Multiple medication adherence and its effect on clinical outcomes among patients with comorbid type 2 diabetes and hypertension.
OBJECTIVE
To investigate multiple medication adherence (MMA) and its impact on microvascular and macrovascular complications using instrumental variables (IVs).


METHODS
A retrospective observational study was conducted using administrative claims and electronic medical records from a large physician group in Southern California (N=2334).


METHODS
We identified individuals between January 2006 and June 2009 newly starting oral diabetes (DM) or hypertension (HTN) medications with preexisting comorbid HTN or DM prescription history.


METHODS
MMA was defined as a proportion of days covered where both DM and HTN medications were simultaneously available over a 33-month follow-up period. Microvascular or macrovascular complications included myocardial infarction, stroke, renal failure, and diabetic retinopathy. Multivariable logistic regressions and an IV estimation using physician-related variables were implemented.


RESULTS
MMA was supoptimal as the mean (SD) proportion of days covered was 0.53 (0.32). Patients were more adherent to medications for a preexisting condition in comparison with those for the newer disease. Older age, number of index medications [OR (95% CI)=1.36 (1.22-1.52)], receiving care from a physician who prescribed statin more frequently [OR (95% CI)=2.63 (1.67-4.14)], and receiving care from the same physician for both DM and HTN [OR (95% CI)=1.57 (1.08-2.27)] were significant factors of being adherent. Using physician-related IVs, MMA reduced microvascular and macrovascular complications. The increase in MMA from 50% to 80% reduced the average predicted probability of microvascular or macrovascular complication rate by 29.5%.


CONCLUSIONS
Adherence to medications for DM and HTN were differed and higher MMA reduced microvascular or macrovascular complications when controlling for endogeneity bias.
*Pharmacy Analytical Services Research Group, Kaiser Permanente Southern California, Downey †Schaeffer Center for Health Policy and Economics, University of Southern, California, Los Angeles, CA.
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D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000959:Antihypertensive Agents / Q000008:administration & dosage* / Q000009:adverse effects; D002140:California / Q000453:epidemiology; D015984:Causality; D015897:Comorbidity; D048909:Diabetes Complications / Q000453:epidemiology*; D003924:Diabetes Mellitus, Type 2 / Q000188:drug therapy* / Q000453:epidemiology; D003930:Diabetic Retinopathy / Q000453:epidemiology; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D006973:Hypertension / Q000188:drug therapy* / Q000453:epidemiology; D007004:Hypoglycemic Agents / Q000008:administration & dosage* / Q000009:adverse effects; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000453:epidemiology; D051437:Renal Insufficiency / Q000453:epidemiology; D012189:Retrospective Studies; D020521:Stroke / Q000453:epidemiology; D016896:Treatment Outcome; D016903:Drug Monitoring
D000959:Antihypertensive Agents; D007004:Hypoglycemic Agents