*Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC †Department of Epidemiology, Division of Cardiology, College of Public Health, College of Medicine, University of Iowa, Iowa City, IA ‡Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC.
Med Care. 2014 Mar;52(3):185-93. doi: 10.1097/MLR.0000000000000050.
Patient long-term adherence to β-blockers, HMG-CoA reductase inhibitors (statins), and angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) after acute myocardial infarction (AMI) is alarmingly low. It is unclear how prevalent patient adherence may be across small geographic areas and whether this geographic prevalence may vary.
This is a retrospective cohort study using Medicare service claims files from 2007 to 2009 with Medicare beneficiaries 65 years and above who were alive 30 days after the index AMI hospitalization between January 1, 2008 and December 31, 2008 (N=85,017). The adjusted proportions of patients adherent to β-blockers, statins, and ACEIs/ARBs, respectively, in the 12 months after discharge across the 306 Hospital Referral Regions (HRRs) were measured and compared by control chart. The intracluster correlation coefficient (ICC) and the additional prediction power from this small-area variation on individual patient adherence were assessed.
The adjusted proportion of patients adherent across HRRs ranged from 58% to 74% (median, 66%) for β-blockers, from 57% to 67% (median, 63%) for ACEIs/ARBs, and from 58% to 73% (median, 66%) for statins. The ICC was 0.053 (95% CI, 0.043-0.064) for β-blockers, 0.050 (95% CI, 0.039-0.061) for ACEIs/ARBs, and 0.041 (95% CI, 0.031-0.052) for statins. The adjusted proportion of patients adherent across HRRs increased the c-statistic by 0.01-0.02 (P < 0.0001).
Nonadherence to evidence-based preventive therapies post-AMI among older adults was prevalent across small geographic regions. Moderate small-area variation in patient adherence exists.
急性心肌梗死(AMI)后,患者长期坚持使用β受体阻滞剂、HMG-CoA 还原酶抑制剂(他汀类药物)和血管紧张素转换酶抑制剂(ACEI)/血管紧张素受体阻滞剂(ARB)的情况令人震惊地低。目前尚不清楚在小地理区域内患者的依从性可能有多普遍,以及这种地理流行程度是否会有所不同。
这是一项回顾性队列研究,使用了 2007 年至 2009 年的医疗保险服务索赔文件,其中包括 2008 年 1 月 1 日至 2008 年 12 月 31 日期间,索引 AMI 住院后 30 天内存活且年龄在 65 岁及以上的 Medicare 受益人(N=85,017)。通过控制图测量并比较了出院后 12 个月内,306 个医院转诊区(HRR)中分别使用β受体阻滞剂、他汀类药物和 ACEI/ARB 的患者的调整后依从率,并评估了该小区域变异对个体患者依从性的个体内相关性系数(ICC)和额外预测能力。
HRR 中患者的调整后依从率范围为β受体阻滞剂 58%至 74%(中位数为 66%),ACEI/ARB 为 57%至 67%(中位数为 63%),他汀类药物为 58%至 73%(中位数为 66%)。β受体阻滞剂的 ICC 为 0.053(95%CI,0.043-0.064),ACEI/ARB 的 ICC 为 0.050(95%CI,0.039-0.061),他汀类药物的 ICC 为 0.041(95%CI,0.031-0.052)。HRR 之间的调整后患者依从率增加了 c 统计量的 0.01-0.02(P<0.0001)。
老年人群中 AMI 后,对循证预防治疗的依从性不佳在小地理区域内普遍存在。患者依从性存在适度的小区域差异。