Sanfélix-Gimeno Gabriel, Peiró Salvador, Ferreros Inma, Pérez-Vicente Raquel, Librero Julián, Catalá-López Ferrán, Ortiz Francisco, Tortosa-Nácher Vicent
Health Services Research Unit, Center for Public Health Research (CSISP-FISABIO), Valencia, Spain.
J Manag Care Pharm. 2013 Apr;19(3):247-57. doi: 10.18553/jmcp.2013.19.3.247.
Pharmacological secondary prevention in patients after an acute coronary syndrome (ACS) has contributed substantially to reductions in cardiovascular morbidity and mortality and, overall, has undergone important improvements in recent years. Nevertheless, there is still a considerable adherence gap and opportunity for improvement.
To assess, in a cohort of patients who survived an ACS, adherence to commonly prescribed secondary prevention drugs, factors associated to adherence, and variations among health care delivery areas.
We combined the medical and pharmacy databases from a regional public health service in Valencia, Spain, to construct a population-based cohort of patients discharged alive after an emergency admission for an ACS to any hospital of the Valencia Health Agency in 2008. We evaluated medication adherence by determining the proportion of days covered (PDC) for each therapeutic group (antiplatelet agents, beta-blockers, angiotensin antagonists, and statins) in the 9 months following hospital discharge. Fully adherent patients were defined as those having enough treatment to cover 75% (PDC75) of the follow-up period.
The study cohort consisted of 7,462 patients. PDC75 was reached by 69.9% of patients taking antiplatelet agents, 43.3% taking beta-blockers, 45.4% taking angiotensin antagonists, and 58.8% taking statins. Approximately 18% of patients did not reach PDC75 with any treatment, while 47.6% did so for 3 or more therapeutic groups. Lower adherence was found in diagnoses other than myocardial infarction. Other factors associated with nonadherence were older age, women, having copayment, foreign born, and most comorbidities (except for hypertension and hyperlipidemia, which were inversely associated, and diabetes and peripheral disease, which were not significantly associated). Health care delivery areas showed certain variability in their performance on these adherence measures that remained after the adjustment for covariates, although confidence intervals overlapped except between areas at the extremes.
The proportion of fully adherent patients remains suboptimal, and important improvements are still possible in secondary prevention of ischemic heart disease. The combination of electronic health information systems may be very useful for monitoring adherence and evaluating the effectiveness of adherence and other quality improvement interventions.
急性冠状动脉综合征（ACS）患者的药物二级预防对降低心血管发病率和死亡率有显著贡献，总体而言，近年来已取得重要进展。然而，依从性差距仍然相当大，仍有改进空间。
在一组ACS存活患者中，评估常用二级预防药物的依从性、与依从性相关的因素以及医疗服务区域之间的差异。
我们合并了西班牙巴伦西亚地区公共卫生服务机构的医疗和药房数据库，以构建一个基于人群的队列，该队列由2008年因ACS紧急入院后从巴伦西亚卫生局的任何医院存活出院的患者组成。我们通过确定出院后9个月内每个治疗组（抗血小板药物、β受体阻滞剂、血管紧张素拮抗剂和他汀类药物）的覆盖天数比例（PDC）来评估药物依从性。完全依从的患者定义为那些有足够治疗覆盖随访期75%（PDC75）的患者。
研究队列包括7462名患者。服用抗血小板药物的患者中69.9%达到PDC75，服用β受体阻滞剂的患者中43.3%达到，服用血管紧张素拮抗剂的患者中45.4%达到，服用他汀类药物的患者中58.8%达到。约18%的患者任何治疗都未达到PDC75，而47.6%的患者在3个或更多治疗组中未达到。除心肌梗死外的其他诊断中依从性较低。与不依从相关的其他因素包括年龄较大、女性、有自付费用、外国出生以及大多数合并症（除高血压和高脂血症呈负相关，糖尿病和外周疾病无显著相关性外）。医疗服务区域在这些依从性指标上的表现存在一定差异，在调整协变量后仍然存在，尽管除了极端区域之间外，置信区间有重叠。
完全依从患者的比例仍然不理想，缺血性心脏病的二级预防仍有很大改进空间。电子健康信息系统的结合可能对监测依从性以及评估依从性有效性和其他质量改进干预措施非常有用。
