Treatment adjustment and medication adherence for complex patients with diabetes, heart disease, and depression: a randomized controlled trial.
OBJECTIVE
Medication nonadherence, inconsistent patient self-monitoring, and inadequate treatment adjustment exacerbate poor disease control. In a collaborative, team-based, care management program for complex patients (TEAMcare), we assessed patient and physician behaviors (medication adherence, self-monitoring, and treatment adjustment) in achieving better outcomes for diabetes, coronary heart disease, and depression.


METHODS
A randomized controlled trial was conducted (2007-2009) in 14 primary care clinics among 214 patients with poorly controlled diabetes (glycated hemoglobin [HbA(1c)] ≥8.5%) or coronary heart disease (blood pressure >140/90 mm Hg or low-density lipoprotein cholesterol >130 mg/dL) with coexisting depression (Patient Health Questionnaire-9 score ≥10). In the TEAMcare program, a nurse care manager collaborated closely with primary care physicians, patients, and consultants to deliver a treat-to-target approach across multiple conditions. Measures included medication initiation, adjustment, adherence, and disease self-monitoring.


RESULTS
Pharmacotherapy initiation and adjustment rates were sixfold higher for antidepressants (relative rate [RR] = 6.20; P <.001), threefold higher for insulin (RR = 2.97; P <.001), and nearly twofold higher for antihypertensive medications (RR = 1.86, P <.001) among TEAMcare relative to usual care patients. Medication adherence did not differ between the 2 groups in any of the 5 therapeutic classes examined at 12 months. TEAMcare patients monitored blood pressure (RR = 3.20; P <.001) and glucose more frequently (RR = 1.28; P = .006).


CONCLUSIONS
Frequent and timely treatment adjustment by primary care physicians, along with increased patient self-monitoring, improved control of diabetes, depression, and heart disease, with no change in medication adherence rates. High baseline adherence rates may have exerted a ceiling effect on potential improvements in medication adherence.
MacColl Center for Health Care Innovation, Group Health Research Institute, Group Health Cooperative, Seattle, Washington 98101, USA. lin.e@ghc.org
Elizabeth H B
EH
Lin
Michael
M
Von Korff
Paul
P
Ciechanowski
Do
D
Peterson
Evette J
EJ
Ludman
Carolyn M
CM
Rutter
Malia
M
Oliver
Bessie A
BA
Young
Jochen
J
Gensichen
Mary
M
McGregor
David K
DK
McCulloch
Edward H
EH
Wagner
Wayne J
WJ
Katon
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000928:Antidepressive Agents / Q000627:therapeutic use; D000959:Antihypertensive Agents / Q000627:therapeutic use; D002318:Cardiovascular Diseases / Q000188:drug therapy; D015897:Comorbidity; D003866:Depressive Disorder / Q000188:drug therapy; D003920:Diabetes Mellitus / Q000188:drug therapy; D004363:Drug Utilization / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007004:Hypoglycemic Agents / Q000627:therapeutic use; D007328:Insulin / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D010348:Patient Care Team; D010817:Physician-Patient Relations; D011364:Professional Practice; D012044:Regression Analysis; D012648:Self Care / Q000379:methods* / Q000706:statistics & numerical data; D016903:Drug Monitoring
D000928:Antidepressive Agents; D000959:Antihypertensive Agents; D007004:Hypoglycemic Agents; D007328:Insulin