Lafata Jennifer Elston, Karter Andrew J, O'Connor Patrick J, Morris Heather, Schmittdiel Julie A, Ratliff Scott, Newton Katherine M, Raebel Marsha A, Pathak Ram D, Thomas Abraham, Butler Melissa G, Reynolds Kristi, Waitzfelder Beth, Steiner John F
School of Medicine, Virginia Commonwealth University, Richmond, VA, USA.
Henry Ford Health System, Detroit, MI, USA.
J Gen Intern Med. 2016 Feb;31(2):188-195. doi: 10.1007/s11606-015-3486-0.
Among patients with diabetes, racial differences in cardiometabolic risk factor control are common. The extent to which differences in medication adherence contribute to such disparities is not known. We examined whether medication adherence, controlling for treatment intensification, could explain differences in risk factor control between black and white patients with diabetes.
We identified three cohorts of black and white patients treated with oral medications and who had poor risk factor control at baseline (2009): those with glycated hemoglobin (HbA1c) >8 % (n = 37,873), low-density lipoprotein cholesterol (LDL-C) >100 mg/dl (n = 27,954), and systolic blood pressure (SBP) >130 mm Hg (n = 63,641). Subjects included insured adults with diabetes who were receiving care in one of nine U.S. integrated health systems comprising the SUrveillance, PREvention, and ManagEment of Diabetes Mellitus (SUPREME-DM) consortium. Baseline and follow-up risk factor control, sociodemographic, and clinical characteristics were obtained from electronic health records. Pharmacy-dispensing data were used to estimate medication adherence (i.e., medication refill adherence [MRA]) and treatment intensification (i.e., dose increase or addition of new medication class) between baseline and follow-up. County-level income and educational attainment were estimated via geocoding. Logistic regression models were used to test the association between race and follow-up risk factor control. Models were specified with and without medication adherence to evaluate its role as a mediator.
We observed poorer medication adherence among black patients than white patients (p < 0.01): 50.6 % of blacks versus 39.7 % of whites were not highly adherent (i.e., MRA <80 %) to HbA1c oral medication(s); 58.4 % of blacks and 46.7 % of whites were not highly adherent to lipid medication(s); and 33.4 % of blacks and 23.7 % of whites were not highly adherent to BP medication(s). Across all cardiometabolic risk factors, blacks were significantly less likely to achieve control (p < 0.01): 41.5 % of blacks and 45.8 % of whites achieved HbA1c <8 %; 52.6 % of blacks and 60.8 % of whites achieved LDL-C <100; and 45.7 % of blacks and 53.6 % of whites achieved SBP <130. Adjusting for medication adherence/treatment intensification did not alter these patterns or model fit statistics.
Medication adherence failed to explain observed racial differences in the achievement of HbA1c, LDL-C, and SBP control among insured patients with diabetes.
在糖尿病患者中，心血管代谢危险因素控制方面的种族差异很常见。药物依从性差异在多大程度上导致了这种差异尚不清楚。我们研究了在控制治疗强化的情况下，药物依从性是否能够解释黑人和白人糖尿病患者在危险因素控制方面的差异。
我们确定了三组接受口服药物治疗且在基线时（2009年）危险因素控制不佳的黑人和白人患者队列：糖化血红蛋白（HbA1c）>8%的患者（n = 37873）、低密度脂蛋白胆固醇（LDL-C）>100mg/dl的患者（n = 27954）以及收缩压（SBP）>130mmHg的患者（n = 63641）。研究对象包括在美国九个综合医疗系统之一接受治疗的有保险的成年糖尿病患者，这些系统组成了糖尿病监测、预防和管理（SUPREME-DM）联盟。基线和随访时的危险因素控制情况、社会人口统计学和临床特征均从电子健康记录中获取。药房配药数据用于估计基线和随访之间的药物依从性（即药物再填充依从性[MRA]）和治疗强化情况（即剂量增加或添加新的药物类别）。通过地理编码估计县级收入和教育程度。使用逻辑回归模型检验种族与随访危险因素控制之间的关联。构建了有和没有药物依从性的模型，以评估其作为中介因素的作用。
我们观察到黑人患者的药物依从性比白人患者差（p < 0.01）：50.6%的黑人对HbA1c口服药物的依从性不高（即MRA < 80%），而白人这一比例为39.7%；58.4%的黑人对降脂药物的依从性不高，白人这一比例为46.7%；33.4%的黑人对降压药物的依从性不高，白人这一比例为23.7%。在所有心血管代谢危险因素方面，黑人实现控制的可能性显著更低（p < 0.01）：41.5%的黑人HbA1c < 8%，白人这一比例为45.8%；52.6%的黑人LDL-C < 100，白人这一比例为60.8%；45.7%的黑人SBP < 130，白人这一比例为53.6%。调整药物依从性/治疗强化情况并未改变这些模式或模型拟合统计量。
在有保险的糖尿病患者中，药物依从性未能解释在HbA1c、LDL-C和SBP控制方面观察到的种族差异。
