patients who filled the prescription on the day of discharge. These findings underscore the importance of discharge planning and patient counseling to improve adherence to medications given at discharge.30 Through education, the hospitalist can directly influence patient and caregiver understanding of the benefit of ACS medications and their effect on long‐term outcomes.

Educating the patient and family about the nature, prognosis, and treatment of cardiac disease is equally important, and secondary prevention measures should be addressed prior to discharge. Prevention includes urging the patient to make therapeutic lifestyle choices such as smoking cessation (a core measure), maintaining a healthy diet, and regular exercise. Addressing these issues is important for the hospitalist and reinforced by the PCP, because adherence to behavioral changes after ACS has been shown to be poor and to directly impact outcomes. In 1 study, one‐third of smokers continued to smoke after 1 month and about one‐third of patients did not adhere to a recommended diet or exercise regimen. At 6 months, those patients who did quit smoking had a 43% lower risk of MI; compliance with the diet and exercise regimen lowered their risk of MI by 48%. Persistent smoking and nonadherence to diet and exercise resulted in an almost 4‐fold increased risk of MI, stroke, or death vs. never‐smokers who adhered to diet and exercise recommendations.31 This presents a clear opportunity for the hospitalist to intervene and affect change. Assessment of needed secondary prevention measures should occur in preparation for discharge, and an emphasis on patient teaching and communicating the plan to the PCP may overcome patient barriers to adhering to recommended lifestyle changes.

Prehospitalization and Hospitalization

Prehospitalization and hospitalization are critical times for the patient with ACS: decisions not only affect the inpatient course but lay the groundwork for care after discharge. For ACS in particular, early identification and understanding of a patient's risk for further ischemic events is critical to determining the therapeutic course, and evidence shows that timely intervention decreases morbidity and mortality.7, 8 Notably, the evaluation and risk stratification of patients with ACS are hospitalist core competencies (Table 1); the initiation of a beta blocker and antiplatelet therapy are considered by the Center for Medicare and Medicaid Services (CMS) to be core measures by which to measure the quality of hospital care. The hospitalist may provide oversight and assure that care is coordinated and patients are assessed and triaged in a timely manner according to recommended guidelines.

Information‐gathering and evaluation begins in the emergency department (ED)9 (Table 2) and continues after admission9 (Table 3), when the hospitalist may need to seek additional medical and medication history to inform risk assessment. In fact, risk assessment should continue throughout the hospital stay as additional diagnostic information is acquired and consultations are provided. Medication reconciliation started during prehospitalization may be complicated by the lack of a reliable source of medication history and should be reevaluated 24 hours after the patient is admitted. Contact with the PCP is appropriate during the hospital stay, with the hospitalist apprising the PCP of diagnoses, interventions, and major clinical events during hospitalization. The PCP may offer valuable insight about issues related to discharge planning.

Discharge planning ideally begins soon after admission in order to adequately address issues which may complicate recovery. Medication reconciliation continues during discharge planning, and CMS core measures still apply relative to the use of beta blockers and antiplatelet therapies. Confirming the accuracy of the patient's medication history during hospitalization is an important step in medication reconciliation to ensure that therapies are appropriate and to avoid discrepancies in discharge medications.

A particular challenge of ACS care is the extensive amount of complex information which must be shared quickly and accurately with all stakeholders. The risk of miscommunication is real, but systems and tools are available to lower this risk. At this juncture, technology‐based resources can be especially useful for obtaining and organizing information. Standardized order entry programs or order sets are a reliable method that clinicians can use to meet quality standards during the patient's hospitalization and are highly recommended for patient safety. The SHM ACS Transitions Workgroup has also developed an adaptable multidisciplinary tracking tool that can be used to monitor a patient with ACS through the anticipated transitions in care. This tool tracks key pieces of clinical information throughout the hospital stay and facilitates communication between clinicians. The tool is detailed to include quality measures such as the CMS core measures and can serve as documentation to measure compliance.10 The tracking tool and examples of order sets for patients with ACS are available from the SHM in the Clinical Tools section of the ACS Quality Improvement (QI) Resource Room available at: http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_ACS/ACS_Home.cfm.

Discharge and Postdischarge

Discharge is one of the most crucial transitions in care, with potential impact on patient outcomes postdischarge, including readmission. In the past decade, initiatives to improve the discharge process, particularly discharge summaries,11 have yielded standards and tools to improve the process. Current standards for a safe discharge12, 13 are summarized in Table 4. Generally, standards address the need for delivery of a written discharge summary to the clinician who is assuming care after discharge; educating patients about their diagnosis, hospital course, and future medical needs; medication reconciliation; and, arrangement of postdischarge services such as follow‐up appointments. Additionally, the SHM has developed a discharge checklist14 (Table 5) and a template15 for the discharge summary, each to facilitate communication between stakeholders. The discharge summary is an obvious target for QI, as it is the most common vehicle for sharing patient information with the PCP and other healthcare providers. Essential elements of a discharge summary are content (Is key information captured?); format (Is content clear, concise, and accurate?); and delivery (Does the discharge summary reach the right people in a timely manner?).

Evidence indicates that the danger for patients at discharge is often related to medication reconciliation, adverse drug events (ADEs), and pending test results or testing needed after hospitalization.6 Errors affect a sizable proportion of patients, with 49% of patients in 1 study subject to at least 1 medical error within 2 months of discharge. This error was directly attributed to discontinuity during the transition from hospitalist care to the affiliated PCP practice. Errors were related to discharge medications, test results, or lack of PCP follow‐up on testing recommended by the inpatient provider (a work‐up error). Patients with a work‐up error were 6 times more likely to be rehospitalized in the 3 months following the first outpatient visit.16 Another study found that 41% of discharged patients had inhospital test results return after they were discharged and that PCPs were often unaware of these results. In some of these cases, test results required action, sometimes urgently.17

Most adverse events after discharge appear to be ADEs, with up to two‐thirds identified as preventable or ameliorable.1820 In a general medical population, Forster et al.20 found that ADEs resulted in significant injury in 71% of patients, serious injury in 13%, and life‐threatening injury in 16%. ADEs also resulted in 27% of patients requiring emergency care or readmission. Anticoagulants and cardiovascular medications were ranked high among medications associated with an ADE; failure to monitor medications was the most common cause of a preventable or ameliorable ADE, suggesting that ACS patients may be particularly at risk for an ADE following discharge. Patients had good recall of general drug information provided at discharge; patients who could not recall receiving specific information about ADEs were more likely to have an ADE. This is an area of opportunity for the hospitalist to improve patient safety during the transition to primary care. It is also of special concern for patients with ACS, given the complexity of medication regimens and the potential for serious drug reactions.

The risk of adverse events after discharge is higher in certain populations such as the elderly. Project BOOST (Better Outcomes for Older adults through Safe Transitions) is a QI initiative to improve patient care during discharge.21 BOOST aims to reduce 30‐day readmission rates for general medicine patients (especially older adults), improve patient satisfaction, improve communication between the institution and the PCP, identify high‐risk patients and mitigate risk, and improve patient and family education with a focus on patient‐specific risk factors.

BOOST uses a multidisciplinary 7P Screening tool to identify high‐risk patients, specifically through discharge planning and risk stratification.21 Seven areas are assessed: Problem medications, Punk (depression), Principal diagnosis, Polypharmacy, Poor health literacy, Patient support, and Prior hospitalization. For each, specific interventions are recommended to lower the risk of untoward events. 7P Screening applies to patients with ACS and can be an important step in identifying concerns at discharge, with the goals of promoting recovery and reducing the risk of readmission. The BOOST tool also includes a Universal Patient Discharge List reflective of those proposed by Project RED (Re‐Engineered Discharge) and the SHM. However, BOOST suggests additional steps to enhance communication: multidisciplinary rounds at discharge, direct communication with the PCP before discharge, phone contact with the patient or caregiver within 3 days of discharge, and phone numbers for hospital personnel familiar with the patient if the patient is unable to reach the PCP about an issue before the patient's first scheduled follow‐up visit. These steps recognize the value of direct communication between the hospitalist, the patient, and the PCP.

Impact of the Hospitalist on Long‐Term Outcomes

Evidenced‐based guidelines stress the need for aggressive modification of risk factors and treatment with antiplatelet, antihypertensive, and lipid‐lowering agents started during hospitalization and continued long‐term as part of secondary prevention strategies.7, 8 There is a missed opportunity for improving patient outcomes after ACS,26, 27 shown by the underuse of guideline‐recommended therapies (antiplatelet therapies such as clopidogrel and aspirin, beta blockers, angiotensin‐converting enzyme [ACE] inhibitors, and statins).28 More than one‐half of patients stopped evidence‐based medications without input from their providers, partly attributed to patients' perception that medication was not needed.26, 27, 29 In another study, 1 in 6 patients who received a DES delayed filling their antiplatelet prescription following discharge (median, 3 days; range, 1‐23 days). Patients who delayed filling the prescription were at increased risk of death or MI compared with patients who filled the prescription on the day of discharge. These findings underscore the importance of discharge planning and patient counseling to improve adherence to medications given at discharge.30 Through education, the hospitalist can directly influence patient and caregiver understanding of the benefit of ACS medications and their effect on long‐term outcomes.

Educating the patient and family about the nature, prognosis, and treatment of cardiac disease is equally important, and secondary prevention measures should be addressed prior to discharge. Prevention includes urging the patient to make therapeutic lifestyle choices such as smoking cessation (a core measure), maintaining a healthy diet, and regular exercise. Addressing these issues is important for the hospitalist and reinforced by the PCP, because adherence to behavioral changes after ACS has been shown to be poor and to directly impact outcomes. In 1 study, one‐third of smokers continued to smoke after 1 month and about one‐third of patients did not adhere to a recommended diet or exercise regimen. At 6 months, those patients who did quit smoking had a 43% lower risk of MI; compliance with the diet and exercise regimen lowered their risk of MI by 48%. Persistent smoking and nonadherence to diet and exercise resulted in an almost 4‐fold increased risk of MI, stroke, or death vs. never‐smokers who adhered to diet and exercise recommendations.31 This presents a clear opportunity for the hospitalist to intervene and affect change. Assessment of needed secondary prevention measures should occur in preparation for discharge, and an emphasis on patient teaching and communicating the plan to the PCP may overcome patient barriers to adhering to recommended lifestyle changes.

Prehospitalization and Hospitalization

Prehospitalization and hospitalization are critical times for the patient with ACS: decisions not only affect the inpatient course but lay the groundwork for care after discharge. For ACS in particular, early identification and understanding of a patient's risk for further ischemic events is critical to determining the therapeutic course, and evidence shows that timely intervention decreases morbidity and mortality.7, 8 Notably, the evaluation and risk stratification of patients with ACS are hospitalist core competencies (Table 1); the initiation of a beta blocker and antiplatelet therapy are considered by the Center for Medicare and Medicaid Services (CMS) to be core measures by which to measure the quality of hospital care. The hospitalist may provide oversight and assure that care is coordinated and patients are assessed and triaged in a timely manner according to recommended guidelines.

Information‐gathering and evaluation begins in the emergency department (ED)9 (Table 2) and continues after admission9 (Table 3), when the hospitalist may need to seek additional medical and medication history to inform risk assessment. In fact, risk assessment should continue throughout the hospital stay as additional diagnostic information is acquired and consultations are provided. Medication reconciliation started during prehospitalization may be complicated by the lack of a reliable source of medication history and should be reevaluated 24 hours after the patient is admitted. Contact with the PCP is appropriate during the hospital stay, with the hospitalist apprising the PCP of diagnoses, interventions, and major clinical events during hospitalization. The PCP may offer valuable insight about issues related to discharge planning.

Discharge planning ideally begins soon after admission in order to adequately address issues which may complicate recovery. Medication reconciliation continues during discharge planning, and CMS core measures still apply relative to the use of beta blockers and antiplatelet therapies. Confirming the accuracy of the patient's medication history during hospitalization is an important step in medication reconciliation to ensure that therapies are appropriate and to avoid discrepancies in discharge medications.

A particular challenge of ACS care is the extensive amount of complex information which must be shared quickly and accurately with all stakeholders. The risk of miscommunication is real, but systems and tools are available to lower this risk. At this juncture, technology‐based resources can be especially useful for obtaining and organizing information. Standardized order entry programs or order sets are a reliable method that clinicians can use to meet quality standards during the patient's hospitalization and are highly recommended for patient safety. The SHM ACS Transitions Workgroup has also developed an adaptable multidisciplinary tracking tool that can be used to monitor a patient with ACS through the anticipated transitions in care. This tool tracks key pieces of clinical information throughout the hospital stay and facilitates communication between clinicians. The tool is detailed to include quality measures such as the CMS core measures and can serve as documentation to measure compliance.10 The tracking tool and examples of order sets for patients with ACS are available from the SHM in the Clinical Tools section of the ACS Quality Improvement (QI) Resource Room available at: http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_ACS/ACS_Home.cfm.

Discharge and Postdischarge

Discharge is one of the most crucial transitions in care, with potential impact on patient outcomes postdischarge, including readmission. In the past decade, initiatives to improve the discharge process, particularly discharge summaries,11 have yielded standards and tools to improve the process. Current standards for a safe discharge12, 13 are summarized in Table 4. Generally, standards address the need for delivery of a written discharge summary to the clinician who is assuming care after discharge; educating patients about their diagnosis, hospital course, and future medical needs; medication reconciliation; and, arrangement of postdischarge services such as follow‐up appointments. Additionally, the SHM has developed a discharge checklist14 (Table 5) and a template15 for the discharge summary, each to facilitate communication between stakeholders. The discharge summary is an obvious target for QI, as it is the most common vehicle for sharing patient information with the PCP and other healthcare providers. Essential elements of a discharge summary are content (Is key information captured?); format (Is content clear, concise, and accurate?); and delivery (Does the discharge summary reach the right people in a timely manner?).

Evidence indicates that the danger for patients at discharge is often related to medication reconciliation, adverse drug events (ADEs), and pending test results or testing needed after hospitalization.6 Errors affect a sizable proportion of patients, with 49% of patients in 1 study subject to at least 1 medical error within 2 months of discharge. This error was directly attributed to discontinuity during the transition from hospitalist care to the affiliated PCP practice. Errors were related to discharge medications, test results, or lack of PCP follow‐up on testing recommended by the inpatient provider (a work‐up error). Patients with a work‐up error were 6 times more likely to be rehospitalized in the 3 months following the first outpatient visit.16 Another study found that 41% of discharged patients had inhospital test results return after they were discharged and that PCPs were often unaware of these results. In some of these cases, test results required action, sometimes urgently.17

Most adverse events after discharge appear to be ADEs, with up to two‐thirds identified as preventable or ameliorable.1820 In a general medical population, Forster et al.20 found that ADEs resulted in significant injury in 71% of patients, serious injury in 13%, and life‐threatening injury in 16%. ADEs also resulted in 27% of patients requiring emergency care or readmission. Anticoagulants and cardiovascular medications were ranked high among medications associated with an ADE; failure to monitor medications was the most common cause of a preventable or ameliorable ADE, suggesting that ACS patients may be particularly at risk for an ADE following discharge. Patients had good recall of general drug information provided at discharge; patients who could not recall receiving specific information about ADEs were more likely to have an ADE. This is an area of opportunity for the hospitalist to improve patient safety during the transition to primary care. It is also of special concern for patients with ACS, given the complexity of medication regimens and the potential for serious drug reactions.

The risk of adverse events after discharge is higher in certain populations such as the elderly. Project BOOST (Better Outcomes for Older adults through Safe Transitions) is a QI initiative to improve patient care during discharge.21 BOOST aims to reduce 30‐day readmission rates for general medicine patients (especially older adults), improve patient satisfaction, improve communication between the institution and the PCP, identify high‐risk patients and mitigate risk, and improve patient and family education with a focus on patient‐specific risk factors.

BOOST uses a multidisciplinary 7P Screening tool to identify high‐risk patients, specifically through discharge planning and risk stratification.21 Seven areas are assessed: Problem medications, Punk (depression), Principal diagnosis, Polypharmacy, Poor health literacy, Patient support, and Prior hospitalization. For each, specific interventions are recommended to lower the risk of untoward events. 7P Screening applies to patients with ACS and can be an important step in identifying concerns at discharge, with the goals of promoting recovery and reducing the risk of readmission. The BOOST tool also includes a Universal Patient Discharge List reflective of those proposed by Project RED (Re‐Engineered Discharge) and the SHM. However, BOOST suggests additional steps to enhance communication: multidisciplinary rounds at discharge, direct communication with the PCP before discharge, phone contact with the patient or caregiver within 3 days of discharge, and phone numbers for hospital personnel familiar with the patient if the patient is unable to reach the PCP about an issue before the patient's first scheduled follow‐up visit. These steps recognize the value of direct communication between the hospitalist, the patient, and the PCP.

Impact of the Hospitalist on Long‐Term Outcomes

Evidenced‐based guidelines stress the need for aggressive modification of risk factors and treatment with antiplatelet, antihypertensive, and lipid‐lowering agents started during hospitalization and continued long‐term as part of secondary prevention strategies.7, 8 There is a missed opportunity for improving patient outcomes after ACS,26, 27 shown by the underuse of guideline‐recommended therapies (antiplatelet therapies such as clopidogrel and aspirin, beta blockers, angiotensin‐converting enzyme [ACE] inhibitors, and statins).28 More than one‐half of patients stopped evidence‐based medications without input from their providers, partly attributed to patients' perception that medication was not needed.26, 27, 29 In another study, 1 in 6 patients who received a DES delayed filling their antiplatelet prescription following discharge (median, 3 days; range, 1‐23 days). Patients who delayed filling the prescription were at increased risk of death or MI compared with patients who filled the prescription on the day of discharge. These findings underscore the importance of discharge planning and patient counseling to improve adherence to medications given at discharge.30 Through education, the hospitalist can directly influence patient and caregiver understanding of the benefit of ACS medications and their effect on long‐term outcomes.

Educating the patient and family about the nature, prognosis, and treatment of cardiac disease is equally important, and secondary prevention measures should be addressed prior to discharge. Prevention includes urging the patient to make therapeutic lifestyle choices such as smoking cessation (a core measure), maintaining a healthy diet, and regular exercise. Addressing these issues is important for the hospitalist and reinforced by the PCP, because adherence to behavioral changes after ACS has been shown to be poor and to directly impact outcomes. In 1 study, one‐third of smokers continued to smoke after 1 month and about one‐third of patients did not adhere to a recommended diet or exercise regimen. At 6 months, those patients who did quit smoking had a 43% lower risk of MI; compliance with the diet and exercise regimen lowered their risk of MI by 48%. Persistent smoking and nonadherence to diet and exercise resulted in an almost 4‐fold increased risk of MI, stroke, or death vs. never‐smokers who adhered to diet and exercise recommendations.31 This presents a clear opportunity for the hospitalist to intervene and affect change. Assessment of needed secondary prevention measures should occur in preparation for discharge, and an emphasis on patient teaching and communicating the plan to the PCP may overcome patient barriers to adhering to recommended lifestyle changes.