Adherence to vascular protection drugs in diabetic patients in Quebec: a population-based analysis

Cardiovascular medication utilization and adherence among adults living in rural and urban areas: a systematic review and meta-analysis

BACKGROUND

Rural residents face numerous barriers to healthcare access and studies suggest poorer health outcomes for rural patients. Therefore we undertook a systematic review to determine if cardiovascular medication utilization and adherence patterns differ for rural versus urban patients.

METHODS

A comprehensive search of major electronic datasets was undertaken for controlled clinical trials and observational studies comparing utilization or adherence to cardiovascular medications in rural versus urban adults with cardiovascular disease or diabetes. Two reviewers independently identified citations, extracted data, and evaluated quality using the STROBE checklist. Risk estimates were abstracted and pooled where appropriate using random effects models. Methods and reporting were in accordance with MOOSE guidelines.

RESULTS

Fifty-one studies were included of fair to good quality (median STROBE score 17.5). Although pooled unadjusted analyses suggested that patients in rural areas were less likely to receive evidence-based cardiovascular medications (23 studies, OR 0.88, 95% CI 0.79, 0.98), pooled data from 21 studies adjusted for potential confounders indicated no rural-urban differences (adjusted OR 1.02, 95% CI 0.91, 1.13). The high heterogeneity observed (I(2) = 97%) was partially explained by treatment setting (hospital, ambulatory care, or community-based sample), age, and disease. Adherence did not differ between urban versus rural patients (3 studies, OR 0.94, 95% CI 0.39, 2.27, I(2) = 91%).

CONCLUSIONS

We found no consistent differences in rates of cardiovascular medication utilization or adherence among adults with cardiovascular disease or diabetes living in rural versus urban settings. Higher quality evidence is needed to determine if differences truly exist between urban and rural patients in the use of, and adherence to, evidence-based medications.

Important treatment gaps in vascular protection for the elderly after type 2 diabetes therapy initiation

BACKGROUND

Canadian practice guidelines recommend the use of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) for vascular protection in individuals with diabetes who are at high risk of cardiovascular events, including those ≥ 65 years. We estimated the proportion of elderly persons who initiated an ACEI or an ARB in the year after beginning oral antidiabetes (OAD) treatment, and we identified factors associated with this initiation.

METHODS

Using the Quebec Health Insurance Board (RAMQ) databases, we conducted a population-based cohort study of individuals ≥ 65 years recently prescribed an OAD. We excluded those who were already taking an ACEI or ARB. Factors associated with ACEI or ARB initiation were identified using multivariate logistic regression.

RESULTS

Among 43,700 individuals, 13,621 (31.2%) initiated an ACEI or ARB in the year after beginning OAD. Individuals were more likely to begin an ACEI or an ARB if they initially received both metformin and a sulfonylurea, lived in a rural region, began OAD treatment between 2001 and 2006, were hospitalized, or had ≥ 22 medical visits in the year before OAD initiation. Individuals ≥ 75 years, those who were prescribed an OAD by a general practitioner, initially received a sulfonylurea, or received ≥ 4 different medications in the year before OAD initiation were less likely to begin an ACEI or ARB.

CONCLUSIONS

In the elderly not already taking ACEIs or ARBs, a low proportion of those undertaking OAD treatment are prescribed the recommended cardioprotection of an ACEI or ARB in the following year. Interventions are needed to close this treatment gap.

Obedience and motivation as mechanisms for adherence to medication: a study in obese type 2 diabetic patients

OBJECTIVE

To clarify the mechanisms of adherence.

METHODS

A cross-sectional, multicenter French study using a self-questionnaire administered by 116 general practitioners to 782 obese type 2 diabetic patients.

RESULTS

The analysis of 670 completed questionnaires revealed a strong association between the adherence to medication and the behavior of fastening the seatbelt when seated in the rear of a car. Multivariate analysis indicated that this behavior was an independent determinant of adherence to medication (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.4-3.6, P < 0.001) with the same OR as the motivation to adhere to medical prescriptions (OR 2.2, 95% CI 1.3-3.6, P = 0.003) in a model with good accuracy (area under the receiver operating characteristic curve 0.774). A multiple correspondence analysis suggested that adherence to medication and seatbelt behavior are "homologous" behaviors, with homology between phenomena defined by the fact that they share a common etiology.

CONCLUSION

ADHERENCE MAY HAVE TWO DIMENSIONS: passive (obedience, the main determinant of seatbelt behavior) and active (motivation). This conclusion has theoretical and practical implications. Firstly, empowerment through patient education can be defined as a process that replaces the passive mechanism of adherence in patients' minds with an active, conscious choice. Secondly, recognizing these two dimensions may help to establish a tailored patient-physician relationship to prevent nonadherence.