Medication Adherence and Social Disparities in Diabetes

描述（由申请人提供）：服药依从性差是糖尿病中一个严重的公共卫生问题，可能会导致风险因素控制不充分，特别是在少数民族和社会经济弱势患者中。现有的医学文献低估了不依从性的比率，因为它几乎完全依赖于依从性估计，这些估计来自于持续使用者的补充历史，因此未能考虑到大量开了新疗法但从未成为持续使用者的患者。我们显示了初步证据，四分之一的未接受治疗的患者开了一种新的心脏代谢药物（降压药、降脂药或降血糖药），但从未补服（“原发性不依从性”）或从未补服（“早期不坚持性”），因此未能成为持续的使用者。需要对依从性有更全面的了解；其中一个包括，首先，坚持服药的所有阶段，从新的处方到停止治疗，其次，坚持服药的阶段如何在临床结果中形成社会差异。我们建议对糖尿病患者进行一项纵向研究，以评估在药物依从性、解释因素和临床后果方面的社会差异。这种“新处方设计”将利用药房管理系统，以电子方式记录医生的处方单、剂量变化、停药单和意外副作用。研究对象将包括Kaiser Permanente北加州糖尿病登记的成员，这是一个庞大的、特征明确的、种族多样化的、有保险的糖尿病患者管理护理人群。与大多数基于人群的样本不同，社会弱势患者在本研究人群中有很好的代表性，该研究人群具有统一的护理机会和质量。鉴于92%的美国糖尿病患者有健康保险，从这些被保险人群中得出的结论应该具有广泛的公共卫生相关性。鉴于这将是第一个评估初级药物依从性的大型流行病学研究，它将更全面地了解药物依从性的社会差异如何影响糖尿病相关风险因素控制的差异，并为旨在减少健康差异的未来干预措施的设计提供信息。本研究将评估糖尿病患者是否按规定服用糖尿病、血压和胆固醇药物（“依从性”），强调依从性的社会模式、临床后果以及治疗开始、维持和停止差异的原因。我们将利用新的电子处方数据，从医生开新处方开始评估药物依从性。研究结果应该可以推广到92%有健康保险的美国糖尿病患者，并对糖尿病患者的药物依从性提供更全面的了解。

DESCRIPTION (provided by applicant): Poor medication adherence is a serious public health problem in diabetes and may play a role in perpetuating inadequate risk factor control, particularly among minority and socioeconomically- disadvantaged patients. Extant medical literature has underestimated rates of nonadherence because it relies almost exclusively on adherence estimates derived from refill history among ongoing users, and thus fails to account for the large number of patients who are prescribed new therapies but never become ongoing users. We show preliminary evidence that one quarter of treatment-naove patients prescribed a new cardiometabolic medication (antihypertensive, antilipemic or antihyperglycemic) never fill ("primary non-adherence") or never refill ("early non-persistence") the new prescription and thus fail to become ongoing users. A more comprehensive understanding of adherence is needed; one that includes, first, all stages of medication adherence, from new prescription to therapy discontinuation and, second, how the stages of adherence shape social disparities in clinical outcomes. We propose a longitudinal study of diabetic patients prescribed a new cardiometabolic medication to assess social disparities in medication adherence, explanatory factors and clinical consequences. This "new prescription design" will take advantage of a pharmacy management system that electronically records physicians' prescription orders, dose changes, discontinuation orders and incident side effects. Study subjects will include members of the Kaiser Permanente Northern California Diabetes Registry, a large, well-characterized, ethnically-diverse, insured population of managed care patients with diabetes mellitus. Socially-disadvantaged patients are well represented in this study population, which has uniform access to and quality of care, unlike most population-based samples. Given that 92% of Americans with diabetes have health insurance, findings from this insured population should have broad public health relevance. Given this will be the first, large epidemiological study to assess primary medication adherence, it will provide a more comprehensive understanding of how social disparities in medication adherence shape disparities in diabetes-related risk factor control and inform the design of future interventions aimed at reducing health disparities. PUBLIC HEALTH RELEVANCE: Project Narrative This study will evaluate whether diabetes, blood pressure and cholesterol medications, are taken by patients with diabetes as prescribed ("adherence"), emphasizing social patterns in adherence, clinical consequences and reasons for differences in therapy initiation, maintenance and discontinuation. We will take advantage of new electronic prescribing data to evaluate medication adherence starting from the point the doctor writes the new prescription. Study findings should be generalizable to the 92% of Americans with diabetes who have health insurance, and provide a more comprehensive understanding of medication adherence in diabetes.