John Kennelly

A computational framework to identify patients with poor adherence to blood pressure lowering medication

BACKGROUND Blood pressure (BP) lowering medications have impressive efficacy in reducing cardiovascular and renal events; but low adherence threatens their effectiveness. Analysis of patterns in electronic prescribing from electronic medical records (EMRs) may have the potential to reveal cohorts of patients with significant adherence problems. METHODS We developed a computational framework to identify patient cohorts with poor adherence to long-term medication through analysis of electronic prescribing patterns. A range of quality reporting criteria can be specified (as an XML document). We illustrate the framework by application to the EMRs of a New Zealand general practice with a focus on adherence to angiotensin-converting enzyme inhibitors (ACE-inhibitors) and/or angiotensin II receptor blockers (ARBs) in patients classified with hypertension and diabetes. We analyse medication supply based on Medication Possession Ratio (MPR) and duration of lapse in ACE-inhibitors/ARBs over a 12-month evaluation period. We describe graphical tools to assist visualisation of prescribing patterns and relationship of the analysis outputs to controlled blood pressure. RESULTS Out of a cohort of 16,504 patient EMRs, 192 patients were found classified with both hypertension and diabetes and under active ACE-inhibitor and/or ARB management. Of these, 107 (56%) patients had an ACE-inhibitor/ARB MPR less than 80% together with a lapse in ACE-inhibitors/ARBs for greater than 30 days. We find non-adherent patients (i.e. MPR <80% or lapse >30 days) are three times more likely to have poor BP than adherent patients (odds ratio=3.055; p=0.012). CONCLUSIONS We have developed a generic computational framework that can be used to formulate and query criteria around issues of adherence to long-term medication based on practice EMRs. Within the context of the example we have used, the observed adherence levels indicate that a substantial proportion of patients classified with hypertension and diabetes have poor adherence, associated with poorer rates of blood pressure control, that can be detected through analysis of electronic prescribing. Further work is required to identify effective interventions using the reporting information to reduce non-adherence and improve patient outcomes.

Using the general practice EMR for improving blood pressure medication adherence.

PURPOSE Analysis of practice electronic medical records (EMRs) demonstrated widespread antihypertensive medication adherence problems in a Pacific-led general practice serving a predominantly Pacific (majority Samoan) caseload in suburban New Zealand. Adherence was quantified in terms of medication possession ratio (MPR, percent of days covered by medication supply) from the practices prescribing data. We studied the effectiveness of general practice staff follow-up guided by EMR data to improve medication adherence. METHODS A framework for identification of suboptimal long-term condition management from routinely-collected EMR data, the ChronoMedIt (Chronological Medical Audit) tool, was applied to data of two Pacific-led general practices to identify patients with low MPR. One practice undertook intervention, the other provided usual care. A cohort was based on MPR<80% for antihypertensive medication in a baseline 6-month period. At the intervention practice a team was established to provide reminders and motivation for these patients and discuss their specific needs for assistance to improve adherence for 12 months. MPR and systolic blood pressure (SBP) was collected at baseline and for last six months of intervention based on practice EMRs; national claims data provided assessment of MPR based on dispensing. Nursing notes were analysed, and patient and provider focus groups were conducted. RESULTS Of the 252 intervention patients with MPR<80% initially, MPR improved 12.0% (p=0.0002) and systolic blood pressure was 3.5mmHg lower (p=0.07) as compared to the control cohort. MPR from national claims data improved by 11.5% (p=0.0001) as compared to the control. Patients welcomed the approach as caring and useful. Providers felt the approach worthy of wider deployment but that it required dedicated staffing. DISCUSSION AND CONCLUSIONS Systematic follow-up of patients with demonstrated poor medication possession appears effective in the context of a Pacific-led general practice serving a largely Pacific caseload. It was possible to exploit the EMR database to identify patients with low antihypertensive medication possession and to raise their level of medication possession significantly. The measured effect on systolic BP was only marginally significant, leaving open the question of the precise value of the intervention in terms of morbidity and mortality. The intervention was found to be feasible and was met with good acceptance from the intervention patients, who appreciated the concern reflected in the follow-up effort. The intervention practice is continuing use of ChronoMedIt to guide long-term condition management with extension to cholesterol and blood sugar.

Burden of atrial fibrillation in Māori and Pacific people in New Zealand: a cohort study

Atrial fibrillation (AF) is a major risk factor for ischaemic stroke and cardiovascular events. In New Zealand (NZ), Māori (indigenous New Zealanders) and Pacific people experience higher rates of AF compared with non‐Māori/non‐Pacific people.