Medication Adherence and Social Disparities in Diabetes

描述（由申请人提供）：药物依从性差是糖尿病中的一个严重公共卫生问题，可能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率，因为它几乎完全依赖于从正在使用者的再填充历史中得出的依从性估计，因此无法解释大量接受新疗法但从未成为正在使用者的患者。初步证据显示，四分之一的未接受治疗的患者处方了新的心脏代谢药物（抗高血压，抗血脂或抗高血糖），从未填写（“原发性不依从”）或从未重新填写（“早期不坚持”）新的处方，因此未能成为持续的用户。需要对依从性有更全面的了解;首先，包括药物依从性的所有阶段，从新处方到治疗中止，其次，依从性阶段如何塑造临床结果的社会差异。我们提出了一个纵向研究的糖尿病患者处方一种新的心脏代谢药物，以评估社会差异的药物治疗的依从性，解释因素和临床后果。这种“新的处方设计”将利用药房管理系统，电子记录医生的处方订单，剂量变化，停药订单和事件的副作用。研究受试者将包括Kaiser Permanente北方加州糖尿病登记处的成员，这是一个大型的、特征良好的、种族多样的、有保险的糖尿病管理护理患者人群。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，该人群具有统一的医疗服务和质量。鉴于92%的美国糖尿病患者有医疗保险，这一保险人群的发现应该具有广泛的公共卫生相关性。鉴于这将是第一个评估主要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形成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。公共卫生相关性：项目叙述本研究将评估糖尿病患者是否按处方（“依从性”）服用糖尿病、血压和胆固醇药物，强调依从性的社会模式、临床后果以及治疗开始、维持和中止差异的原因。我们将利用新的电子处方数据来评估从医生开新处方开始的药物依从性。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，并提供更全面的了解糖尿病药物依从性。

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.