Schmittdiel Julie A, Uratsu Connie S, Karter Andrew J, Heisler Michele, Subramanian Usha, Mangione Carol M, Selby Joe V
Division of Research, Kaiser Permanente Medical Care Program, Oakland, CA, USA.
J Gen Intern Med. 2008 May;23(5):588-94. doi: 10.1007/s11606-008-0554-8. Epub 2008 Mar 4.
Despite the availability of effective hypertension, hyperlipidemia, and hyperglycemia therapies, target levels of systolic blood pressure (SBP), LDL-cholesterol (LDL-c), and hemoglobin A1c control are often not achieved.
To examine the relative importance of patient medication nonadherence versus clinician lack of therapy intensification in explaining above target cardiovascular disease (CVD) risk factor levels.
Cross-sectional assessment.
In 2005, 161,697 Kaiser Permanente Northern California adult diabetes patients were included in the study.
"Above target" was defined as most recent A1c >/=7.0% for hyperglycemia, LDL-c >/=100 mg/dL for hyperlipidemia, and SBP >/=130 mmHg for hypertension. Poor adherence was defined as medication gaps for >/=20% of days covered for all medications for each condition separately. Treatment intensification was defined as an increase in the number of drug classes, increased dosage of a class, or a switch to a different class within the 3 months before or after notation of above target levels.
Poor adherence was found in 20-23% of patients across the 3 conditions. No evidence of poor adherence with no treatment intensification was found in 30% of hyperglycemia patients, 47% of hyperlipidemia patients, and 36% of hypertension patients. Poor adherence or lack of therapy intensification was evident in 53-68% of patients above target levels across conditions.
Both nonadherence and lack of treatment intensification occur frequently in patients above target for CVD risk factor levels; however, lack of therapy intensification was somewhat more common. Quality improvement efforts should focus on these modifiable barriers to CVD risk factor control.
尽管有有效的高血压、高脂血症和高血糖治疗方法，但收缩压（SBP）、低密度脂蛋白胆固醇（LDL-c）和糖化血红蛋白A1c的目标控制水平往往无法实现。
探讨患者药物治疗依从性差与临床医生治疗强化不足在解释心血管疾病（CVD）危险因素水平高于目标值方面的相对重要性。
横断面评估。
2005年，161,697名北加利福尼亚州凯撒医疗集团的成年糖尿病患者被纳入研究。
“高于目标值”定义为：高血糖时最近的糖化血红蛋白A1c≥7.0%，高脂血症时低密度脂蛋白胆固醇≥100mg/dL，高血压时收缩压≥130mmHg。依从性差定义为每种疾病所有药物的覆盖天数中有≥20%的药物服用中断。治疗强化定义为在记录到高于目标水平之前或之后的3个月内，药物类别数量增加、某一类别药物剂量增加或更换为另一类别药物。
在这3种情况下，20%-23%的患者存在依从性差的问题。在30%的高血糖患者、47%的高脂血症患者和36%的高血压患者中，未发现无治疗强化情况下的依从性差证据。在所有情况下，53%-68%高于目标水平的患者存在依从性差或治疗强化不足的情况。
在CVD危险因素水平高于目标值的患者中，不依从和治疗强化不足都很常见；然而，治疗强化不足更为普遍。质量改进工作应关注这些可改变的CVD危险因素控制障碍。
