Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Seattle, WA 98101.
Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA.
J Clin Psychiatry. 2018 May/Jun;79(3). doi: 10.4088/JCP.16m11324.
Previous research and improvement efforts have presumed that patients' nonadherence to antidepressant medication reflects physicians' quality of care. We used population-based health records to examine whether adherence to antidepressant medication actually varies between prescribing physicians.
Electronic health records and insurance claims data from 5 integrated health systems in Washington, Idaho, Minnesota, Colorado, Hawaii, and California were used to identify 150,318 adults starting new episodes of antidepressant treatment for depression between January 1, 2010, and December 31, 2012. Early adherence was defined as any refill or dispensing of antidepressant medication in the 180 days following an initial antidepressant prescription. Patient-level demographic and clinical characteristics potentially associated with adherence were identified from health system records.
Average probability of early adherence was 82% for psychiatrists and 74% for primary care physicians. Among individual physicians, the range of raw or unadjusted early adherence rates (5th to 95th percentiles) was from 33% to 100% for psychiatrists and from 0% to 100% for primary care physicians. After accounting for sampling variation and case mix differences, the range of adjusted early adherence rates (5th to 95th percentiles) was from 72% to 78% for psychiatrists and from 64% to 69% for primary care physicians.
After accounting for sampling variation and case mix differences, early adherence to antidepressant medication varies minimally among prescribing physicians. Early discontinuation of antidepressant treatment is not an appropriate measure of individual physician performance, and efforts to improve adherence should emphasize system-level interventions rather than the performance of individual physicians.
之前的研究和改进工作假设，患者对抗抑郁药物的不依从反映了医生的护理质量。我们使用基于人群的健康记录来检查抗抑郁药物的依从性是否实际上在开处方医生之间有所不同。
使用来自华盛顿、爱达荷州、明尼苏达州、科罗拉多州、夏威夷州和加利福尼亚州的 5 个综合医疗系统的电子健康记录和保险索赔数据，确定了 2010 年 1 月 1 日至 2012 年 12 月 31 日期间 150,318 名新开始抗抑郁治疗的成年人的新抗抑郁治疗发作。早期依从性被定义为初始抗抑郁处方后 180 天内任何抗抑郁药物的补充或配药。从健康系统记录中确定了与依从性相关的潜在患者水平的人口统计学和临床特征。
精神病医生的早期依从率平均为 82%，初级保健医生为 74%。在个别医生中，原始或未经调整的早期依从率（第 5 到 95 个百分位）范围为精神病医生 33%至 100%，初级保健医生 0%至 100%。在考虑抽样变异性和病例组合差异后，调整后的早期依从率（第 5 到 95 个百分位）范围为精神病医生 72%至 78%，初级保健医生 64%至 69%。
在考虑抽样变异性和病例组合差异后，抗抑郁药物的早期依从性在开处方医生之间差异极小。抗抑郁药物治疗的早期停药不是衡量个别医生表现的适当指标，而提高依从性的努力应强调系统层面的干预，而不是个别医生的表现。
