Di Martino Mirko, Alagna Michela, Cappai Giovanna, Mataloni Francesca, Lallo Adele, Perucci Carlo Alberto, Davoli Marina, Fusco Danilo
Department of Epidemiology, Lazio Regional Health Service, Roma, Italy.
Faculty of Education-Free University of Bolzano, Bolzano, Italy.
BMJ Open. 2016 Apr 4;6(4):e010926. doi: 10.1136/bmjopen-2015-010926.
To measure the adherence to polytherapy after myocardial infarction (MI), to compare the proportions of variation attributable to hospitals of discharge and to primary care providers, and to identify determinants of adherence to medications.
This is a population-based study. Data were obtained from the Information Systems of the Lazio Region, Italy (5 million inhabitants).
Patients hospitalised with incident MI in 2007-2010.
The outcome was chronic polytherapy after MI. Adherence was defined as a medication possession ratio ≥0.75 for at least three of the following drugs: antiplatelets, β-blockers, ACEI angiotensin receptor blockers, statins.
A 2-year cohort study was performed. Cross-classified multilevel models were applied to analyse geographic variation and compare proportions of variability attributable to hospitals of discharge and primary care providers. The variance components were expressed as median ORs MORs. If the MOR is 1.00, there is no variation between clusters. If there is considerable between-cluster variation, the MOR will be large.
A total of 9606 patients were enrolled. About 63% were adherent to chronic polytherapy. Adherence was higher for patients discharged from cardiology wards (OR=1.56 vs other wards, p<0.001) and for patients with general practitioners working in group practice (OR=1.14 vs single-handed, p=0.042). A relevant variation in adherence was detected between local health districts (MOR=1.24, p<0.001). When introducing the hospital of discharge as a cross-classified level, the variation between local health districts decreased (MOR=1.13, p=0.020) and the variability attributable to hospitals of discharge was significantly higher (MOR=1.37, p<0.001).
Secondary prevention pharmacotherapy after MI is not consistent with clinical guidelines. The relevant geographic variation raises equity issues in access to optimal care. Adherence was influenced more by the hospital that discharged the patient than by the primary care providers. Cross-classified models proved to be a useful tool for defining priority areas for more targeted interventions.
测量心肌梗死（MI）后联合治疗的依从性，比较出院医院和基层医疗服务提供者所致变异的比例，并确定药物治疗依从性的决定因素。
这是一项基于人群的研究。数据来自意大利拉齐奥地区的信息系统（500万居民）。
2007年至2010年因首次发生MI而住院的患者。
观察指标为MI后的慢性联合治疗。依从性定义为以下至少三种药物的药物持有率≥0.75：抗血小板药物、β受体阻滞剂、ACEI（血管紧张素转换酶抑制剂）/血管紧张素受体阻滞剂、他汀类药物。
进行了一项为期2年的队列研究。应用交叉分类多水平模型分析地理变异，并比较出院医院和基层医疗服务提供者所致变异的比例。方差成分以中位数比值比（MORs）表示。如果MOR为1.00，则各聚类间无变异。如果聚类间存在显著变异，则MOR会很大。
共纳入9606例患者。约63%的患者坚持慢性联合治疗。从心脏病病房出院的患者依从性更高（比值比=1.56，与其他病房相比，p<0.001），有在团体执业的全科医生的患者依从性更高（比值比=1.14，与单干的相比，p=0.042）。在当地卫生区之间检测到依从性存在显著差异（MOR=1.24，p<0.001）。当将出院医院作为交叉分类水平引入时，当地卫生区之间的差异减小（MOR=1.13，p=0.020），而出院医院所致的变异显著更高（MOR=1.37，p<0.001）。
MI后的二级预防药物治疗不符合临床指南。相关的地理变异在获得最佳治疗方面引发了公平问题。患者的依从性受出院医院的影响大于基层医疗服务提供者。交叉分类模型被证明是确定更有针对性干预的优先领域的有用工具。
