Department of Epidemiology, Lazio Regional Health Service, ASL Roma 1, Via Cristoforo Colombo, 112, 00147, Rome, Italy.
Management and Healthcare Laboratory, Scuola Superiore Sant'Anna, Pisa, Italy.
BMC Cardiovasc Disord. 2021 Apr 14;21(1):180. doi: 10.1186/s12872-021-01969-9.
The benefits of chronic polytherapy in reducing readmissions and death after myocardial infarction (MI) have been clearly shown. However, real-world evidence shows poor medication adherence and large geographic variation, suggesting critical issues in access to optimal care. Our objectives were to measure adherence to polytherapy, to compare the amount of variation attributable to hospitals of discharge and to community-based 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 and Tuscany Regions, Italy (9.5 million inhabitants). Patients hospitalized with incident MI in 2010-2014 were analyzed. The outcome measure was medication adherence, defined as a Medication Possession Ratio (MPR) ≥ 0.75 for at least 3 of the following drugs: antiplatelets, β-blockers, ACEI/ARBs, statins. A 2-year cohort-study was performed. Cross-classified multilevel models were applied to analyze geographic variation. The variance components attributable to hospitals of discharge and community-based providers were expressed as Median Odds Ratio (MOR).
A total of 32,962 patients were enrolled. About 63% of patients in the Lazio cohort and 59% of the Tuscan cohort were adherent to chronic polytherapy. Women and patients aged 85 years and over were most at risk of non-adherence. In both regions, adherence was higher for patients discharged from cardiology wards (Lazio: OR = 1.58, p < 0.001, Tuscany: OR = 1.59, p < 0.001) and for patients with a percutaneous coronary intervention during the index admission. Relevant variation between community-based providers was observed, though when the hospital of discharge was included as a cross-classified level, in both Lazio and Tuscany regions the variation attributable to hospitals of discharge was the only significant component (Lazio: MOR = 1.30, p = 0.001; Tuscany: MOR = 1.31, p = 0.001).
Adherence to best practice treatments after MI is not consistent with clinical guidelines, and varies between patient groups as well as within and between regions. The variation attributable to providers is affected by the hospital of discharge, up to two years from the acute episode. This variation is likely to be attributable to hospital discharge processes, and could be reduced through appropriate policy levers.
慢性多疗法在降低心肌梗死后再入院和死亡方面的益处已得到明确证实。然而，实际证据表明，药物依从性较差且存在较大的地域差异，这表明在获得最佳治疗方面存在重大问题。我们的目的是衡量多疗法的依从性，比较出院医院和社区提供者之间的变异量，并确定药物依从性的决定因素。
这是一项基于人群的研究。数据来自意大利拉齐奥和托斯卡纳地区的信息系统（拥有 950 万居民）。分析了 2010-2014 年因初次心肌梗住院的患者。主要结局指标为药物依从性，定义为以下至少 3 种药物的药物持有率（MPR）≥0.75：抗血小板药物、β受体阻滞剂、ACEI/ARB、他汀类药物。进行了为期 2 年的队列研究。应用交叉分类多水平模型分析地理变异。将归因于出院医院和社区提供者的方差分量表示为中位数优势比（MOR）。
共纳入 32962 例患者。拉齐奥队列中有 63%的患者和托斯卡纳队列中有 59%的患者对慢性多疗法有依从性。女性和 85 岁及以上的患者最有可能不依从。在两个地区，从心脏病病房出院的患者（拉齐奥：OR=1.58，p<0.001；托斯卡纳：OR=1.59，p<0.001）和在指数入院期间接受经皮冠状动脉介入治疗的患者的依从性更高。尽管在包括出院医院作为交叉分类水平后，在拉齐奥和托斯卡纳地区，仅观察到社区提供者之间存在相关的变异，但出院医院的变异是唯一显著的组成部分（拉齐奥：MOR=1.30，p=0.001；托斯卡纳：MOR=1.31，p=0.001）。
心肌梗死后最佳治疗方法的依从性与临床指南不一致，并且在患者群体之间以及在区域内和区域之间存在差异。归因于提供者的变异受出院医院的影响，从急性发作后两年内均可观察到。这种变异可能归因于出院过程，可通过适当的政策杠杆加以减少。
