Journal
ANNALS OF FAMILY MEDICINE
Volume 10, Issue 1, Pages 6-14Publisher
ANNALS FAMILY MEDICINE
DOI: 10.1370/afm.1343
Keywords
Treatment adjustment; medication adherence; multicondition; diabetes; coronary heart disease; depression; collaborative care; treat-to-target; chronic care model; TEAMcare
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Funding
- John A. Hartford Foundation
- Johnson Johnson
- Rewarding Health
- Group Health Cooperative
- Wyeth
- Eli Lilly
- Forest Laboratories
- Pfizer
- National Institute of Mental Health [MH041739, MH069741]
- NATIONAL INSTITUTE OF MENTAL HEALTH [K08MH069741, R01MH041739] Funding Source: NIH RePORTER
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PURPOSE Medication nonadherence, inconsistent patient self-monitoring, and inadequate treatment adjustment exacerbate poor disease control. In a collaborative, team-based, care management program for complex patients (TEAMcare), we assessed patient and physician behaviors (medication adherence, self-monitoring, and treatment adjustment) in achieving better outcomes for diabetes, coronary heart disease, and depression. METHODS A randomized controlled trial was conducted (2007-2009) in 14 primary care clinics among 214 patients with poorly controlled diabetes (glycated hemoglobin [HbA(1c)] >= 8.5%) or coronary heart disease (blood pressure >140/90 mm Hg or low-density lipoprotein cholesterol >130 mg/dL) with coexisting depression (Patient Health Questionnaire-9 score >= 10). In the TEAMcare program, a nurse care manager collaborated closely with primary care physicians, patients, and consultants to deliver a treat-to-target approach across multiple conditions. Measures included medication initiation, adjustment, adherence, and disease self-monitoring. RESULTS Pharmacotherapy initiation and adjustment rates were sixfold higher for antidepressants (relative rate [RR] = 6.20; P < .001), threefold higher for insulin (RR = 2.97; P < .001), and nearly twofold higher for antihypertensive medications (RR = 1.86, P < .001) among TEAMcare relative to usual care patients. Medication adherence did not differ between the 2 groups in any of the 5 therapeutic classes examined at 12 months. TEAMcare patients monitored blood pressure (RR = 3.20; P < .001) and glucose more frequently (RR = 1.28; P = .006). CONCLUSIONS Frequent and timely treatment adjustment by primary care physicians, along with increased patient self-monitoring, improved control of diabetes, depression, and heart disease, with no change in medication adherence rates. High baseline adherence rates may have exerted a ceiling effect on potential improvements in medication adherence.
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