What is the clinical evidence from this study?

Study design: Cohort. Population: Cardiometabolic diseases (hypertension, dyslipidemia, diabetes) (n=92766). Primary outcome: Biometric control (blood pressure, HbA1c, LDL-C) status (HR 0.58, 95% CI 0.55–0.60).

What does this research mean for the field?

Poor medication adherence and therapeutic inertia independently contribute to poor disease control in cardiometabolic diseases, with therapeutic inertia having a greater impact than medication adherence. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.CHALLENGES_CONSENSUS.

November 7, 2022Open Access

Medication non-adherence and therapeutic inertia independently contribute to poor disease control for cardiometabolic diseases

Key Result

Patients who did not retrieve their medication were 42% less likely to achieve LDL-C control compared to those who adhered to their medication regimen (HR 0.58).

Study Design

Type

Cohort (n=92,766)

Multicenter

Structured PICO

Do therapeutic inertia and medication non-adherence independently reduce the likelihood of achieving biometric control in primary care patients with cardiometabolic diseases?

Population

92,766 primary care patients >35 years old diagnosed with at least one cardiometabolic condition (hypertension, dyslipidemia, or diabetes) and at least one health gap (elevated BP, HbA1c, or LDL-C) at baseline.

Intervention

Therapeutic inertia (absence of any EHR record of a medication order or intensification) and medication non-adherence (proportion of days covered <80% or no medication retrieved).

Comparator

No therapeutic inertia (treatment initiated or intensified) and medication adherence (proportion of days covered ≥80%).

Outcome

First time to achieve biometric control (BP, HbA1c, or LDL-C) during the follow-up period (from index date to 12/31/2020).surrogate

Therapeutic inertia has a substantially greater impact on the persistence of cardiometabolic health gaps, particularly for LDL-C, than patient medication non-adherence.

Main Result

Effect estimate: HR 0.58 (95% CI 0.55–0.60)

Limitations

Single healthcare system study
Recall bias in medication dispense data
Lack of differentiation between primary and secondary prevention of ASCVD
Difficulty in discerning white-coat hypertension
Limited structured data capturing reasons for TI

Abstract

Abstract Poorly controlled cardiometabolic biometric health gap measures e.g.,uncontrolled blood pressure (BP), HbA1c, and low-density lipoprotein cholesterol (LDL-C) are mediated by medication adherence and clinician-level therapeutic inertia (TI). The study of comparing relative contribution of these two factors to disease control is lacking. We conducted a retrospective cohort study using 7 years of longitudinal electronic health records (EHR) from primary care cardiometabolic patients who were 35 years or older. Cox-regression modeling was applied to estimate how baseline proportion of days covered (PDC) and TI were associated with cardiometabolic related health gap closure. 92,766 patients were included in the analysis, among which 89.9%, 85.8%, and 73.3% closed a BP, HbA1c, or LDL-C gap, respectively, with median days to gap closure ranging from 223 to 408 days. Patients who did not retrieve a medication were the least likely to achieve biometric control, particularly for LDL-C (HR = 0.58, 95% CI: 0.55–0.60). TI or uncertainty of TI was associated with a high risk of health gap persistence, particularly for LDL-C (HR ranges 0.46–0.48). Both poor medication adherence and TI are independently associated with persistent health gaps, and TI has a much higher impact on disease control compared to medication adherence, implying disease management strategies should prioritize reducing TI.

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