Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska academy, University of Gothenburg, Goteborg, Sweden.
Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
BMJ Open Diabetes Res Care. 2019 Apr 8;7(1):e000639. doi: 10.1136/bmjdrc-2018-000639. eCollection 2019.
To analyze the risk of cardiovascular (CV) events and mortality in relation to adherence to lipid-lowering medications by healthcare centers and patients with type 2 diabetes mellitus (T2DM).
We included 121 914 patients (12% secondary prevention) with T2DM reported by 1363 healthcare centers. Patients initiated lipid-lowering medications between July 2006 and December 2012 and were followed from cessation of the first filled supply until multidose dispensed medications, migration, CV events, death or December 2016. The study period was divided into 4-month intervals through 2014, followed by annual intervals through 2016. Adherence measures were assessed for each interval. Patients' (refill) adherence was measured using the medication possession ratio (MPR). Healthcare centers' (guideline) adherence represented the prescription prevalence of lipid-lowering medications according to guidelines. The risk of CV events and mortality was analyzed for each interval using Cox proportional hazard regression and Kaplan-Meier.
Compared with high-adherent patients (MPR >80%), low-adherent primary prevention patients (MPR ≤80%) showed higher risk of all outcomes: 44%-51 % for CV events, doubled for all-cause mortality and 79%-90% for CV mortality. Corresponding risks for low-adherent secondary prevention patients were 17%-19% for CV events, 88%-97% for all-cause and 66%-79% for CV mortality. Primary prevention patients treated by low-adherent healthcare centers (guideline adherence <48%) had a higher risk of CV events and CV mortality. Otherwise, no difference in the risk of CV events or mortality was observed by guideline adherence level.
Our results demonstrate the importance of high refill adherence and thus the value of individualized care among patients with T2DM.
分析与降脂药物治疗的依从性相关的心血管（CV）事件和死亡率风险，涉及到医疗中心和 2 型糖尿病（T2DM）患者。
我们纳入了 1363 家医疗中心报告的 121914 名 T2DM 患者（12%为二级预防）。患者在 2006 年 7 月至 2012 年 12 月期间开始服用降脂药物，并在首次配药结束后至多剂量配药、迁移、CV 事件、死亡或 2016 年 12 月期间进行随访。研究期间分为 2014 年之前的 4 个月间隔期，以及之后的每年间隔期。在每个间隔期评估患者的（续药）依从性。患者的（续药）依从性通过药物使用比例（MPR）进行测量。医疗中心的（指南）依从性代表了根据指南开具降脂药物的处方比例。通过 Cox 比例风险回归和 Kaplan-Meier 分析每个间隔期的 CV 事件和死亡率风险。
与高依从性患者（MPR>80%）相比，低依从性的一级预防患者（MPR≤80%）表现出更高的所有结局风险：CV 事件风险为 44%-51%，全因死亡率风险增加一倍，CV 死亡率风险为 79%-90%。对于低依从性的二级预防患者，CV 事件风险为 17%-19%，全因死亡率风险为 88%-97%，CV 死亡率风险为 66%-79%。接受低依从性医疗中心（指南依从性<48%）治疗的一级预防患者，CV 事件和 CV 死亡率风险更高。否则，未观察到指南依从性水平对 CV 事件或死亡率风险的差异。
我们的研究结果表明，T2DM 患者的高续药依从性至关重要，因此个体化护理具有重要价值。
