Health Services Research & Development

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2007 HSR&D National Meeting Abstract

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National Meeting 2007

1012 — Are Providers Looking at Adherence before Leaping to Intensify Medications? A Medical Record Review

Butchart AT (COE - Ann Arbor) , Kerr EA (COE - Ann Arbor), Hogan MM (COE - Ann Arbor), Hofer TP (COE - Ann Arbor), Heisler M (COE - Ann Arbor)

Objectives:
Among patients with Type 2 diabetes, poor blood pressure (BP) control is the greatest cause of morbidity and mortality. Medications are the cornerstone of effective BP treatment, yet many patients with hypertension are not adherent to their medication regimen. We explored whether providers detected and documented patients’ medication adherence problems and whether providers increased patients’ medications in the absence of medication adherence assessment in a sample of VA diabetes patients who had both elevated BPs and evidence of poor BP medication refill adherence.

Methods:
Automated pharmacy and medical data were used to select a sample of 103 diabetes patients in VISN11 in FY 2003 and 2004 who had elevated BPs and whose pharmacy records showed significant gaps in their BP medication refill adherence over the study period. Of 3037 BP medication refills for these patients, 781 fills (24%) were preceded by a gap in medication possession lasting more than 10 days, and evidence of provider awareness of these gaps was sought. Three physicians reviewed the 850 primary care visit notes found in this 2 year time period in the patients’ EMRs.

Results:
Reviewers found that 62% (n=465) of medication refill gaps were not noted at all by providers in the medical record, suggesting providers were unaware of potential adherence problems. For 20% (n=151) of the gaps, poor adherence was noted as an explanation in the medical record. Alternative explanations, such as having been hospitalized outside the VA system, were found for 15% (n=111) of the gaps. Providers assessed and noted medication adherence at 22% of all visits and 25% (n=128) of the visits at which patients’ BP was >=140/90 but intensified medications at 48% (n=246) of these high BP visits. 70% (n=173) of these intensification events occurred without any documentation of adherence assessment.

Implications:
Primary care providers rarely documented assessment of adherence problems among patients who have gaps in BP medication refill rates, even in the face of high BP at the clinic visit. Further, providers frequently intensified treatment regimens without assessing adherence to already prescribed medications.

Impacts:
To improve BP control among patients with diabetes, we need to develop efficient, systematic ways to assess and document patients’ poor medication adherence as a possible contributor to poor BP control. This assessment and documentation process is an essential step before intensifying medications.