Feldman Becca S, Cohen-Stavi Chandra J, Leibowitz Morton, Hoshen Moshe B, Singer Shepherd R, Bitterman Haim, Lieberman Nicky, Balicer Ran D
Clalit Research Institute, Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel.
Clalit Research Institute, Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel; Department of Medicine, New York University School of Medicine, New York, New York, United States of America.
PLoS One. 2014 Sep 26;9(9):e108145. doi: 10.1371/journal.pone.0108145. eCollection 2014.
This study assesses the attributable impact of adherence to oral glucose medications as a risk factor for poor glycemic control in population subgroups of a large general population, using an objective medication adherence measure.
Using electronic health records data, adherence to diabetes medications over a two-year period was calculated by prescription-based Medication Possession Ratios for adults with diabetes diagnosed before January 1, 2010. Glycemic control was determined by the HbA1c test closest to the last drug prescription during 2010-2012. Poor control was defined as HbA1c>75 mmol/mol (9.0%). Medication adherence was categorized as "good" (>80%), "moderate" (50-80%), or "poor" (<50%). Logistic regression models assessed the role medication adherence plays in the association between disease duration, age, and poor glycemic control. We calculated the change in the attributable fraction of glucose control if the non-adherent diabetic medication population would become adherent by age-groups.
Among 228,846 diabetes patients treated by oral antiglycemic medication, 46.4% had good, 28.8% had moderate, and 24.8% had poor adherence. Good adherence rates increased with increasing disease duration, while glycemic control became worse. There was a strong inverse association between adherence level and poor control (OR = 2.50; CI = 2.43-2.58), and adherence was a significant mediator between age and poor control.
A large portion of the diabetes population is reported to have poor adherence to oral diabetes medications, which is strongly associated with poor glycemic control in all disease durations. While poor adherence does not mediate the poorer glycemic control seen in patients with longer-standing disease, it is a significant mediator of poor glycemic control among younger diabetes patients. A greater fraction of poorly controlled younger patients, compared to older patients, could be prevented if at least 80% adherence to their medications was achieved. Therefore, our results suggest that interventions to improve adherence should focus on this younger sub-group.
本研究使用客观的药物依从性测量方法，评估在一大群普通人群的亚组中，口服降糖药物依从性作为血糖控制不佳的危险因素的可归因影响。
利用电子健康记录数据，通过基于处方的药物持有率计算2010年1月1日前诊断为糖尿病的成年人在两年期间对糖尿病药物的依从性。血糖控制情况通过2010 - 2012年期间最接近最后一次药物处方的糖化血红蛋白（HbA1c）检测来确定。控制不佳定义为HbA1c>75 mmol/mol（9.0%）。药物依从性分为“良好”（>80%）、“中等”（50 - 80%）或“差”（<50%）。逻辑回归模型评估药物依从性在病程、年龄与血糖控制不佳之间的关联中所起的作用。我们计算了如果未依从糖尿病药物治疗的人群按年龄组实现依从性，血糖控制可归因分数的变化。
在228,846名接受口服降糖药物治疗的糖尿病患者中，46.4%依从性良好，28.8%中等，24.8%依从性差。良好依从率随病程延长而增加，而血糖控制情况变差。依从水平与控制不佳之间存在强烈的负相关（OR = 2.50；CI = 2.43 - 2.58），且依从性是年龄与控制不佳之间的显著中介因素。
据报道，很大一部分糖尿病患者对口服糖尿病药物的依从性较差，这在所有病程中都与血糖控制不佳密切相关。虽然依从性差并不能介导病程较长患者中较差的血糖控制，但它是年轻糖尿病患者血糖控制不佳的一个重要中介因素。与老年患者相比，如果至少80%的年轻患者实现药物依从性，那么更多血糖控制不佳的年轻患者可以得到预防。因此，我们的结果表明，改善依从性的干预措施应侧重于这个年轻亚组。
