Department of Internal Medicine, University of Michigan, Ann Arbor, USA.
BMC Health Serv Res. 2012 Aug 21;12:270. doi: 10.1186/1472-6963-12-270.
Many patients have uncontrolled blood pressure (BP) because they are not taking medications as prescribed. Providers may have difficulty accurately assessing adherence. Providers need to assess medication adherence to decide whether to address uncontrolled BP by improving adherence to the current prescribed regimen or by intensifying the BP treatment regimen by increasing doses or adding more medications.
We examined how provider assessments of adherence with antihypertensive medications compared with refill records, and how providers' assessments were associated with decisions to intensify medications for uncontrolled BP. We studied a cross-sectional cohort of 1169 veterans with diabetes presenting with BP ≥140/90 to 92 primary care providers at 9 Veterans Affairs (VA) facilities from February 2005 to March 2006. Using VA pharmacy records, we utilized a continuous multiple-interval measure of medication gaps (CMG) to assess the proportion of time in prior year that patient did not possess the prescribed medications; CMG ≥20% is considered clinically significant non-adherence. Providers answered post-visit Likert-scale questions regarding their assessment of patient adherence to BP medications. The BP regimen was considered intensified if medication was added or increased without stopping or decreasing another medication.
1064 patients were receiving antihypertensive medication regularly from the VA; the mean CMG was 11.3%. Adherence assessments by providers correlated poorly with refill history. 211 (20%) patients did not have BP medication available for ≥ 20% of days; providers characterized 79 (37%) of these 211 patients as having significant non-adherence, and intensified medications for 97 (46%). Providers intensified BP medications for 451 (42%) patients, similarly whether assessed by provider as having significant non-adherence (44%) or not (43%).
Providers recognized non-adherence for less than half of patients whose pharmacy records indicated significant refill gaps, and often intensified BP medications even when suspected serious non-adherence. Making an objective measure of adherence such as the CMG available during visits may help providers recognize non-adherence to inform prescribing decisions.
许多患者的血压（BP）得不到控制，因为他们没有按照医嘱服药。医务人员可能难以准确评估患者的服药依从性。医务人员需要评估患者的服药依从性，以确定是通过提高对当前规定治疗方案的依从性来控制血压，还是通过增加剂量或增加更多药物来强化降压治疗方案。
我们检查了医务人员对降压药物的依从性评估与药物补充记录的对比情况，以及医务人员的评估与强化血压控制药物治疗的决策之间的关系。我们研究了 2005 年 2 月至 2006 年 3 月期间，在 9 家退伍军人事务部（VA）医疗中心的 1169 例糖尿病合并血压≥140/90mmHg 的退伍军人，对 92 位初级保健医生进行了横断面研究。使用 VA 药房记录，我们采用连续多间隔药物中断（CMG）测量方法，评估了患者在前一年未服用规定药物的时间比例；CMG≥20%被认为是临床显著的不依从。医务人员在就诊后通过李克特量表回答关于患者对降压药物的依从性评估问题。如果增加或增加药物而不停止或减少另一种药物，则认为降压方案被强化。
1064 例患者正在从 VA 定期服用降压药物，平均 CMG 为 11.3%。医务人员的依从性评估与药物补充记录相关性较差。211 例（20%）患者至少有 20%的日子没有服用降压药物；医务人员将这 211 例患者中的 79 例（37%）患者描述为存在显著不依从，其中 97 例（46%）患者强化了药物治疗。医务人员强化了 451 例（42%）患者的降压药物治疗，无论医务人员认为这些患者是否存在显著不依从（44%）或不存在显著不依从（43%）。
不到一半的患者因药物补充记录显示明显的药物中断而被医务人员认为存在不依从，即使怀疑严重不依从，医务人员也经常强化降压药物治疗。在就诊期间提供客观的依从性测量方法，如 CMG，可能有助于医务人员识别不依从，从而为处方决策提供信息。
