Warren Jim, Kennelly John, Warren Debra, Elley C Raina, Wai Kuinileti Chang, Manukia Marilyn, Davy Jennifer, Mabotuwana Thusitha, Robinson Elizabeth
National Institute for Health Innovation, University of Auckland, New Zealand.
Stud Health Technol Inform. 2012;178:228-34.
Analysis of practice electronic medical records (EMRs) demonstrated widespread antihypertensive medication adherence problems in a Pacific-led general practice serving a predominantly Pacific (majority Samoan) caseload in suburban New Zealand. Adherence was quantified in terms of medication possession ratio (MPR, percent of days covered by medication supply) from the practice's prescribing data. We studied the effectiveness of general practice staff follow-up guided by EMR data to improve medication adherence.
A framework for identification of suboptimal long-term condition management from routinely-collected EMR data, the ChronoMedIt (Chronological Medical Audit) tool, was applied to data of two Pacific-led general practices to identify patients with low MPR. One practice undertook intervention, the other provided usual care. A cohort was based on MPR<80% for antihypertensive medication in a baseline 6-month period. At the intervention practice a team was established to provide reminders and motivation for these patients and discuss their specific needs for assistance to improve adherence for 12 months. MPR and systolic blood pressure (SBP) was collected at baseline and for last six months of intervention based on practice EMRs; national claims data provided assessment of MPR based on dispensing. Nursing notes were analysed, and patient and provider focus groups were conducted.
Of the 252 intervention patients with MPR<80% initially, MPR improved 12.0% (p=0.0002) and systolic blood pressure was 3.5mmHg lower (p=0.07) as compared to the control cohort. MPR from national claims data improved by 11.5% (p=0.0001) as compared to the control. Patients welcomed the approach as caring and useful. Providers felt the approach worthy of wider deployment but that it required dedicated staffing.
Systematic follow-up of patients with demonstrated poor medication possession appears effective in the context of a Pacific-led general practice serving a largely Pacific caseload. It was possible to exploit the EMR database to identify patients with low antihypertensive medication possession and to raise their level of medication possession significantly. The measured effect on systolic BP was only marginally significant, leaving open the question of the precise value of the intervention in terms of morbidity and mortality. The intervention was found to be feasible and was met with good acceptance from the intervention patients, who appreciated the concern reflected in the follow-up effort. The intervention practice is continuing use of ChronoMedIt to guide long-term condition management with extension to cholesterol and blood sugar.
对实践电子病历（EMR）的分析表明，在新西兰郊区一家以太平洋岛民为主导的全科诊所中，普遍存在抗高血压药物依从性问题，该诊所的主要服务对象是太平洋岛民（多数为萨摩亚人）。根据诊所的处方数据，以药物持有率（MPR，即药物供应覆盖天数的百分比）来量化依从性。我们研究了以EMR数据为指导的全科诊所工作人员随访对提高药物依从性的有效性。
将一种从常规收集的EMR数据中识别长期病情管理欠佳情况的框架——ChronoMedIt（按时间顺序进行的医疗审核）工具，应用于两家以太平洋岛民为主导的全科诊所的数据，以识别MPR较低的患者。一家诊所进行干预，另一家提供常规护理。以基线6个月期间抗高血压药物的MPR<80%为依据确定一个队列。在干预诊所，成立了一个团队，为这些患者提供提醒和激励，并讨论他们在改善依从性方面的具体援助需求，为期12个月。根据诊所的EMR收集基线时以及干预最后六个月的MPR和收缩压（SBP）；国家索赔数据提供基于配药情况的MPR评估。对护理记录进行了分析，并开展了患者和提供者焦点小组。
最初MPR<80%的252名干预患者中，与对照组相比，MPR提高了12.0%（p=0.0002），收缩压降低了3.5mmHg（p=0.07）。与对照组相比，国家索赔数据中的MPR提高了11.5%（p=0.0001）。患者对这种方法表示欢迎，认为其贴心且有用。提供者认为这种方法值得更广泛地推广，但需要专门的人员配备。
在一家以太平洋岛民为主导、主要服务太平洋岛民患者的全科诊所中，对已证明药物持有情况不佳的患者进行系统随访似乎是有效的。利用EMR数据库识别抗高血压药物持有率低的患者并显著提高他们的药物持有水平是可行的。对收缩压的测量效果仅略微显著，这使得干预在发病率和死亡率方面的确切价值存在疑问。发现该干预是可行的，并且受到干预患者的良好接受，他们赞赏随访工作中体现的关怀。干预诊所正在继续使用ChronoMedIt来指导长期病情管理，并将其扩展到胆固醇和血糖方面。
