title: Adherence to evidence-based drug therapies after myocardial infarction: is geographic variation related to hospital of discharge or primary care providers? A cross-classified multilevel design.
abstract: OBJECTIVE
  To measure the adherence to polytherapy after myocardial infarction (MI), to compare the proportions of variation attributable to hospitals of discharge and to primary care providers, and to identify determinants of adherence to medications.
  
  
  METHODS
  This is a population-based study. Data were obtained from the Information Systems of the Lazio Region, Italy (5 million inhabitants).
  
  
  METHODS
  Patients hospitalised with incident MI in 2007-2010.
  
  
  METHODS
  The outcome was chronic polytherapy after MI. Adherence was defined as a medication possession ratio ≥0.75 for at least three of the following drugs: antiplatelets, β-blockers, ACEI angiotensin receptor blockers, statins.
  
  
  METHODS
  A 2-year cohort study was performed. Cross-classified multilevel models were applied to analyse geographic variation and compare proportions of variability attributable to hospitals of discharge and primary care providers. The variance components were expressed as median ORs MORs. If the MOR is 1.00, there is no variation between clusters. If there is considerable between-cluster variation, the MOR will be large.
  
  
  RESULTS
  A total of 9606 patients were enrolled. About 63% were adherent to chronic polytherapy. Adherence was higher for patients discharged from cardiology wards (OR=1.56 vs other wards, p<0.001) and for patients with general practitioners working in group practice (OR=1.14 vs single-handed, p=0.042). A relevant variation in adherence was detected between local health districts (MOR=1.24, p<0.001). When introducing the hospital of discharge as a cross-classified level, the variation between local health districts decreased (MOR=1.13, p=0.020) and the variability attributable to hospitals of discharge was significantly higher (MOR=1.37, p<0.001).
  
  
  CONCLUSIONS
  Secondary prevention pharmacotherapy after MI is not consistent with clinical guidelines. The relevant geographic variation raises equity issues in access to optimal care. Adherence was influenced more by the hospital that discharged the patient than by the primary care providers. Cross-classified models proved to be a useful tool for defining priority areas for more targeted interventions.
authors.affiliation: Department of Epidemiology, Lazio Regional Health Service, Roma, Italy.
authors.forename: Mirko
authors.initials: M
authors.lastname: Di Martino
authors.affiliation: Faculty of Education-Free University of Bolzano, Bolzano, Italy.
authors.forename: Michela
authors.initials: M
authors.lastname: Alagna
authors.affiliation: Department of Epidemiology, Lazio Regional Health Service, Roma, Italy.
authors.forename: Giovanna
authors.initials: G
authors.lastname: Cappai
authors.affiliation: Department of Epidemiology, Lazio Regional Health Service, Roma, Italy.
authors.forename: Francesca
authors.initials: F
authors.lastname: Mataloni
authors.affiliation: Department of Epidemiology, Lazio Regional Health Service, Roma, Italy.
authors.forename: Adele
authors.initials: A
authors.lastname: Lallo
authors.affiliation: Senior Epidemiologist Consultant, Roma, Italy.
authors.forename: Carlo Alberto
authors.initials: CA
authors.lastname: Perucci
authors.affiliation: Department of Epidemiology, Lazio Regional Health Service, Roma, Italy.
authors.forename: Marina
authors.initials: M
authors.lastname: Davoli
authors.affiliation: Department of Epidemiology, Lazio Regional Health Service, Roma, Italy.
authors.forename: Danilo
authors.initials: D
authors.lastname: Fusco
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016507:Cardiology Service, Hospital; D002317:Cardiovascular Agents / Q000627:therapeutic use*; D002908:Chronic Disease; D015331:Cohort Studies; D004359:Drug Therapy, Combination; D019317:Evidence-Based Medicine; D005260:Female; D058005:General Practitioners; D006297:Health Services Accessibility; D006761:Hospitals; D006801:Humans; D007558:Italy; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D009203:Myocardial Infarction / Q000517:prevention & control*; D010351:Patient Discharge; D011320:Primary Health Care / Q000592:standards*; D055502:Secondary Prevention
chemical_list: D002317:Cardiovascular Agents
keywords: Adherence to poly-therapy; Geographic variation; Hospital of discharge; Primary care providers