OBJECTIVE -To determine medication adherence and predictors of suboptimal adherence in a community cohort of patients with diabetes and to test the hypothesis that adherence decreases with increased number of medicines prescribed. RESEARCH DESIGN AND METHODS-A total of 128 randomly selected patients with type 2 diabetes from a single community health center responded to a pharmacistadministered questionnaire regarding medication use. Survey data were linked to clinical data available from the electronic medical record. We assessed self-reported adherence rates for each diabetes-related medicine, barriers and attitudes regarding medication use, and HbA 1c , total cholesterol, and blood pressure levels.RESULTS -Patients were taking a mean of 4.1 (Ϯ1.9) diabetes-related medicines. The average 7-day adherence was 6.7 Ϯ 1.1 days. Total number of medicines prescribed was not correlated with medication adherence. Adherence was significantly lower for medicines not felt to be improving current or future health (6.1 vs. 6.9 days out of 7, P Ͻ 0.001). Among patients on three or more medicines, 71% (15 of 21 patients) with suboptimal adherence were perfectly adherent with all but one medicine. Side effects were the most commonly reported problem with medication use. Of 29 medicines causing side effects that interfered with adherence, 24 (83%) did so for Ͼ1 month, and only 7 (24%) were reported to the patient's primary care physician.CONCLUSIONS -In this sample, patients reported very high medication adherence rates regardless of number of medicines prescribed. Among patients on multiple medicines, most patients with suboptimal adherence were perfectly adherent to all but one medicine. Unreported side effects and a lack of confidence in immediate or future benefits were significant predictors of suboptimal adherence. Physicians should not feel deterred from prescribing multiple agents in order to achieve adequate control of hyperglycemia, hypertension, and hyperlipidemia. Diabetes Care 26:1408 -1412, 2003P olypharmacy is the natural consequence of providing evidence-based medical care to patients with type 2 diabetes (1). Typically, multidrug regimens are required to control hyperglycemia and the associated metabolic risk factors of hypertension and hyperlipidemia (2). Patient adherence to prescribed medications is crucial to the goal of reaching metabolic control.Previous research on medication adherence in type 2 diabetes has focused primarily on adherence to hypoglycemic medicines, the association of adherence to glycemic control, and interventions to improve adherence to insulin and oral hypoglycemic agents (3-7). Less is known about medication adherence in the setting of polypharmacy (8,9). Widely used selfreport instruments for measuring adherence in diabetes, such as the Summary of Diabetes Self-Care Activities (10), do not ask about medication adherence on an individual medicine-by-medicine basis. Results from studies that have assessed concurrent adherence in multidrug therapy for HIV disease (11-13) and for tuberc...

In this community cohort, patients reported few adherence barriers and very high medication adherence rates. Our patient-tailored intervention did not further reduce these barriers or improve self-reported adherence. The high prevalence of medication discrepancies appeared to mostly reflect inaccuracies in the medical record rather than patient errors.

This article reviews the experience of a large, heterogeneous integrated delivery network that incorporated physician quality metrics into pay-for-performance contracts. The authors present criteria for including measures in pay-for-performance contracts and offer a practical approach to determining withhold return or bonus distribution based on improvement and performance. They demonstrate interventions undertaken to improve performance, including the development of a claims-based registry. Empirical data show that the network performance improved more than the comparable state and national performance during the period of this observational study. The authors conclude that pay-for-performance contracts led to development of medical management programs including a claims-based registry and nonphysician interventions, which helped significantly improve selected HEDIS scores.