*Pharmacy Analytical Services Research Group, Kaiser Permanente Southern California, Downey †Schaeffer Center for Health Policy and Economics, University of Southern, California, Los Angeles, CA.
Med Care. 2013 Oct;51(10):879-87. doi: 10.1097/MLR.0b013e31829fa8ed.
To investigate multiple medication adherence (MMA) and its impact on microvascular and macrovascular complications using instrumental variables (IVs).
A retrospective observational study was conducted using administrative claims and electronic medical records from a large physician group in Southern California (N=2334).
We identified individuals between January 2006 and June 2009 newly starting oral diabetes (DM) or hypertension (HTN) medications with preexisting comorbid HTN or DM prescription history.
MMA was defined as a proportion of days covered where both DM and HTN medications were simultaneously available over a 33-month follow-up period. Microvascular or macrovascular complications included myocardial infarction, stroke, renal failure, and diabetic retinopathy. Multivariable logistic regressions and an IV estimation using physician-related variables were implemented.
MMA was supoptimal as the mean (SD) proportion of days covered was 0.53 (0.32). Patients were more adherent to medications for a preexisting condition in comparison with those for the newer disease. Older age, number of index medications [OR (95% CI)=1.36 (1.22-1.52)], receiving care from a physician who prescribed statin more frequently [OR (95% CI)=2.63 (1.67-4.14)], and receiving care from the same physician for both DM and HTN [OR (95% CI)=1.57 (1.08-2.27)] were significant factors of being adherent. Using physician-related IVs, MMA reduced microvascular and macrovascular complications. The increase in MMA from 50% to 80% reduced the average predicted probability of microvascular or macrovascular complication rate by 29.5%.
Adherence to medications for DM and HTN were differed and higher MMA reduced microvascular or macrovascular complications when controlling for endogeneity bias.
利用工具变量（IVs）研究多重药物依从性（MMA）及其对微血管和大血管并发症的影响。
这是一项在加利福尼亚州南部的一个大型医生集团使用行政索赔和电子病历进行的回顾性观察研究（N=2334）。
我们确定了 2006 年 1 月至 2009 年 6 月期间新开始口服糖尿病（DM）或高血压（HTN）药物且有预先存在的 HTN 或 DM 处方史的个体。
MMA 定义为在 33 个月的随访期间，同时提供 DM 和 HTN 药物的天数占比。微血管或大血管并发症包括心肌梗死、中风、肾衰竭和糖尿病视网膜病变。实施多变量逻辑回归和使用医生相关变量的 IV 估计。
MMA 并不理想，平均（SD）天数覆盖率为 0.53（0.32）。与患有新疾病的患者相比，患者对预先存在的疾病的药物治疗更有依从性。年龄较大、索引药物数量[比值比（95%置信区间）=1.36（1.22-1.52）]、经常开他汀类药物的医生就诊[比值比（95%置信区间）=2.63（1.67-4.14）]和同时接受 DM 和 HTN 治疗的同一位医生就诊[比值比（95%置信区间）=1.57（1.08-2.27）]是依从性的重要因素。使用医生相关的 IVs，MMA 降低了微血管和大血管并发症的发生率。MMA 从 50%增加到 80%，可降低微血管或大血管并发症发生率的平均预测概率 29.5%。
控制内生性偏差后，DM 和 HTN 药物的依从性存在差异，更高的 MMA 可降低微血管或大血管并发症的发生率。
