PENGARUH PEMBERIAN UMPAN BALIK TEKANAN DARAH KEPADA DOKTER TERHADAP INTENSIFIKASI DAN LUARAN TERAPI PASIEN ASKES HIPERTENSI Kajian Farmakoepidemiologi

RITA SUHADI, Prof. dr. Iwan Dwiprahasto, MD.MMedSc.PhD.

2013 | Disertasi | S3 Kedokteran Umum

Pengendalian tekanan darah (TD) menurunkan kejadian kardiovaskular. Intensifikasi terapi (IT) memperbaiki pengendalian TD. Dalam praktek klinis IT relatif rendah dan merupakan penghambat dalam pengendalian TD pasien. Penelitian non-random multisenter di 4 rumah sakit ini bertujuan mengevaluasi cost-effectiveness terapi, pengaruh pemberian umpan balik TD pasien kepada dokter terhadap perubahan nilai IT, pengendalian TD, dan akseptabilitas dokter terhadap program tersebut. Penelitian terdiri dari 2 periode, periode 1 berupa studi kohort selama 6 bulan dan dilanjutkan periode 2 selama 8 bulan berupa penelitian eksperimental non-random dengan kontrol. Kriteria inklusi dan ekslusi pasien: dewasa, rawat jalan, dibiayai Askes, hipertensi/mendapat obat hipertensi, ≥4 kunjungan pada periode 2, dan tidak menjalani hemodialisis. Dokter subyek Perlakuan mendapatkan umpan balik TD dan informasi target TD pada bulan 1, 2, 4, dan 6 di periode 2 penelitian. Rumus IT menggunakan standard-based method dan cost effectiveness diukur dengan grafik plot dan Incremental Cost Effectiveness Ratio. Profil pasien Perlakuan (P=385) dan Kontrol (K=271); proporsi pasien komorbid (P) 78.7% vs. (K) 91.5%; persistensi ±80% (tinggi). Selain ketaatan dan jumlah obat kardiovaskular, profil awal lainnya tidak berbeda P vs. K p>0.05. Profil antihipertensi P vs. K sama p>0.05, yang paling sering digunakan amlodipin dan valsartan; antihipertensi dosis satu kali sehari 78.8% vs. 78.6% dan dosis tinggi (P) 53.2% vs. (K) 41.3% (p>0.05). Perbandingan TD sistolik (TDS) antara pasien P vs. K: TDS awal (P) 144.1 vs. (K) 139.6 mmHg (p<0.05), rerata TDS periode2 (P) 140.4 vs. (K) 140.6mmHg p>0.05; selisih TDS awal-akhir (P) 5.9 vs. (K) -0.9mmHg (p<0.05); dan selisih TDS target-akhir (P) -6.1 vs. (K) -9.6mmHg (p<0.05). Pemberian umpan balik memperbaiki pencapaian target rerata TDS periode2 vs. Kontrol dengan odds ratio 1.58(CI95%:1.07-2.34). Selisih nilai IT periode1-2; (P) 0.04±0.29 vs. (K) -0.05±0.29 p<0.01. Proporsi kategori IT tertinggi (0-(-)0.2): (P) 26.5% vs. (K) 20.3% p<0.05. Makin tinggi nilai IT (Perlakuan) mempunyai parameter TDawal, TDakhir, rerata TDS periode 1 dan 2, selisih TDawal-akhir, selisih TDtarget-akhir (uji-T) dan TDS bulanan makin baik (uji between-subjects effects repeated measurement Anova). Hanya pasien IT tertinggi Perlakuan yang berhasil mencapai target TDS lebih baik untuk TDS akhir (P) 3.7 vs. (K) -2.6mmHg dan rerata TDS (P) 2.1 vs. (K)- 7.8mmHg (p<0.05). Berdasarkan odds ratio kunjungan pasien yang melakukan IT vs. tidak melakukan IT pengendalian TD yang lebih baik sebesar (P)1.79 vs. (K) 2.03, sedangkan pasien Perlakuan dengan nilai rerata IT 0-(-)>0.2 vs. IT <(-)0.8 mempunyai odds ratio 3.8(CI 95%:1.3-10.9) pasien dengan rerata TDS yang mencapai target. Obat kardiovaskular (CVD) merupakan komponen biaya terbesar (P) 81% vs. (K) 71% dan biaya antihipertensi (P) 55.5% vs. (K) 51.3% dari biaya obat CVD. Pasien Perlakuan makin baik nilai kategori IT makin kecil rerata biaya terapinya perkunjungan. Hasil grafik plot pasien Perlakuan bersifat cost effectiveness. Perbaikan nilai IT meningkatkan biaya antihipertensi (p<0.05), tetapi tidak meningkatkan biaya obat CVD dan total. Hasil analisis Incremental Cost Effectiveness Ratio (ICER) pasien Perlakuan mempunyai efektivitas lebih baik berdasarkan parameter efektivitas TDS akhir, rerata TDS, nilai IT dan menggunakan biaya antihipertensi dan semua obat CVD lebih tinggi, tetapi menghabiskan biaya total sama vs. Kontrol. Simpulan penelitian adalah pemberian umpan balik TD kepada dokter meningkatkan efektivitas biaya; umpan balik TD kepada dokter meningkatkan nilai intensifikasi terapi Perlakuan lebih baik vs. Kontrol (p<0.05); IT meningkatkan pengendalian TD pasien Perlakuan berdasarkan penurunan TDS awal-akhir, selisih TDS akhir-TDS target, odds ratio rerata TDS yang berhasil mencapai target lebih baik vs. Kontrol (p<0.05); dan dokter menyatakan dapat menerima program pemberian umpan balik untuk peningkatan IT.

Appropriate blood pressure (BP) control reduced cardiovascular (CVD) event. Therapy intensification (TI) improved BP control. TI was found relatively rare in clinical practice and became the barrier in BP control. A non-randomized and multicenter study in 4 hospitals was done with the aims to evaluate the effect of BP feedback intervention to physicians on the cost-effectiveness of the therapy, the increase of TI score, the improvement of BP control, and the acceptability of the intervention program by the physicians. The study consisted 2 periods, the first period was cohort for 6 months and the second period was the nonrandomized study with control for 8 months follow-up. Subjects of adults, outpatients, with “Askes” insurance, high BP/with antihypertensive medicine, and ≥4visits in 2 nd period were included but the subjects in hemodialysis were excluded. Physicians in intervention group received 4 times feedback in month 1, 2, 4, and 6 in the 2 nd period. The TI score was calculated with standard-based method and cost effectiveness was determined with scatter plot analysis and Incremental Cost Effectiveness Ratio. Subjects’ profile of intervention (I) vs. non-intervention (NI) groups were: 385 vs. 271 subjects; proportion of comorbid (I) 78.7% vs. (NI) 91.5% (p<0.05); high persistence ±80% in both groups. Except for mean possession ratio (MPR) and numbers of CVD medicine; the other baseline profiles were similar including hypertensive medicine (p>0.05); amlodipine and valsartan as the most frequently prescribed; once daily hypertensive medicine (I) 78.8 vs. (NI) 78.6%; and the dosage form in higher dose (I) 53.2% vs. (NI) 41.3% (p<0.05). The comparisons of the systolic BP (SBP) variables were: baseline SBP (I) 144.1 vs. (NI) 139.6mmHg (p<0.05); mean SBP in the 2 nd period (I) 140.4 vs. (NI) 140.6mmHg (p>0.05); ∆final-baseline SBP (I) 5.9 vs. (NI) -0.9 mmHg; and ∆final-target SBP (I) -6.1 vs. (NI) -9.6mmHg (p<0.05). Feedback intervention improved mean SBP in the 2 nd period with odds ratio 1.58(95%CI: 1.07-2.34). The results of TI were: ∆TI score in 1 st –2 nd period (I) 0.04±0.29 vs. (NI) -0.05±0.29 p<0.01; the proportion of subjects with the highest TI score (0-(-)0.2) (I) 26.5% vs. (NI) 20.3%; in the intervention subjects the better the TI score had the better outcomes based on baseline, final, mean, ∆final-baseline, and ∆finaltarget SBP with t-test, and better monthly SBP with the test of between-subjects effects in repeated measurement Anova; the best TI score subgroup in intervention subjects was the only subgroup reached SBP target and better than the NI subjects at (I) 3.7 vs. (NI)-2.6mmHg for final SBP and for mean SBP (I) 2.1 vs. (NI) -7.8mmHg (p<0.05). Proportion of TI vs. non-TI reached good SBP control odds ratio (I) 1.79 vs. (K) 2.03 p<0.05, meanwhile the intervention subjects the highest (0 - (-)0.2) vs. the lowest <(-)0.8 TI score had the better SBP control with odds ratio 3.8(CI 95%:1.3-10.9). The CVD medicine comprised the largest proportion of medication cost (I) 81% vs. (NI) 71% of the total cost and the hypertensive medicines comprised (I) 55.5% vs. (NI) 51.3% of CVD medicine. The better the TI score had the lower mean therapy cost in each visit. The scatter plots showed that the intervention subjects were in cost effective results. The improvement of TI score increased the cost of hypertensive medicine among the intervention subjects but did not increase the “all CVD medicine” and total cost. The incremental cost effectiveness ratio (ICER) analysis of the intervention subjects had better effectiveness based on the parameter of final SBP, mean SBP, and TI score; spent higher cost for hypertensive and CVD medicine cost, but not for the total cost. The conclusion: the blood pressure feedback intervention to physicians increased the cost effectiveness; TI score; and blood pressure control based on ∆baseline-final SBP, ∆final-target SBP, and odds ratio BP reached the target (p<0.05).

Kata Kunci : umpan balik tekanan darah kepada dokter; intensifikasi terapi; pengendalian tekanan darah; cost effectiveness analysis