title: Refill adherence to oral hypoglycemic agents and glycemic control in veterans.
abstract: BACKGROUND
  Although medication nonadherence may contribute to inadequate diabetes control, adherence is not routinely measured. Persistence, the continuous refill of medications, is one metric that could be integrated into clinical care if associated with glycemic control.
  
  
  OBJECTIVE
  To characterize the association of persistence levels (non-, good, overpersistence) with hemoglobin A(1c) (A1C) over 1 year in newly medicated diabetics in the Veterans Administration.
  
  
  METHODS
  Eligible veterans were > or =18 years and first filled a prescription for oral hypoglycemic agents (OHA) between January 1, 2000, and December 31, 2002. The date the OHA was first dispensed was defined as the baseline date. Subjects must have filled at least 1 prescription for any drug, but no diabetes medications, during the 12 months preceding the baseline date. Persistence was measured in days supply of medication over 365 days and defined as non- (<0.80), good (> or =0.8-1.10), and over- (>1.10) persistence. The main outcome measure was achieving goal A1C (< or =7.0%) after 1 year.
  
  
  RESULTS
  A total of 56,181 veterans were included. Veterans were male (97%) and white (67%) with comorbid hypertension (58%) and hyperlipidemia (40%). Median age was 63 years, while median baseline A1C was 7.7%. Fifty-two percent of patients had good persistence; 25% were overpersistent. Good persistence was associated with achieving goal A1C (RR 1.07; 95% CI 1.06 to 1.09). The association of overpersistence with the same outcome (RR 0.95; 95% CI 0.94 to 0.97) was lower than good persistence, but higher than nonpersistence (RR 0.93; 95% CI 0.92 to 0.94).
  
  
  CONCLUSIONS
  Good persistence was associated with glycemic control. Overpersistent patients were common and more likely than nonpersistent patients, but less likely than good persisters to attain goal A1C. Estimating these different strata of persistence may be useful in identifying patients at risk of poor glycemic control.
authors.affiliation: Department of Internal Medicine, Section of General Internal Medicine, School of Medicine, Yale University, Veterans Affairs Connecticut Healthcare System, West Haven, CT 06516, USA. nancy.kim@yale.edu
authors.forename: Nancy
authors.initials: N
authors.lastname: Kim
authors.forename: Joseph V
authors.initials: JV
authors.lastname: Agostini
authors.forename: Amy C
authors.initials: AC
authors.lastname: Justice
mesh_terms: D000284:Administration, Oral; D000368:Aged; D001786:Blood Glucose / Q000032:analysis; D015331:Cohort Studies; D003924:Diabetes Mellitus, Type 2 / Q000097:blood / Q000188:drug therapy*; D011307:Drug Prescriptions / Q000706:statistics & numerical data*; D004363:Drug Utilization / Q000706:statistics & numerical data; D005260:Female; D006442:Glycated Hemoglobin / Q000032:analysis; D006801:Humans; D007004:Hypoglycemic Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D015233:Models, Statistical; D015999:Multivariate Analysis; D010349:Patient Compliance; D012189:Retrospective Studies; D016896:Treatment Outcome; D014728:Veterans / Q000706:statistics & numerical data
chemical_list: D001786:Blood Glucose; D006442:Glycated Hemoglobin; D007004:Hypoglycemic Agents; C517652:hemoglobin A1c protein, human
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