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Association between refill adherence to lipid-lowering medications and the risk of cardiovascular disease and mortality in Swedish patients with type 2 diabetes mellitus: a nationwide cohort study.

Association between refill adherence to lipid-lowering medications and the risk of cardiovascular disease and mortality in Swedish patients with type 2 diabetes mellitus: a nationwide cohort study.
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Karlsson SA, Hero C, Svensson AM, Franzén S, Miftaraj M, Gudbjörnsdottir S, Eeg-Olofsson K, Eliasson B, Andersson Sundell K,


Karlsson SA, Hero C, Svensson AM, Franzén S, Miftaraj M, Gudbjörnsdottir S, Eeg-Olofsson K, Eliasson B, Andersson Sundell K, (click to view)

Karlsson SA, Hero C, Svensson AM, Franzén S, Miftaraj M, Gudbjörnsdottir S, Eeg-Olofsson K, Eliasson B, Andersson Sundell K,

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BMJ open 2018 03 308(3) e020309 doi 10.1136/bmjopen-2017-020309
Abstract
OBJECTIVES
To analyse the association between refill adherence to lipid-lowering medications, and the risk of cardiovascular disease (CVD) and mortality in patients with type 2 diabetes mellitus.

DESIGN
Cohort study.

SETTING
National population-based cohort of Swedish patients with type 2 diabetes mellitus.

PARTICIPANTS
86 568 patients aged ≥18 years, registered with type 2 diabetes mellitus in the Swedish National Diabetes Register, who filled at least one prescription for lipid-lowering medication use during 2007-2010, 87% for primary prevention.

EXPOSURE AND OUTCOME MEASURES
Refill adherence of implementation was assessed using the medication possession ratio (MPR), representing the proportion of days with medications on hand during an 18-month exposure period. MPR was categorised by five levels (≤20%, 21%-40%, 41%-60%, 61%-80% and >80%). Patients without medications on hand for ≥180 days were defined as non-persistent. Risk of CVD (myocardial infarction, ischaemic heart disease, stroke and unstable angina) and mortality by level of MPR and persistence was analysed after the exposure period using Cox proportional hazards regression and Kaplan-Meier, adjusted for demographics, socioeconomic status, concurrent medications and clinical characteristics.

RESULTS
The hazard ratios for CVD ranged 1.33-2.36 in primary prevention patients and 1.19-1.58 in secondary prevention patients, for those with MPR ≤80% (p<0.0001). The mortality risk was similar regardless of MPR level. The CVD risk was 74% higher in primary prevention patients and 33% higher in secondary prevention patients, for those who were non-persistent (p<0.0001). The mortality risk was 6% higher in primary prevention patients and 18% higher in secondary prevention patients, for non-persistent patients (p<0.0001). CONCLUSIONS
Higher refill adherence to lipid-lowering medications was associated with lower risk of CVD in primary and secondary prevention patients with type 2 diabetes mellitus.

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