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Objective: Despite evidence indicating therapeutic benefit for adhering to a prescribed regimen, many patients do not take their medications as prescribed. Non-adherence often leads to morbidity and to higher health care costs. The objective of the study was to assess patient characteristics associated with medication adherence across eight diseases. Design:Retrospective data from a repository within an integrated health system was used to identify patients ≥18 years of age with ICD-9-CM codes for primary or secondary diagnoses for any of eight conditions (depression, hypertension, hyperlipidemia, diabetes, asthma or chronic obstructive pulmonary disease, multiple sclerosis, cancer, or osteoporosis). Electronic pharmacy data was then obtained for 128 medications used for treatment.Methods: Medication possession ratios (MPR) were calculated for those with one condition and one drug (n=15,334) and then for the total population having any of the eight diseases (n=31,636). The proportion of patients adherent (MPR ≥80%) was summarized by patient and living-area (census) characteristics. Bivariate associations between drug adherence and patient characteristics (age, sex, race, education, and comorbidity) were tested using contingency tables and chi-square tests. Logistic regression analysis examined predictors of adherence from patient and living area characteristics. Results:Medication adherence for those with one condition was higher in males, Caucasians, older patients, and those living in areas with higher education rates and higher income. In the total population, adherence increased with lower comorbidity and increased number of medications. Substantial variation in adherence was found by condition with the lowest adherence for diabetes (51%) and asthma (33%). Conclusions:The expectation of high adherence due to a covered pharmacy benefit, and to enhanced medication access did not hold. Differences in medication adherence were found across condition and by patient characteristics. Great room for improvement remains, specifically for diabetes and asthma.

PURPOSE We wanted to assess the impact of an electronic health record-based diabetes clinical decision support system on control of hemoglobin A 1c (glycated hemoglobin), blood pressure, and low-density lipoprotein (LDL) cholesterol levels in adults with diabetes. METHODSWe conducted a clinic-randomized trial conducted from October 2006 to May 2007 in Minnesota. Included were 11 clinics with 41 consenting primary care physicians and the physicians' 2,556 patients with diabetes. Patients were randomized either to receive or not to receive an electronic health record (EHR)-based clinical decision support system designed to improve care for those patients whose hemoglobin A 1c , blood pressure, or LDL cholesterol levels were higher than goal at any offi ce visit. Analysis used general and generalized linear mixed models with repeated time measurements to accommodate the nested data structure. RESULTSThe intervention group physicians used the EHR-based decision support system at 62.6% of all offi ce visits made by adults with diabetes. The intervention group diabetes patients had signifi cantly better hemoglobin A 1c (intervention effect -0.26%; 95% confi dence interval, -0.06% to -0.47%; P = .01), and better maintenance of systolic blood pressure control (80.2% vs 75.1%, P = .03) and borderline better maintenance of diastolic blood pressure control (85.6% vs 81.7%, P = .07), but not improved low-density lipoprotein cholesterol levels (P = .62) than patients of physicians randomized to the control arm of the study. Among intervention group physicians, 94% were satisfi ed or very satisfi ed with the intervention, and moderate use of the support system persisted for more than 1 year after feedback and incentives to encourage its use were discontinued.CONCLUSIONS EHR-based diabetes clinical decision support signifi cantly improved glucose control and some aspects of blood pressure control in adults with type 2 diabetes. INTRODUCTIOND espite recent improvement trends in the United States, in 2008 less than 20% of patients with diabetes concurrently reach evidence-based goals for hemoglobin A 1c (glycated hemoglobin), systolic and diastolic blood pressure, and low-density lipoprotein (LDL) cholesterol levels.1,2 Care is unsatisfactory in both subspecialty and primary care settings, but because more than 80% of diabetes care is delivered by primary care physicians, effective strategies to improve diabetes care in primary care settings are urgently needed.Among the major barriers to better diabetes care is lack of timely intensifi cation of pharmacotherapy in patients who have not achieved recommended clinical goals. Many factors contribute to this problem, including competing demands at the time of the visit 3 and medication In theory, treatment intensifi cation and control of hemoglobin A 1c , blood pressure, and lipid levels in patients with diabetes mellitus could be improved by providing patient-specifi c and drug-specifi c clinical decision support at the time of a clinical encounter. Electronic health recor...

Key Points Question How long does blood pressure remain lower compared with usual care after a 12-month intensive intervention (home telemonitoring and pharmacist management)? Findings In this follow-up of a cluster randomized trial of 326 patients with uncontrolled hypertension, research clinic measurements showed that home blood pressure telemonitoring with pharmacist management lowered blood pressure more than usual care in the first 18 months, but this was not sustained through 54 months. The results from routine clinical measurements suggested significantly lower blood pressure in the intervention group for up to 24 months. Meaning Long-term maintenance strategies may be needed to sustain blood pressure intervention effects over several years.

Poor mental health places staff at risk for burnout and likely contributes to staff leaving hospice care; this is a critical issue as the profession attempts to attract new staff to meet the expanding demands for hospice care.