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的一个严重的公共卫生问题，可能在长期不充分的风险因素控制中发挥作用，特别是在少数族裔和社会经济不利的患者中。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持续使用者的再灌装历史中得出的依从性估计，因此无法解释开了新疗法但从未成为持续使用者的大量患者。我们的初步证据表明，四分之一的接受治疗的患者开出了一种新的心脏代谢药物(降压药、降脂药或降糖药)，从未服用(“主要不坚持”)或从未重新服用(“早期不坚持”)，因此未能成为持续使用者。需要更全面地了解依从性；首先，包括药物依从性的所有阶段，从新处方到停止治疗，以及第二，依从性阶段如何塑造临床结果的社会差异。我们建议对糖尿病患者开出一种新的心脏代谢药物进行纵向研究，以评估在服药依从性、解释因素和临床后果方面的社会差异。这一“新处方设计”将利用一个药房管理系统，该系统以电子方式记录医生的处方订单、剂量变化、停用订单和事件副作用。研究对象将包括Kaiser Permanente North California糖尿病登记处的成员，这是一个庞大的、特征良好的、种族多样化的、有保险的糖尿病管理护理患者群体。与大多数以人口为基础的样本不同，社会弱势患者在这项研究人群中得到了很好的代表，他们有统一的获得和护理质量。鉴于92%的美国糖尿病患者拥有医疗保险，这一保险人群的研究结果应该具有广泛的公共卫生相关性。鉴于这将是第一项评估初级用药依从性的大型流行病学研究，它将提供更全面的理解，了解服药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，并为未来旨在减少健康差异的干预措施的设计提供信息。公共卫生相关性：项目简介这项研究将评估糖尿病患者是否按处方(“坚持”)服用糖尿病、血压和胆固醇药物，强调坚持治疗的社会模式、临床后果以及治疗开始、维持和停止方面存在差异的原因。我们将利用新的电子处方数据来评估服药依从性，从医生开具新处方开始。研究结果应该适用于92%有医疗保险的美国糖尿病患者，并提供对糖尿病患者服药依从性的更全面的了解。

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.