Adherence with prescribed medications

Transcription

National electronic Library for Medicines
Medicines Management Overview
March 2013
ADHERENCE WITH PRESCRIBED MEDICATIONS
An annotated bibliography of publications in 2012
Summary
Contents
Summary
This annotated bibliography with 331 references is based
on papers published in 2012 and included in the National
Electronic Library for Medicines (NeLM). The references are
grouped into sections (alphabetical order by first author
within each section) and a detailed subject index is
provided.
1
General Reviews and
Commentaries
2
Measuring Adherence
6
Adherence Levels in
Practice
29
Factors Affecting
Adherence
51
Effect of Adherence on
Outcomes and Costs 120
Interventions to Improve
Adherence
149
Subject Index
Randomised controlled trials are indentified with
systematic reviews and meta-analyses with
202

Produced for the
National electronic
Library for Medicines
by:
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Information Specialist,
London and South East
Medicines Information
Service, Guy’s Hospital,
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Tel: 020 7188 5026
[email protected]
 and
.
As can be seen from the index entries, most attention has
been devoted to conditions requiring long-term treatment,
such as diabetes, hypertension and schizophrenia, although
non-adherence has also been shown in acute outpatient
treatment and in patients discharged from emergency
Wunits.
e
i Non-adherence is widespread and appears to be associated
g
with significant adverse clinical and economic outcomes.
h
t Causes are multi-factorial.
mNumerous interventions have been trialled, generally
a focusing on patient education and counselling on one hand,
n and reminder mechanisms on the other. Pharmacists have
a been involved in a number of these. Many interventions
g have been shown to improve adherence, although evidence
e for their effect on clinical outcomes or their costm
effectiveness is less extensive.
e
n
t
m
a
n
a
g
e
m
e
General Reviews and Commentaries
Reviewers emphasise the high cost of non-adherence, both in financial
terms and in relation to health outcomes. They show the importance of
involving patients in programmes to improve adherence rather than
relying on mechanistic solutions alone.
1. An alternative view of medication compliance: from a prescriptive attitude to a
therapeutic alliance between patient and carer - concepts and factors
(Penser autrement l'observance médicamenteuse: d'une posture injonctive à une alliance
thérapeutique entre le patient et le soignant - concepts et determinants)
M Baudrant-Boga, A Lehmann, B Allenet
Annales Pharmaceutiques Francaises Jan 2012;70(1):15-25
Patient compliance is a dynamic behaviour, which varies over time and in form. The
impact of poor adherence is both medical (loss of immediate and/or long-term
benefits) and economic (direct and indirect costs). Adhering and remaining engaged
with daily drug treatment appear to be a challenge for the chronic patient. In this
context, we begin by reviewing the evolution of the terminology around adherence.
This evolution underlies the paradigm shift behind this concept and opens new areas
for action. Based on this perspective representing the patient's adherence to his or
her drug therapy, we detail the various factors influencing medication adherence
categorised into five dimensions: illness, medication, demographic and socioeconomic, patient and/or patient support and care system. The impact of these
factors is described and underlying explanatory models outlined. Understanding the
issues underlying adherence to drug treatment will help devise further personalised
interventions, which must be multi-faceted in response to the multiplicity of factors
involved. (98 refs.)
http://www.sciencedirect.com/science/article/pii/S0003450911001374
2. Medication adherence in older adults with cognitive impairment: a systematic
evidence-based review
NL Campbell, MA Boustani, EN Skopeljia, S Gao, FW Unverzagt, MD Murray
American Journal of Geriatric Pharmacotherapy Jun 2012;10(3):165-177
Background: Cognitive impairment challenges the ability to adhere to the complex
medication regimens needed to treat multiple medical problems in older adults.
Objective: The aim was to conduct a systematic evidence-based review to identify
barriers to medication adherence in cognitively impaired older adults and
interventions aimed at improving medication adherence.
Methods: A search was performed of MEDLINE, EMBASE, PsycINFO, GoogleDocs and
CINAHL for articles published between 1966 and 29 Feb 2012. Studies included
older adults with a diagnosis of cognitive impairment of any degree (mild cognitive
impairment or mild, moderate or severe dementia). To identify barriers to
adherence, we reviewed observational studies. To identify relevant interventions, we
reviewed clinical trials targeting medication adherence in cognitively impaired older
adults. We excluded studies lacking a measure of medication adherence or lacking
an assessment of cognitive function, case reports or series, reviews and those
focusing on psychiatric disorders or infectious diseases. Population demographics,
baseline cognitive function, medication adherence methods, barriers to adherence
and prospective intervention methodologies were extracted.
2
Results: The initial search identified 594 articles. 10 studies met inclusion criteria for
barriers to adherence and 3 met inclusion criteria for interventional studies. Unique
barriers to adherence included understanding new directions, living alone, scheduling
medication administration into the daily routine, using potentially inappropriate
medications and uncooperative patients. Two studies evaluated reminder systems
and showed no benefit in a small group of participants. One study improved
adherence through telephone and televideo reminders at each dosing interval. The
results of the review are limited by reviewing only published articles, missing barriers
or interventions due to lack of subgroup analysis, study selection and extraction
completed by one reviewer, and articles with at least an abstract published in
English.
Conclusions: The few studies identified limit the assessment of barriers to medication
adherence in the cognitively impaired population. Successful interventions suggest
that frequent human communication as reminder systems are more likely to improve
adherence than nonhuman reminders.
http://www.ajgeripharmacother.com/article/S1543-5946(12)00066-9/abstract
3. The 'cost' of medication nonadherence: consequences we cannot afford to
accept
MA Chisholm-Burns, CA Spivey
Journal of the American Pharmacists Association Nov-Dec 2012;52(6):823-826
Objective: To provide a brief overview of the extent of medication nonadherence in
the United States, its impact on patient health and health care costs, its causes, and
possible strategies that health care practitioners can use to improve medication
adherence.
Summary: Medication use and health care costs have increased dramatically during
the previous decade in the United States. Adherence to medication therapy often is
a critical aspect of medical treatment, particularly the treatment of chronic conditions
such as diabetes and hypertension. Despite the importance of adherence,
medication nonadherence is a serious problem, with the World Health Organization
noting that the average nonadherence rate is 50% among those with chronic
illnesses. Consequences of nonadherence include worsening condition, increased
comorbid diseases, increased health care costs and death. Nonadherence results
from many causes; therefore, no easy solutions exist. The first step to addressing
nonadherence is to recognise that collaboration must occur between health care
practitioners and patients to increase adherence, with the goal of achieving optimal
health outcomes.
Conclusions: The relationship between health care practitioners and patients and
open, ongoing communication between the stakeholders are essential to combating
medication nonadherence. Given their training and accessibility, pharmacists are
well positioned to address nonadherence.
http://www.japha.org/data/Journals/JAPhA/25506/JAPhA_52_6_823.pdf
4. Disease management and medication compliance
J Cohen, K Christensen, L Feldman
Population Health Management Feb 2012;15(1):20-28
Lack of medication compliance is harmful to health care systems from both a clinical
and economic perspective. This study examines the methods that disease
management organisations employ to identify nonadherent patients and to measure
effectiveness of compliance programmes for patients with diabetes, hyperlipidaemia
and cystic fibrosis. In addition, this study investigates the degree to which disease
managers assume risk in their contracts, and whether compliance strategies are
3
being coordinated with payer'' use of value-based insurance design, in which patient
cost sharing is a function of the relative value of pharmaceuticals. This study's
findings suggest that disease management may be falling short in terms of: (a)
comprehensive commitment to expert-recommended at-home devices used to selfdiagnose and measure health indicators; (b) early adoption of expert-recommended
new technologies to measure and improve compliance; (c) intensity of use of
standard tests in outpatient clinics; (d) coordination of compliance strategies with
payers' use of value-based insurance design; and (e) the proportion of risk assumed
in disease management contracts.
http://online.liebertpub.com/doi/abs/10.1089/pop.2011.0020
5. Non-adherence in difficult asthma: time to take it seriously
LG Heaney, R Horne
Thorax Mar 2012;67(3):268-270
Recent studies have demonstrated a high prevalence of non-adherence with antiinflammatory medication in patients referred for specialist assessment with difficultto-control asthma. As well as poor asthma outcome and increased healthcare cost,
failure to detect non-adherence makes identification of true treatmentresistant/refractory asthma challenging. This is because guideline definitions of
refractory asthma are all predicated on failure to respond to high-dose antiinflammatory therapy but do not state how adherence with this therapy should be
assessed. With the advent of novel expensive biological therapies, the systematic
identification of non-adherence becomes more essential to avoid targeting therapies
at an inappropriate patient group. Novel biomarkers of steroid exposure, in
combination with more traditional surrogate measures such as prescription filling
assessment, may allow more objective assessments of non-adherence to be
developed in the future. When identified, non-adherence can potentially be targeted
and improved, but the key challenge is to empower patients to make informed
choices about medicines rather than decisions influenced by misplaced beliefs about
benefit and harm. There is an urgent need for the systematic development of
individualised interventions which allow non-adherence to be effectively managed.
Thus, non-adherence must become a priority in the clinical assessment of difficult-tocontrol asthma because addressing non-adherence is likely to deliver greater
benefits in this group than any novel treatment. It is essential that future research
examines strategies and interventions to address non-adherence in subjects with
difficult-to-control asthma.
http://thorax.bmj.com/content/67/3/268.abstract
6. Patient adherence to tyrosine kinase inhibitor therapy in chronic myeloid
leukaemia
EJ Jabbour, H Kantarjian, L Eliasson, AM Cornelison, D Marin
American Journal of Hematology Jul 2012;87(7):687-691
A review. Dramatically improved survival associated with tyrosine kinase inhibitor
(TKI) therapy has transformed the disease model for chronic myeloid leukaemia
(CML) to one of long-term management, but treatment success is challenged with
poor medication adherence. Many risk factors associated with poor adherence can
be ameliorated by close monitoring, dose modification and supportive care.
Controlling risk factors for poor adherence in combination with patient education that
includes direct communication between the health care team and the patient are
essential components for maximising the benefits of TKI therapy. (25 refs.)
http://onlinelibrary.wiley.com/doi/10.1002/ajh.23180/pdf
4
7. Does taking prescription medication as prescribed make a difference?
WN Kelly, J Jorgenson
American Journal of Pharmacy Benefits May-Jun 2012;4(3):95-98
The rate of nonadherence to taking medications as prescribed is estimated to be
30% to 50% in the United States. Poor medication adherence is correlated with
poorer patient outcomes and 125,000 deaths yearly. Nonadherence is responsible
for more than one-third of medication-related hospitalisations that add as much as
$290 billion to the cost of healthcare each year. Despite these numbers,
interventions to improve adherence have had only modest success.
Research evidence shows that interventions targeting behaviour changes or using a
combination of methods work best. Single interventions that have shown some
success include those that reduce the number of daily doses of medications, use
motivational strategies, package medications into special containers (e.g. pill boxes,
blister packs), provide more convenient care, educate patients or involve monitoring
and feedback.
As the US healthcare system attempts to move from a volume-based curve to one
that is value-based with the emphasis on improved quality and reduced cost,
medication adherence presents an opportunity to address both elements. It also
presents a significant opportunity for pharmacists as the 'medication therapy experts'
on the healthcare team to take a leading role in improving medication adherence.
(25 refs.)
http://www.ajpblive.com/media/pdf/AJPB_12mayJunKellySHBC_95to98.pdf
8. Rethinking adherence
JF Steiner
Annals of Internal Medicine 16 Oct 2012;157(8):580-585
In 2012, the US Centers for Medicare and Medicaid Services (CMS) will introduce
measures of adherence to oral hypoglycaemic, antihypertensive and cholesterollowering drugs into its Medicare Advantage quality programme. To meet these
quality goals, delivery systems will need to develop and disseminate strategies to
improve adherence. The author considers that the design of adherence interventions
has too often been guided by the mistaken assumptions that adherence is a single
behaviour that can be predicted from readily available patient characteristics and
that individual clinicians alone can improve adherence at the population level.
Effective interventions require recognition that adherence is a set of interacting
behaviours influenced by individual, social, and environmental forces; adherence
interventions must be broadly based, rather than targeted to specific population
subgroups; and counselling with a trusted clinician needs to be complemented by
outreach interventions and removal of structural and organisational barriers. To
achieve the adherence goals set by CMS, front-line clinicians, interdisciplinary teams,
organisational leaders and policymakers will need to coordinate efforts in ways that
exemplify the underlying principles of health care reform.
http://annals.org/article.aspx?articleid=1379776
5
Measuring Adherence
Quantitative techniques widely used in research are pill counts10,
questionnaires completed by patients or their carers34, and electronic
devices (of which MEMS is the commonest) that record when a tablet
container, inhaler15, nebuliser23 or other drug package is used.
Electronic monitoring is generally regarded as the “gold standard” of
these methods, although it should be pointed out that it doesn’t
generally record that the patient has actually taken the medication as
prescribed12. Direct measurement of drug levels in the body46 or in
urine13 may prove to be the ultimate technique, but is not yet used to
any great extent in studies of adherence.
Although some studies14 have found them accurate, the reliability of
patients’ self reports has been questioned48; however, this method is
ofen used for convenience and cheapness.
Validation of qualitative methods has been less researched, but there is
a study27 of interview techniques to establish reasons for
discontinuation.
There has also been research into identifying patients with sub-optimal
adherence, to enable interventions to be targeted259. This typically
involves assessment by health professionals28,29 or analysis of data
collected for other purposes, such as dispensing records42, electronic
medical records31,33, electronic prescribing18 or claims data from health
insurers16.
9. Selection of tools for reconciliation, compliance and appropriateness of
treatment in patients with multiple chronic conditions
ER Alfaro Lara, MD Vega Coca, M Galvan Banqueri, R Marin Gil, María Dolores Nieto Martínb,
Concepción Perez Guerrero, M Ollero Baturone, B Santos-Ramos
European Journal of Internal Medicine Sep 2012;23(6):506-512
Background: The healthcare models developed for patients with multiple chronic
diseases agree on the need for improving drug therapy in these patients. The issues
of patient compliance, appropriateness of prescribing and the reconciliation process
are of vital importance for patients receiving multiple drug treatment.
Objective: To identify and select the most appropriate tools for measuring treatment
compliance and appropriateness in multiple-disease patients, as well as the best
reconciliation strategy.
Methods: The study used the Delphi methodology. We identified compliance and
appropriateness questionnaires and scales, as well as functional organisation models
for reconciliation that had been used in patients with multiple chronic conditions.
Based on the strength of the evidence, their usefulness in these patients and ease of
use, the panel selected the most appropriate ones.
Results: We selected 46 indications for the panel: 5 on compliance, 20 on
appropriateness and 31 on reconciliation. The tool considered most appropriate and
with a high degree of agreement was the 'Adherence to Refills and Medication Scale'
questionnaire. For appropriateness, the Medication Appropriateness Index
6
questionnaire was considered appropriate. The STOPP/START criteria were the most
appropriate. The greatest degree of agreement regarding reconciliation was on the
information that needed to be collected and the variables considered as
discrepancies.
Conclusions: The 'Adherence to Refills and Medication Scale' questionnaire for
compliance, the STOPP/START criteria, the Medication Appropriateness Index
questionnaire for appropriateness and the development of a specific strategy for
reconciliation were considered appropriate for the assessment of drug therapy in
patients with multiple chronic conditions.
http://www.sciencedirect.com/science/article/pii/S095362051200163X
10. Adherence to varenicline among African American smokers: an exploratory
analysis comparing plasma concentration, pill count, and self-report
TS Buchanan, CJ Berg, L Sanderson Cox, N Nazir, NL Benowitz, et al.
Nicotine and Tobacco Research Sep 2012;14(9):1083-1091
Introduction: Measuring adherence to smoking cessation pharmacotherapy is
important to evaluating its effectiveness. Blood levels are considered the most
accurate measure of adherence but are invasive and costly. Pill counts and selfreport are more practical, but little is known about their relationship to blood levels.
This study compared the validity of pill count and self-report against plasma
varenicline concentration for measuring pharmacotherapy adherence.
Methods: Data were obtained from a randomised pilot study of varenicline for
smoking cessation among African-American smokers. Adherence was measured on
Day 12 via plasma varenicline concentration, pill count, 3-day recall and a visual
analogue scale (VAS; adherence was represented on a line with two extremes 'no
pills' and 'all pills').
Results: The sample consisted of 55 African-American moderate to heavy smokers
(average 16.8 cigarettes/day, SD = 5.6) and 63.6% were female. Significant
correlations (p less than 0.05) were found between plasma varenicline concentration
and pill count (r = 0.56), 3-day recall (r = 0.46) and VAS (r = 0.29). Using plasma
varenicline concentration of 2.0 ng/mL as the cutpoint for adherence, pill count
demonstrated the largest area under the receiver operating characteristic curve (AUC
= 0.85, p = 0.01) and had 88% sensitivity (95% CI, 75.0 to 95.0) and 80%
specificity (95% CI, 30.0 to 99.0) for detecting adherence.
Conclusions: Of 3 commonly used adherence measures, pill count was the most valid
for identifying adherence in this sample of African-American smokers. Pill count has
been used across other health domains and could be incorporated into treatment to
identify nonadherence, which, in turn, could maximise smoking cessation
pharmacotherapy use and improve abstinence rates.
http://ntr.oxfordjournals.org/content/14/9/1083.abstract
11. Objective assessment of nonadherence and unknown co-medication in
hospitalized patients
F Carow, K Rieger, I Walter-Sack, MR Meyer, FT Peters, HH Maurer, WE Haefeli
European Journal of Clinical Pharmacology Aug 2012;68(8):1191-1199
Purpose: The intake of medications (drugs) without the knowledge of the treating
physician (unknown co-medication) and nonadherence strongly influence drug
safety. The aim of our study was to objectively assess unknown co-medication and
nonadherence in hospitalised patients by screening urine for a large number of drugs
using highly sensitive full scan gas chromatograpy/mass spectrometry (GC/MS).
Secondary objectives were to determine the relationship of co-medication and
7
nonadherence to the number of drugs prescribed and to compare history-taking by a
pharmacist versus a physician.
Methods: In 152 patients at a hospital in Germany, the drug histories taken by
physicians, patients' self-reported adherence, and information compiled during as
many as three structured interviews conducted by a trained pharmacist on days 1-2,
3-4 and 7-11 of the hospital stay were compared with the GC/MS results from urine
samples collected after each interview.
Results: In the interviews performed by the pharmacist, 235 additional drugs were
identified that were not documented in the chart. Of all the drugs indicated in any
interview, 16.9% were identified only by the physician, 24.1% only by the
pharmacist and 59% by both. Overall, in 78% of the patients at least one additional
drug was identified by urine screening. The findings suggest overall nonadherence
to at least one drug in 13.0% of patients on admission and in 23.3% of patients at
any time during hospitalisation. Nonadherence was less frequent for critical dose
drugs and correlated with the number of drugs prescribed.
Conclusions: The drug history among hospitalised patients is often incomplete, and
nonadherence and unknown co-medication are alarmingly frequent. This lack of
knowledge might impact the overall success of drug therapies in the hospital setting.
http://link.springer.com/article/10.1007%2Fs00228-012-1229-2
12. Practical and analytic issues in the electronic assessment of adherence
P Cook, S Schmiege, M McClean, L Aagaard, M Kahook
Western Journal of Nursing Research Aug 2012;34(5):598-620
Although medication adherence can be measured many ways, researchers often view
electronic dose monitoring devices like the Medication Event Monitoring System
(MEMS) as more valid than patient self-reports. MEMS are popular but have
potential problems. Based on the literature and MEMS data analyses, the authors
suggest the following approaches: (a) a 1- to 2-month run-in should be used to
reduce MEMS reactivity, (b) MEMS should be used with other measures of
adherence, (c) adherence should be measured continuously, or a cutoff should be
defined based on pharmacological properties of the medication and the
consequences of nonadherence, (d) MEMS data usually should be aggregated weekly
or monthly and evaluated using multilevel modelling, (e) MEMS-based screening for
nonadherence may miss some patients in need of intervention and (f) researchers
should use strategies like training patients to use MEMS and purchasing extra MEMS
caps to improve the completeness and accuracy of MEMS data.
http://wjn.sagepub.com/content/34/5/598.abstract
13. Improved detection of opioid use in chronic pain patients through monitoring
of opioid glucuronides in urine
JA Dickerson, TJ Laha, MB Pagano, BR O'Donnell, AN Hoofnagle
Journal of Analytical Toxicology Oct 2012;36(8):541-547
When chronic pain patients are suspected of being non-compliant, their therapy can
be withdrawn. Therefore, sensitive and specific confirmatory testing is important for
identifying diversion and adherence.
This work aimed to develop a novel liquid chromatography tandem mass
spectrometry (LC-MS-MS) method to detect 14 opioids and 6 opioid glucuronide
metabolites in urine with minimal sample preparation.
Analytes included were morphine, oxymorphone, hydromorphone, oxycodone,
hydrocodone, codeine, fentanyl, norfentanyl, 6-monoacetylmorphine, meperidine,
normeperidine, propoxyphene, methadone, buprenorphine, morphine-3-glucuronide,
morphine-6-glucuronide, oxymorphone glucuronide, hydromorphone glucuronide,
8
codeine-6-glucuronide and norbuprenorphine glucuronide. Samples were processed
by centrifugation and diluted in equal volume with a deuterated internal standard
containing 14 opioids and 4 opioid glucuronides.
The separation of all compounds was complete in 9 minutes. The assay was linear
between 10 and 1000 ng/mL (fentanyl 0.25-25 ng/mL). Intra-assay imprecision
(500 ng/mL, fentanyl 12.5 ng/mL) ranged from 1.0 to 8.4% coefficient of variation.
Inter-assay precision ranged from 2.9 to 6.0%. Recovery was determined by spiking
5 patient specimens with opioid and opioid glucuronide standards at 100 ng/mL
(fentanyl 2.5 ng/mL). Recoveries ranged from 82 to 107% (median 98.9%).
The method correlated with our current quantitative LC–MS-MS assay for opioids,
which employs different chromatography. Internal standards were not available for
every analyte to critically evaluate for ion suppression. Instead, a novel approach
was designed to achieve the most rigorous quality control possible, in which the
recovery of each analyte was evaluated in each negative sample.
http://jat.oxfordjournals.org/content/36/8/541.abstract
14. Accuracy of measures of medication adherence in a cholesterol-lowering
regimen
J Dunbar-Jacob, SM Sereika, M Houze, FS Luyster, JA Callan
This study examined the concordance between multiple measures of adherence, as
well as sensitivity to detection of poor adherers, specificity and predictive validity
using a daily cholesterol-lowering regimen. Participants (N = 180) aged 24 to 60
years participated in an adherence ancillary study in a clinical trial. Males
constituted 53.9% of this well-educated, community sample. Data on adherence
were collected over a 6-month period, using electronic monitoring, self-report,
specific recall and pill counts. Electronically monitored (odds ratio (OR) = 5.348)
and Shea self-report (OR = 2.678) predicted cholesterol lowering. Days (78.9%)
and intervals (84.2%) adherent and the Shea (73.7%) were sensitive to the
detection of poor adherers. Moderate associations were found between measures of
the same type. Low correlations were found otherwise. The electronic monitor was
the most accurate and informative measure. The Shea self-report was the most
accurate brief, global estimate of adherence. Other measures were not associated
with clinical outcome or sensitive to poor adherence.
15. The reliability and patient acceptability of the SmartTrack device: a new
electronic monitor and reminder device for metered dose inhalers
JM Foster, L Smith, T Usherwood, SM Sawyer, CS Rand, HK Reddel
Journal of Asthma Sep 2012;49(6):657-662
Objective: The SmartTrack (ST; Nexus6 Limited) is a new adherence monitoring
device for pressurised metered-dose inhalers (pMDI), with remote upload and
ringtone reminder capabilities. Our aim was to assess its reliability and patient
acceptability.
Methods: Baseline Quality Control (QC): Actuation log accuracy and device
functionality tests were undertaken. Simulated Patient Use: Salmeterol/fluticasone
inhalers with STs were actuated two times twice daily for 48 hours. Accuracy of
reminders, data logging and uploads was tested. Patient Field Testing: Devices were
quality tested before dispensing. Asthma patients each field-tested one ST for 7
days and recorded actuations in a diary. Uploaded data were compared to pMDI
dose counter and patient diaries. Patient-reported ease of use for the ST was
recorded.
9
Results: Baseline QC: 9/10 devices had 100% accuracy; one had an electrical circuit
failure. Simulated Patient Use: Accuracy was 99% (2/342 actuations duplicated).
Patient Field Testing: One device failed pre-dispensing testing (electrical circuit
failure). Eight devices were field-tested by asthma patients (mean age 45 years, 5
females). Mean actuation log accuracy was 97%. Reminders were 100% accurate.
All devices successfully uploaded data. Average patient-rated difficulty of use was
6/100 (1 = extremely easy, 100 = extremely difficult).
Conclusions: The ST has acceptable reliability and utility comparable to other
electronic monitoring devices. Its remote data upload capability, reminder functions
for missed doses, and graphical display of medication use for patient- and physicianfeedback are useful additional features.
http://informahealthcare.com/doi/abs/10.3109/02770903.2012.684253
16. Performance of compliance and persistence measures in predicting clinical and
economic outcomes using administrative data from German sickness funds
S Frey, T Stargardt
Pharmacotherapy Oct 2012;32(10):880-889
Objective: To compare the performance of various compliance and persistence
measures in predicting schizophrenia-related hospitalisation rates and inpatient
costs.
Design: Retrospective, nonrandomised cohort study.
Data Source: Prescription claims databases from three German sickness funds
(public health insurance programmes).
Patients: A total of 1484 patients who were hospitalised in 2003 for a schizophreniarelated episode and subsequently received long-term antipsychotic
pharmacotherapy.
Measurements and Main Results: Data on age, sex, schizophrenia, prescription
drugs, hospitalisations and inpatient expenditures were collected for each patient
from the three German sickness funds. Refill compliance measures based on singleinterval availability and multiple-interval availability, as well as refill persistence,
were calculated for each patient over 1 year. Ten measurement variables were
compared with respect to their performance in predicting disease-related
hospitalisation and inpatient expenditure, using multivariate logistic regression and
gamma regression, respectively. C-statistics were calculated to determine each
measure's predictive performance. Likelihood ratio tests showed that inclusion of
compliance and persistence measures significantly improved (p less than 0.05)
outcomes prediction in 6 of 10 hospitalisation models and in 3 of 10 inpatient cost
models compared with a baseline model that included only age, sex and disease
severity covariates. Refill compliance as a continuous variable of drug persistence,
including transfer of oversupplies into subsequent periods, performed best in
predicting hospitalisation (C = 0.669). Availability ratios, capped at 100%, were
superior to default availability ratios in predicting hospitalisation. Allowing for crossperiod carryover improved the discriminatory performance of the persistence models.
Conclusions: Refill persistence measures appear sufficiently flexible to account for
hospitalisations common in schizophrenia and other psychiatric diseases. A
continuous refill persistence measure should be used to assess compliance in
psychiatric conditions when working with administrative data.
http://onlinelibrary.wiley.com/doi/10.1002/j.1875-9114.2012.01120/abstract
17. Developing the Diagnostic Adherence to Medication Scale (the DAMS) for use in
clinical practice
S Garfield, L Eliasson, S Clifford, A Willson, B Nick
10
BMC Health Services Research 8 Oct 2012;12:350
Background: There is a need for an adherence measure, to monitor adherence
services in clinical practice, which can distinguish between different types of nonadherence and measure changes over time. In order to be inclusive of all patients it
needs to be able to be administered to both patients and carers and to be suitable
for patients taking multiple medications for a range of clinical conditions. A
systematic review found that no adherence measure met all these criteria. We
therefore wished to develop a theory-based adherence scale (the DAMS) and
establish its content, face and preliminary construct validity in a primary care
population.
Methods: The DAMS (consisting of 6 questions) was developed from theory by a
multidisciplinary team and the questions were initially tested in small patient
populations. Further to this, patients were recruited when attending a General
Practice and interviewed using the DAMS and two other validated self-reported
adherence measures, the Morisky-8 and Lu questionnaires. A semi-structured
interview was used to explore acceptability and reasons for differences in responses
between the DAMS and the other measures. Descriptive data were generated and
Spearman rank correlation tests were used to identify associations between the
DAMS and the other adherence measures.
Results: 100 patients completed the DAMS in an average of 1 minute 28 seconds and
reported finding it straightforward to complete. An adherence score could not be
calculated for the 4 (4%) patients only taking 'when required' medication. 36
(37.5%) of the remaining patients reported some non-adherence. Adherence ratings
of the DAMS were significantly associated with levels of self reported adherence on
all other measures Spearman Rho 0.348-0.719, (p less than 0.01). Differences in
trends could generally be explained by qualitative data.
Conclusions: The DAMS has been developed for routine monitoring of adherence in
clinical practice. It was acceptable to patients taking single or multiple medication
and valid when tested against other adherence measures. However, 'when required'
medication needs to be excluded. Further tests of the DAMS against objective
measures such as MEMS are in progress and reliability needs to be established.
Further investigation of the carers' version of the DAMS is required.
http://www.biomedcentral.com/content/pdf/1472-6963-12-350.pdf
18. Instantaneous detection of nonadherence: quality, strength, and weakness of
an electronic prescription database
P Harbig, I Barat, P Lund Nielsen, EM Damsgaard
Pharmacoepidemiology and Drug Safety Mar 2012;21(3):323-328
Background: The 'personal electronic medicine profile' (PEM) is a Web-based tool for
electronic prescription and monitoring of purchased medicine. It is based on the
National Prescription Database and contains data on all prescriptions in Denmark. It
includes information on time of drug purchase, number of tablet, and prescribed
daily dosage. This allows calculation of the expected time for new purchases.
Purpose: To study the accuracy of the PEM as a tool for monitoring drug
nonadherence as compared with pill counts (PCs).
Methods: 583 randomly selected elderly Danish citizens older than 65 years taking
more than 4 drugs were studied. They were visited three times by a nurse who
counted their medicine supply. Contingency table analysis was used to compare
drug nonadherence calculated from PC with that revealed by PEM. For PC and PEM,
an adherence level of at least 80% was defined as acceptable.
Results: PEM could not accurately process (non)adherence in 44% of all drugs. The
probability of identifying drug nonadherence with PEM was low (negative predictive
11
value 23%). Incomplete prescription information (34%) and inaccurate dosage
recording (10%) were the major sources of error.
Conclusions: PEM is inferior to PC for accurate monitoring of drug nonadherence.
The inaccuracy is due to erroneous prescription information. PEM could be a
powerful tool for electronic monitoring of drug nonadherence if prescription
information was recorded uniformly and correctly. To increase the accuracy, we
recommend informal free-text dosing instruction to be translated into a formal one
by use of appropriate software such as library of phrases.
http://onlinelibrary.wiley.com/doi/10.1002/pds.2351/abstract
19. Surveillance of medication use: early identification of poor adherence
MA Jonikas, KD Mandl
Journal of the American Medical Informatics Association Jul 2012;19(4):649-654
Background: We sought to measure population-level adherence to
antihyperlipidaemics, antihypertensives and oral hypoglycaemics, and to develop a
model for early identification of subjects at high risk of long-term poor adherence.
Methods: Prescription-filling data for 2 million subjects derived from a US payor's
insurance claims were used to evaluate adherence to three chronic drugs over 1
year. We relied on patterns of prescription fills, including the length of gaps in
medication possession, to measure adherence among subjects and to build models
for predicting poor long-term adherence.
Results: All prescription fills for a specific drug were sequenced chronologically into
drug eras. 61.3% to 66.5% of the prescription patterns contained medication gaps
of longer than 30 days during the first year of drug use. These interrupted drug eras
include long-term discontinuations, where the subject never again filled a
prescription for any drug in that category in the dataset, which represent 23.7% to
29.1% of all drug eras. Among the prescription-filling patterns without large
medication gaps, 0.8% to 1.3% exhibited long-term poor adherence. Our models
identified these subjects as early as 60 days after the first prescription fill, with an
area under the curve (AUC) of 0.81. Model performance improved as the predictions
were made at later time-points, with AUC values increasing to 0.93 at the 120-day
time-point.
Conclusions: Dispensed medication histories (widely available in real time) are useful
for alerting providers about poorly adherent patients and those who will be nonadherent several months later. Efforts to use these data in point of care and
decision support facilitating patients in need of intervention are warranted.
http://jamia.bmj.com/content/19/4/649.full.pdf%20html
20. Secondary analysis of electronically monitored medication adherence data for
a cohort of hypertensive African-Americans
GJ Knafl, A Schoenthaler, G Ogedegbe
Patient Preference and Adherence 22 Mar 2012;6:207-219
Background: Electronic monitoring devices (EMDs) are regarded as the 'gold
standard' for assessing medication adherence in research. Although EMD data
provide rich longitudinal information, they are typically not used to their maximum
potential. Instead, EMD data are usually combined into summary measures, which
lack sufficient detail for describing complex medication-taking patterns. This paper
uses recently developed methods for analyzing EMD data that capitalise more fully
on their richness.
Methods: Recently developed adaptive statistical modelling methods were used to
analyse EMD data collected with Medication Event Monitoring System (MEMS (TM))
caps in a clinical trial testing the effects of motivational interviewing on adherence to
12
antihypertensive medications in a cohort of hypertensive African-Americans followed
for 12 months in primary care practices. This was a secondary analysis of EMD data
for 141 of the 190 patients from this study for whom MEMS data were available.
Results: Nonlinear adherence patterns for 141 patients were generated, clustered
into seven adherence types, categorised into acceptable (for example, high or
improving) versus unacceptable (for example, low or deteriorating) adherence, and
related to adherence self-efficacy and blood pressure. Mean adherence self-efficacy
was higher across all time points for patients with acceptable adherence in the
intervention group than for other patients. By 12 months, there was a greater drop
in mean post-baseline blood pressure for patients in the intervention group, with
higher baseline blood pressure values than those in the usual care group.
Conclusions: Adaptive statistical modelling methods can provide novel insights into
patients' medication-taking behaviour, which can inform development of innovative
approaches for tailored interventions to improve medication adherence.
http://www.dovepress.com/getfile.php?fileID=12360
21. Psychometric evaluation of the Adherence in Diabetes Questionnaire
LJ Kristensen, M Thastum, AH Mose, NH Birkebaek (Danish Society for Diabetes in
Childhood and Adolescence)
Diabetes Care Nov 2012;35(11):2161-2166
Objective: To assess the psychometric properties of a short, new, self-administered
questionnaire (17-19 items) for evaluating the adherence behaviour of children and
adolescents with type 1 diabetes and their caregivers. This instrument has separate
versions depending on the means of insulin administration, i.e. continuous
subcutaneous insulin infusion (Adherence in Diabetes Questionnaire (ADQ)-I) or
conventional insulin injection (ADQ-C).
Research Design and Methods: A total of 1028 caregivers and 766 children and
adolescents 2-17 years of age were recruited through the Danish Registry of
Childhood Diabetes and completed the national web survey, including the ADQ and
psychosocial measures of self-efficacy, parental support, family conflict and aspects
of diabetes-related quality of life. Blood samples were obtained for central HbA1c
analysis. The psychometric properties of the ADQ were evaluated, and the
association with glycaemic control was assessed.
Results: There was good internal consistency for both the youth and caregiver
reports and strong agreement between the caregiver and youth reports. Higher ADQ
scores, indicating better adherence, were associated with better self-efficacy, more
parental support, less diabetes-related conflict and less experience with treatment
barriers. Factor analysis supported maintaining the one-factor structure of the ADQ.
Higher ADQ scores were associated with lower HbA1c levels.
Conclusions: The ADQ showed good psychometric properties. Although the testretest reliability and sensitivity to change of the instrument still need to be
established, the ADQ appears to be a valuable tool for assessing adherence in
families with children and adolescents with type 1 diabetes in both clinical and
research settings.
http://care.diabetesjournals.org/content/35/11/2161.abstract
22. Comparing medication adherence methods in lipid-modifying therapy
J LaFleur, C McAdam-Marx, GL White, JL Lyon, GM Oderda
Journal of Pharmacy Technology Mar-Apr 2012;28(2):58-67
Background: Investigators have employed a number of different methods to
calculate adherence estimates for patients taking lipid-modifying therapy (LMT),
including measures with different numerator and denominator options. Although at
13
least one method is known to correlate well with cardiovascular outcomes, most
have not been evaluated in outcomes studies.
Objectives: To evaluate different methods for measuring adherence, using LMT as a
case example, and to determine whether estimates for adherence differ statistically
and/or whether different methods can lead to different conclusions about patient
adherence.
Methods: Adherence ratios were calculated using 8 different methods for 12,448
patients who were in a US managed-care system and were considered new starts
with statin therapy. The calculated measures were compared and tested for
differences. Patients were categorised as 'adherent' by each method, using a
threshold of 0.8, and the proportions of patients categorised as adherent were
compared for differences between adherence calculation methods.
results: Adherence ratios calculated with like observation intervals did not vary
substantially, regardless of which method for measuring medication availability was
used. Those calculated with different observation intervals had substantial
variability. Mean adherence ratios ranged between 0.777 and 0.798 for difference in
days' observation intervals; they ranged between 0.618 and 0.630 for the predefined
interval. Differences between ratios calculated using these different denominators
were statistically significant (p less than 0.008). Correlations between ratios were
statistically significant for all comparisons (p less than 0.001). Correlation
coefficients (gamma) were 0.64 for comparisons between ratios with different
denominators versus 1.0 for comparisons with like denominators. Categorisation as
'adherent' or 'nonadherent' differed between the methods for about 20% of patients.
Conclusions: Significant differences were found to be based on observation period
but not on medication availability. Studies of adherence should be interpreted with
caution depending on which method is used, and particular interest should be paid to
whether the choice of methods is consistent with study objectives and to the
observation interval, as different methods may lead to different conclusions about
patient adherence. Further research in LMT and other therapeutic areas is needed to
determine which methods correlate best with positive patient outcomes, such as
reductions in low-density lipoprotein cholesterol and cardiovascular events.
http://www.jpharmtechnol.com/abstracts/volume28/March-April/pg58.php
23. New nebulizer technology to monitor adherence and nebulizer performance in
cystic fibrosis
P McCormack, KW Southern, PS McNamara
Journal of Aerosol Medicine and Pulmonary Drug Delivery Dec 2012;25(6):307-309
Topical delivery of aerosolised therapies is an established treatment for chronic
airway infection and inflammation in cystic fibrosis (CF). Recent developments in
nebuliser technology have enabled Adaptive Aerosol Delivery (AAD) of mesh
generated aerosol particles resulting in more efficient airway deposition than existing
jet nebulisers. An additional feature of these new devices is the ability to record and
examine the performance of the device by downloading stored data (electronic data
capture).
In a series of studies we have used this downloading facility to monitor treatment
times and examine adherence to nebuliser therapy in paediatric patients at a
children's hospital in England. We found routine adherence monitoring is possible in
a busy CF clinic. We have shown that good adherence to treatment can be
maintained in both patients chronically infected with Pseudomonas aeruginosa on
long-term therapy, and in patients with first/new growths of Pseudomonas on shortterm eradication therapy. When adherence was examined from an individual
perspective, we demonstrated a wide variation both between and within individual
14
patients. A further modification of AAD technology, Target Inhalation Mode (TIM)
optimises patient inhalations through a direct feedback mechanism. This new
breathing mode has also been evaluated in our paediatric CF clinic in a recent
randomised controlled trial (RCT) and we have shown that children maintain
adherence to treatment through the TIM mouthpiece and average treatment times
reduced from 6.9 to 3.7 min when using TIM.
This is a new era of aerosol delivery and novel advances in medical devices need to
be monitored and assessed rigorously, particularly as new and potentially expensive
therapies emerge from translational studies. Electronic data capture enables CF
teams to work in an open partnership with patients to achieve the common goals of
improving drug delivery and reducing patient burden.
http://online.liebertpub.com/doi/abs/10.1089/jamp.2011.0934
24. Text messaging to measure asthma medication use and symptoms in urban
African American emerging adults: a feasibility study
K MacDonell, W Gibson-Scipio, P Lam, S Naar-King, X Chen
Journal of Asthma Dec 2012;49(10):1092-1096
Objective: Urban African-American adolescents and young adults face
disproportionate risk of asthma morbidity and mortality. This study was the first to
assess the feasibility of Ecological Momentary Assessment via text messaging to
measure asthma medication use and symptoms in African-Americans aged 18–25
years.
Methods: This study used automated text messaging with N = 16 participants for 14
consecutive days. Participants sent event-based messages whenever they
experienced asthma symptoms or took asthma rescue or controller medications.
They also received time-based messages daily that prompted for a response about
asthma medications or symptoms.
Results: Feasibility was assessed using response rates and participant feedback.
Rates of event-based messages were relatively low (M = 0.85 messages sent per
participant/day), but participants were very responsive to time-based messages
(78.5%). All participants expressed positive feedback about the programme, though
40.0% reported confusion with event-based messages and most preferred timebased messages. The assessment found low medication adherence rates and
reasons for missing medication consistent with previous research with youth with
asthma.
Conclusions. Text messaging may be a useful method to measure medication use
and symptoms in 'real time', particularly using time-based prompts. Results could
be used to provide personalised feedback on adherence as part of a tailored
intervention.
25. Development and psychometric evaluation of the Treatment Adherence
Questionnaire for Patients with Hypertension
C Ma, S Chen, L You, Z Luo, C Xing
Journal of Advanced Nursing Jun 2012;68(6):1402-1413
Aim: Report on the development and psychometric testing of the Treatment
Adherence Questionnaire for Patients with Hypertension.
Background: Hypertension is the most prevalent health problem among adult
patients affecting approximately 200 million people in China and about 1 billion
persons worldwide. Adherence to medication and lifestyle for hypertensive patients
result in blood pressure control and reduce adverse outcomes. At present, few
15
specific instruments are available to completely evaluate medication and lifestyle
adherence for hypertensive patients.
Methods: A multi-phase psychometric questionnaire development method was used
to develop the instrument. The item pool was generated using literature review and
focus group. Content validity was evaluated by expert panel. Then, the field testing
was conducted with a convenience sampling of 278 hypertensive patients from Dec
2009 to May 2010 in Guangdong Province, China. Exploratory and confirmatory
factor analyses were used to test construct validity. Finally, internal consistency and
test–retest reliability were assessed.
Results: The new measure consisted of six dimensions with 28 items, explaining
62.54% of the total variance in the data. Confirmative factor analysis supported a
good overall fit of the 6-factor model. Cronbach's alpha of the overall questionnaire
was 0.86 and 0.82 for test–retest reliability.
Conclusions: The questionnaire was a brief and psychometrically sound instrument to
evaluate hypertensive patients’ treatment adherence, to be applied in the research
and clinical fields.
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2648.2011.05835.x/abstract
26. Measuring therapeutic adherence in systemic lupus erythematosus with
electronic monitoring
MF Marengo, CA Waimann, S de Achaval, H Zhang, A Garcia-Gonzalez, MN Richardson, JD
Reveille, ME Suarez-Almazor
Lupus Oct 2012;21(11):1158-1165
Objective: An electronic monitoring system was used to quantify adherence to
prescribed oral therapies by patients with systemic lupus erythematosus (SLE).
Methods: Participants were included from a larger longitudinal study cohort of 110
patients recruited from publicly-funded rheumatology clinics in the USA, 78 of whom
agreed to have their SLE drug therapy electronically monitored for 2 years with the
Medication Events Monitoring System (MEMS, AARDEX Group). Adherence was
determined as the percentage of days (weeks for methotrexate) the patient took the
medication as prescribed by the physician. Collected data included SLEDAI; SLICC
damage index for SLE (SDI); medical outcome study social support survey (MOSSSS); Center for Epidemiologic Studies depression scale (CESD); and quality of life
(SF-12).
Results: 90% of the cohort was female, 45% were Hispanic and 49% were AfricanAmerican. Mean age was 36.3 years, disease duration was 5.9 years, SLEDAI score
was 3.2, and SDI score was 0.9. Adherence was 62% for all drugs combined and did
not differ significantly for individual medications. Patients with more depression (p
less than 0.02), and higher number of pills taken daily (p less than 0.02) were more
likely to be non-adherent. Only one-fourth of the patients had an average adherence
of 80% or higher; these patients had a better mental component score (SF-12) at 24
months than non-adherent patients (p less than 0.01).
Conclusions: Electronic monitoring demonstrated that only one-fourth of the patients
had an adherence rate of 80% or above. Polypharmacy and depression were
associated with non-adherence.
http://lup.sagepub.com/content/21/11/1158.abstract
27. Validation of a patient interview for assessing reasons for antipsychotic
discontinuation and continuation
LS Matza, GA Phillips, DA Revicki, H Ascher-Svanum, KG Malley, AC Palsgrove, DE Faries, V
Stauffer, BK Kinon, AG Awad, RS Keefe, D Naber
Patient Preference and Adherence 13 Jul 2012;6:521-532
16
Introduction: The Reasons for Antipsychotic Discontinuation Interview (RAD-I) was
developed to assess patients' perceptions of reasons for discontinuing or continuing
an antipsychotic. The current study examined reliability and validity of domain
scores representing three factors contributing to these treatment decisions:
treatment benefits, adverse events and distal reasons other than direct effects of the
medication.
Methods: Data were collected from patients with schizophrenia or schizoaffective
disorder and their treating clinicians. For approximately 25% of patients, a second
rater completed the RAD-I for assessment of inter-rater reliability.
Results: All patients (n = 121; 81 discontinuation, 40 continuation) reported at least
one reason for discontinuation or continuation (mean = 2.8 reasons for
discontinuation; 3.4 for continuation). Inter-rater reliability was supported (kappas
= 0.63 to 1.0). Validity of the discontinuation domain scores was supported by
associations with symptom measures (the Positive and Negative Syndrome Scale for
Schizophrenia, the Clinical Global Impression - Schizophrenia Scale; r = 0.30 to
0.51; all P less than 0.01), patients' primary reasons for discontinuation, and
adverse events. However, the continuation domain scores were not significantly
associated with these other indicators.
Discussion: Results support the reliability, convergent validity and known-groups
validity of the RAD-I for assessing patients' reasons for antipsychotic discontinuation.
Further research is needed to examine validity of the RAD-I continuation section.
Some of the authors are or were with Eli Lilly and Co.
28. Physician assessments of medication adherence and decisions to intensify
medications for patients with uncontrolled blood pressure: still no better than a
coin toss
J Meddings, EA Kerr, M Heisler, TP Hofer
BMC Health Services Research 21 Aug 2012;12:270
Background: Many patients have uncontrolled blood pressure (BP) because they are
not taking medications as prescribed. Providers may have difficulty accurately
assessing adherence. Providers need to assess medication adherence to decide
whether to address uncontrolled BP by improving adherence to the current
prescribed regimen or by intensifying the BP treatment regimen by increasing doses
or adding more medications.
Methods: We examined how provider assessments of adherence with
antihypertensive medications compared with refill records, and how providers'
assessments were associated with decisions to intensify medications for uncontrolled
BP. We studied a cross-sectional cohort of 1169 veterans with diabetes presenting
with BP 140/90 or above to 92 primary care providers at 9 US Veterans Affairs (VA)
facilities from Feb 2005 to Mar 2006. Using VA pharmacy records, we utilised a
continuous multiple-interval measure of medication gaps (CMG) to assess the
proportion of time in the prior year that patients did not possess the prescribed
medications; CMG of 20% or more is considered clinically significant non-adherence.
Providers answered post-visit Likert-scale questions regarding their assessment of
patient adherence to BP medications. The BP regimen was considered intensified if
medication was added or increased without stopping or decreasing another
medication.
Results: 1064 patients were receiving antihypertensive medication regularly from the
VA; the mean CMG was 11.3%. Adherence assessments by providers correlated
poorly with refill history. 211 (20%) patients did not have BP medication available
for 20% or more of days; providers characterised 79 (37%) of these 211 patients as
17
having significant non-adherence, and intensified medications for 97 (46%).
Providers intensified BP medications for 451 (42%) patients, similarly whether
assessed by provider as having significant non-adherence (44%) or not (43%).
Conclusions: Providers recognised non-adherence for less than half of patients whose
pharmacy records indicated significant refill gaps, and often intensified BP
medications even when they suspected serious non-adherence. Making an objective
measure of adherence such as the CMG available during visits may help providers
recognise non-adherence to inform prescribing decisions.
29. Let's talk about medication: concordance in rating medication adherence
among multimorbid patients and their general practitioners
D Ose, C Mahler, I Vogel, S Ludt, J Szecsenyi, T Freund
Patient Preference and Adherence 28 Nov 2012;6:839-845
Background: Medication adherence can be essential for improving health outcomes.
Patients with multiple chronic conditions, often receiving multiple medications, are at
higher risk for medication nonadherence. Previous research has focused on
concordance between patients and providers about which medication should be
taken. However, the question of whether patients and providers are concordant in
rating actual medication intake has not been answered as yet. This study aimed to
explore the extent and predictors of patient-provider concordance in rating
medication adherence in patients with multiple chronic conditions.
Methods: Overall medication adherence was measured by self-report (Medication
Adherence Report Scale, MARS-D) in a sample of 92 patients with multiple chronic
conditions in Baden-Württemberg, Germany. 12 treating primary care physicians
were asked to rate medication adherence in these patients using a mirrored version
of the MARS-D. Concordance between external rating and self-reported medication
adherence was analysed descriptively. Predictors of concordance in rating
medication adherence were explored in a multilevel analysis.
Results: Patients rate their medication adherence markedly higher than their general
practitioner. Accordingly, the percentage of concordance ranges between 40%
(forgot to take medication) and 61% (deliberately omitted a dose). In multilevel
analysis, concordance in rating medication adherence was positively associated with
being the single primary care provider (beta 2.24, P less than 0.0001) and frequent
questioning about medication use (beta 0.66, P = 0.0031). At the patient level, 'not
(being) married' (beta -0.81, P = 0.0064) and 'number of prescribed medications'
(beta -0.10, P = 0.0203) were negative predictors of patient-provider concordance in
rating medication adherence.
Conclusions: Concordance for rating medication adherence between general
practitioners and their patients was low. Talking about medication on a regular basis
and better continuity of care may enhance patient-provider concordance in rating
medication adherence as a prerequisite for shared decisions concerning medication in
patients with multiple chronic conditions.
30. System for integrated adherence monitoring: real-time non-adherence risk
assessment in pediatric kidney transplantation
ALH Pai, J Rausch, A Tackett, K Marsolo, D Drotar, J Goebel
Pediatric Transplantation Jun 2012;16(4):329-334
This study reports initial results of the development of the SIAM, a non-adherence
risk assessment system for tacrolimus and sirolimus for the paediatric kidney
transplant population. 48 youths between 10 and 25 years of age diagnosed with
18
chronic kidney disease or a kidney transplant used an electronic pill bottle (EM; time
stamps each bottle opening) to dispense their medication for at least 30 days or until
their next clinic appointment. Youth also completed a self-report adherence
measure, and standard deviations were calculated for the last four medication serum
trough levels obtained for each patient. Estimation models were developed for each
medication (i.e., SIAMtacro and SIAMsiro) to assign weights to these clinically
available adherence measures (self-report and trough levels) for the calculation of a
non-adherence risk composite score. SIAMtacro models included both self-report
and tacrolimus trough levels and significantly predicted EM. For sirolimus, the model
predictive of adherence as measured by EM consisted of the standard deviation of
sirolimus trough levels only (SIAMsiro). Non-adherence risk can be effectively
assessed using clinically available assessment tools. However, the best methods for
using self-report and trough levels to predict non-adherence probably differ
depending on the medication for which adherence is being assessed.
See also related editorials: Creating a monster: non-adherence underlying late
transplant rejection (p.312-314) and Measuring adherence to medications: are
complex methods superior to simple ones? (p.315-317).
31. Screening electronic Veterans' health records for medication discontinuation
TS Rector, S Nugent, M Spoont, S Noorbaloochi, HE Bloomfield
American Journal of Managed Care Jul 2012;18(7):352-358
Objectives: Determine the viable yield of screening electronic US Veterans Health
Administration (VHA) records to identify patients who stop taking a long-term
medication for reasons that might be addressed by healthcare providers.
Study Design: Prospectively screened cohort with mailed follow-up of positive
screens.
Methods: Electronic healthcare records were screened to identify patients receiving
care in a US Veterans Administration (VA) Health Care System who became past due
for resupply of medication (statin) prescribed to reduce cholesterol and risks of
adverse cardiovascular events. Subsequently, administrative data were used to
classify and characterise patients as true or false positive screens. A follow-up
survey mailed to the first 1000 positive screens asked them if they were still taking a
statin provided by the VHA, and if not, why?
Results: From Feb to Jul 2010, 1000 (4.6%) of the statin-recipient cohort of 21,935
became past due for a resupply. Subsequently 824 (3.8%; 95% CI, 3.5% to 4.0%)
were classified as true positives (positive predictive value 82%; 95% CI, 80% to
85%), and 176 (0.8%; 95% CI, 0.7% to 0.9%) as false positives. However, the 824
true positives included 95 deceased, 17 long-term care residents, 302 who reported
good reasons for no longer getting the statin, and 208 who eventually got another
supply. The overall yield of good candidates for efforts to reinstate long-term use of
statins was only 20%.
Conclusions: The viable yield from electronically screening VA healthcare records to
find patients who stopped taking statins was low. More complete records and
sophisticated screening programs are needed to improve the yield.
http://www.ajmc.com/publications/issue/2012/2012-7-vol18-n7/Screening-ElectronicVeterans-Health-Records-for-Medication-Discontinuation
32. Psychometric properties of the Oteoporosis-Specific Morisky Medication
Adherence Scale in postmenopausal women with osteoporosis newly treated with
bisphosphonates
19
K Reynolds, HN Viswanathan, CD O'Malley, P Muntner, TN Harrison, TC Cheetham, J-WY
Hsu, DT Gold, S Silverman, A Grauer, DE Morisky
Annals of Pharmacotherapy May 2012;46(5):659-670
Background; Poor adherence to oral osteoporosis medications is common. Strategies
for improving adherence begin with identification of the problem. The 8-item
Morisky Medication Adherence Scale for self-reported adherence to antihypertensive
medications was modified for assessing adherence to oral osteoporosis medications.
An evaluation of the measurement properties of the Osteoporosis-Specific Morisky
Medication Adherence Scale (OS-MMAS) was needed.
Objective: To examine the psychometric properties of the OS-MMAS in women with
postmenopausal osteoporosis.
Methods: 500 women aged 55 years and older with osteoporosis who were newly
prescribed daily or weekly oral bisphosphonates between 15 May 2010 and 15 Aug
2010 were randomly selected from Kaiser Permanente Southern California, a large
US integrated health care delivery system, and mailed a self-administered survey
that included the 8-item OS-MMAS, Self-Efficacy for Appropriate Medication Use
Scale (SEAMS), Beliefs about Medicines Questionnaire (BMQ), Treatment Satisfaction
Questionnaire for Medication (TSQM), Gastrointestinal Symptom Rating Scale
(GSRS), and 12-item Short-Form Health Survey (SF-12v2). OS-MMAS scores can
range from 0 to 8, with higher scores indicating better medication adherence.
Internal consistency reliability was evaluated using Cronbach α coefficient. Testretest reliability was assessed using intraclass correlation coefficients (ICCs) in a
subset of 102 participants. Construct validity was assessed using confirmatory factor
analysis and correlations between OS-MMAS and related measures.
Results: Of 197 participants, 150 reported that they were still taking their
bisphosphonate at the time of the survey and completed the OS-MMAS. Overall,
30.7%, 32.7% and 36.7% had low, medium and high OS-MMAS scores (below 6, 6
to below 8 and 8, respectively). Cronbach alpha was 0.82 and the ICC was 0.77.
Convergent validity was supported by significant correlations with SEAMS, BMQ
necessity and TSQM scores. In confirmatory factor analysis, a single-factor scale
was supported.
Conclusions: The OS-MMAS showed strong psychometric properties with good
reliability and construct validity and may provide a valuable assessment of selfreported medication adherence in women newly prescribed oral osteoporosis
medications.
http://www.theannals.com/content/46/5/659.abstract
33. EMR-based medication adherence metric markedly enhances identification of
nonadherent patients
S Roee Singer, M Hoshen, E Shadmi, M Leibowitz, N Flaks-Manov, H Bitterman, RD Balicer
American Journal of Managed Care Oct 2012;18(10):e372-e377
Objectives: To determine whether addition of written-prescription data to existing
adherence measures improves identification of nonadherent patients and prediction
of changes in low-density lipoprotein (LDL) cholesterol.
Study Design: Retrospective database analysis of all health plan members prescribed
a statin in 2008 and followed up to 2010.
Methods: We examined statin use in a 4-million-member health plan with 100%
electronic medical record coverage (Clalit Health Services, Israel). A novel type of
medication possession ratio (MPR), integrating prescribed with dispensed medication
data, was developed. This measure, MPRp, was compared with a standard
dispensed-only adherence measure, MPRd. Adherence below 20% was considered
nonadherence. The two adherence measures were compared regarding (1) the
20
number of patients identified as nonadherent, (2) percentage changes in LDL from
study enrollment to study termination and (3) receiver-operator curves assessing the
association between adherence and a 24% decrease in LDL.
Results: A total of 67,517 patients received 1,386,270 written prescriptions over the
3-year period. MPRp identified 93% more patients as nonadherent than did MPRd (P
less than 0.001). These newly identified patients exhibited minimal LDL decreases
over the course of the study. Adherence by MPRp was more strongly associated with
decreases in LDL than was adherence by MPRd (area under the curve 0.815 vs
0.770; P less than 0.001). During the study period, 18.2% of patients did not fill
any prescriptions and were thus unidentifiable by dispensed-only measures.
Conclusions: Addition of written-prescription data to adherence measures identified
nearly twice the number of nonadherent patients and markedly improved prediction
of changes in LDL.
http://www.ajmc.com/articles/EMR-Based-Medication-Adherence-Metric-MarkedlyEnhances-Identification-of-Nonadherent-Patients
34. Usefulness of parental response to questions about adherence to prescribed
inhaled corticosteroids in young children
A Schultz, PD Sly, G Zhang, A Venter, SG Devadason, P Niels le Souef
Archives of Disease in Childhood Dec 2012;97(12):1092-1096
Background: Adherence to prescribed inhaled medication is often low in young
children. Poor adherence to medication may contribute to lack of symptom control.
Doctors are not good at predicting the adherence rates of their patients, and parental
report of adherence does not correlate with objective measures of adherence. The
objective of this study was to investigate whether parental admission of nonadherence and reasons given for non-adherence correlated with objectively
measured adherence.
Methods: Adherence to prescribed inhaled corticosteroid treatment was monitored
electronically (Smartinhaler Nexus6) in 132 children aged 2-6 years who were
participating in a randomised controlled trial in Australia comparing different inhaler
devices (including the Funhaler). Follow-up was carried out every 3 months for a
year. Parental answers to simple questions about adherence were compared to
electronically measured adherence.
Results: Mean adherence ranged from zero to 100%. Intra-participant adherence
varied throughout the year-long study period (mean variance for individual children
between quarterly periods was 28.5%). Parents who reported missed doses,
generally missed at least half of the prescribed doses. Parents who reported that not
a single prescribed dose was missed, still missed 20% of doses on average.
Adherence was particularly low when parents cited initiating their own trial off
medication as a reason for missing doses.
Conclusions: By examining parental response to questions enquiring whether any
doses were missed, healthcare providers can gain a modest degree of insight into
their patients' true adherence to prescribed medication. Adherence to prescribed
asthma medication is extremely variable in young children.
Trial Registration: Data from this study were derived from a randomised controlled
trial (ACTRN 12608000294358).
http://adc.bmj.com/content/97/12/1092.abstract
35. Measuring adherence in a community-based elderly population
PS Shelton, DB Mozingo, PS Avissar, M Karg, AL Charboneau, W Rich
Consultant Pharmacist Nov 2012;27(11):771-781
21
Objective: To examine the reliability and validity of the Medication Adherence
Individual Review-Screening Tool (MedAdhIR-ST) for assessing medication
adherence in a community-dwelling elderly population.
Design: A prospective, observational pilot study comparing the reliability and validity
of the MedAdhIR-ST and the Medication Adherence Questionnaire (MAQ).
Setting: Independent senior-housing apartments and senior centres in Wake County,
North Carolina, USA.
Participants: Eligible subjects included individuals 60 years of age or older who were
living in the community and managing their own medication regimens.
Interventions: Each subject was asked to participate in two assessment visits, two
weeks (+/- 3 days) apart, in which the questions of the MedAdhIR-ST and MAQ were
administered.
Main Outcome Measure: Medication adherence.
Results: Both tools showed moderate-to-high test/retest reliability in the study
population (correlation coefficient of 0.632 for MAQ, and 0.699 for MedAdhIR-ST),
and moderate internal consistency (Cronbach's alpha of 0.551 and 0.584,
respectively). Moderate concordance in the ability to assess adherence was
observed between MedAdhIR-ST and MAQ (positive correlation coefficient of 0.450).
When compared with refill records, MedAdhIR-ST was slightly more sensitive (67%
vs 43%) and specific (60% vs 50%) for detecting adherence and nonadherence,
respectively, compared with MAQ. Exploratory factor analysis indicated that
MedAdhIR-ST is multidimensional.
Conclusions: MedAdhIR-ST appears to be a reliable and valid tool for screening
nonadherence in a community-dwelling elderly population.
http://ascp.metapress.com/content/9460rp1h448w6r74/?p=eed9f1d5bf6e4940a4da035dca
9f9c9b&pi=2
36. Self-reported adherence measures: what do they assess and how should we
use them?
JF Steiner
Medical Care Dec 2012;50(12):1011-1012
Editorial discussing this topic with particular reference to a paper in this issue by
Voils et al. (p.1013-1019).
http://journals.lww.com/lwwmedicalcare/Citation/2012/12000/Self_reported_Adherence_Measures__What_Do_They.1.a
spx
37. A mobile phone text message program to measure oral antibiotic use and
provide feedback on adherence to patients discharged from the emergency
department
B Suffoletto, J Calabria, A Ross, C Callaway, DM Yealy
Academic Emergency Medicine Aug 2012;19(8):949-958
Objectives: Nonadherence to prescribed medications impairs therapeutic benefits.
The authors measured the ability of an automated text messaging (short message
service (SMS)) system to improve adherence to post-discharge antibiotic
prescriptions.
Methods: This was a randomised, controlled trial in an urban emergency department
(ED) in Pennsylvania, USA with an annual census of 65,000. A convenience sample
of adult patients being discharged with a prescription for oral antibiotics was
enrolled. Participants received either a daily SMS query about prescription pickup,
and then dosage taken, with educational feedback based on their responses
(intervention), or the usual printed discharge instructions (control). A standardised
22
phone follow-up interview was used on the day after the intended completion date to
determine antibiotic adherence: 1) the participant filled prescription within 24 hours
of discharge and 2) no antibiotic pills were left on the day after intended completion
of prescription.
Results: Of the 200 patients who agreed to participate, follow-up was completed in
144 (72%). From the 144, 26% (95% CI, 19% to 34%) failed to fill their discharge
prescriptions during the first 24 hours and 37% (95% CI, 29% to 45%) had pills left
over, resulting in 49% (95% CI, 40% to 57%) nonadherent patients. There were no
differences in adherence between intervention participants and controls (57% vs.
45%; p = 0.1). African-American race, greater than twice-daily dosing and selfidentifying as expecting to have difficulty filling or taking antibiotics at baseline were
associated with nonadherence.
Conclusions: Almost one-half (49%) of our patients do not adhere to antibiotic
prescriptions after ED discharge. Future work should improve the design and
deployment of SMS interventions to optimise their effect on improving adherence to
medication after ED discharge.
38. Identification of and intervention to address therapeutic gaps in care
DR Touchette, S Rao, PK Dhru, W Zhao, Y-K Choi, I Bhandari, GD Stettin
American Journal of Managed Care Oct 2012;18(10):e364-e371
Objectives: To determine whether therapeutic gap identification, notification of
community pharmacists and intervention results in increased gap closure, reduced
gap closure time and fewer adherence gaps reopening.
Study Design: Prospective, controlled, cluster-randomised study.
Methods: State of Illinois (USA) employees and beneficiaries of State health plans
filling prescriptions at independently owned community pharmacies were included.
For selected chronic conditions and medications, gaps in medication adherence and
omitted essential therapies were identified from prescription claims data (Medco) and
sent as alerts for resolution with the patient and/or physician. Adherence and
omission gap closure at 90 days were analysed with Kaplan-Meier (KM) survival
curve approach and Cox proportional hazards models including covariates.
Results: A total of 1433 intervention and 1181 control adherence gaps were
identified, while 677 intervention and 534 control omission gaps were generated.
Pharmacists intervened on 639 (44.6%) adherence and 506 (74.7%) omission gaps.
Gaps were closed more often in intervention than control at 30 days (55.5% in
intervention vs 50.6% in control), 45 days (61.1% vs 58.4%, respectively), 60 days
(66.1% vs 65.2%, respectively) and 90 days (73.0% vs 72.9%, respectively;
adjusted hazard ratio (HR) = 1.242; P = 0.022; 95% CI, 1.115 to 1.385).
Adherence gaps reopened less frequently in the intervention group (HR = 0.863; P =
0.012; 95% CI, 0.769 to 0.968). A total of 89 (13.1%) intervention and 29 (5.4%)
control omission gaps closed within 90 days (adjusted HR = 1.770; P = 0.005; 95%
CI, 1.182 to 2.653).
Conclusions: Independent community pharmacists reduced gaps in care and had
fewer reopened adherence gaps, suggesting improvement in adherence. A
continuation study will examine the impact of the program on long-term adherence.
http://www.ajmc.com/articles/Identification-of-and-Intervention-to-Address-TherapeuticGaps-in-Care
39. Determining the feasibility of objective adherence measurement with blister
packaging smart technology
HA van Onzenoort, C Neef, WW Verberk, HP van Iperen, PW de Leeuw, P-HM van der Kuy
23
American Journal of Health-System Pharmacy 15 May 2012;69(10):872-879
Purpose: The results of a feasibility study of blister-pack smart technology for
monitoring medication adherence are reported.
Methods: Research in the area of objective therapy compliance measurement has led
to the development of microprocessor-driven systems that record the time a unit
dose is removed from blister packaging. One device under development is the Smart
Blister - a label imprinted with event-detection circuitry that can be affixed to
standard commercial blister cards. In the first trial of the device in actual clinical
practice, 115 community-dwelling Dutch patients receiving valsartan maintenance
therapy (160mg once daily) were given 14-day blister packages equipped with the
Smart Blister. On the return of empty blister cards to the 20 participating
community pharmacies, the stored information was scanned and downloaded for
data analysis and patient counselling purposes.
Results: A total of 245 Smart Blister-equipped packages were used by valsartan
recipients during the 8-month study. The device was largely effective in recording
patient and blister-card identification data and other desired information. However,
in 17% of cases, the Smart Blister system registered multiple tablet-removal events
at the same time, presumably indicating unintentional breakage of nearby conductive
circuits and the need for design refinements. The Smart Blister-equipped medication
cards were generally well received by patients and pharmacies.
Conclusions: An evaluation of the functionality and robustness of the Smart Blister in
a real-world clinical practice situation yielded some promising results, but the
findings also indicated a need for design refinements and additional performance
testing of the device.
http://www.ajhp.org/content/69/10/872.abstract
40. Electronic monitoring of adherence, treatment of hypertension, and blood
pressure control
HAW van Onzenoort, WJ Verberk, AA Kroon, AGH Kessels, C Neef, P-HM van der Kuy, PW de
Leeuw
American Journal of Hypertension Jan 2012;25(1):54-59
Background: Although it is generally acknowledged that electronic monitoring of
adherence to treatment improves blood pressure (BP) control by increasing patients'
awareness to their treatment, little information is available on the long-term effect of
this intervention.
Methods: In this observational study among a total of 470 patients with mild-tomoderate hypertension, adherence was measured in 228 patients by means of both
the Medication Event Monitoring System (MEMS) and pill count (intervention group),
and in 242 patients by means of pill count alone (control group). During a follow-up
period of 1 year consisting of seven visits to the physician's office, BP measurements
were performed and medication adjusted based on the achieved BP. In addition, at
each visit adherence to treatment was assessed.
Results: On the basis of pill counts, median adherence to treatment did not differ
between the intervention group and the control group (96.1% vs 94.2%; P = 0.97).
In both groups, systolic and diastolic BP decreased similarly: 23/13 vs 22/12 mm Hg
in the intervention and control group respectively. Drug changes and the number of
drugs used were associated with BP at the start of study, but not with electronic
monitoring.
Conclusions: In this study, electronic monitoring of adherence to treatment by
means of MEMS did not lead to better long-term BP control nor did it result in less
drug changes and drug use.
http://ajh.oxfordjournals.org/content/25/1/54.full.pdf+html
24
41. Initial validation of a self-report measure of the extent of and reasons for
medication nonadherence
CI Voils, ML Maciejewski, RH Hoyle, BB Reeve, P Gallagher, CL Bryson, WS Yancy
Medical Care Dec 2012;50(12):1013-1019
Background: Self-report measures of medication nonadherence confound the extent
of and reasons for medication nonadherence. Each construct is assessed with a
different type of psychometric model, which dictates how to establish reliability and
validity.
Objectives: To evaluate the psychometric properties of a self-report measure of
medication nonadherence that assesses separately the extent of nonadherence and
reasons for nonadherence.
Research Design: Cross-sectional survey involving the new measure and comparison
measures to establish convergent, discriminant, and predictive validity. The new
measure was readministered 2-21 days later.
Subjects: A total of 202 veterans with treated hypertension were recruited from the
Durham Veterans Affairs Medical Center (North Carolina, USA).
Measures: A new self-report measure assessed the extent of nonadherence and
reasons for nonadherence. Comparison measures included self-reported medication
self-efficacy, beliefs about medications, impression management, conscientiousness,
habit strength and an existing nonadherence measure.
Results: Three items assessing the extent of nonadherence produced reliable scores
for this sample, alpha = 0.84 (95% CI, 0.80 to 0.87). Correlations with comparison
measures provided evidence of convergent and discriminant validity. Correlations
with systolic (r = 0.27, P less than 0.0001) and diastolic (r = 0.27, P less than
0.0001) blood pressure provided evidence of predictive validity. Reasons for
nonadherence were assessed with 21 independent items. Intraclass correlations
were 0.58 for the extent score and ranged from 0.07 to 0.64 for the reasons.
Conclusions: The dual conceptualization of medication nonadherence allowed a
stronger evaluation of the reliability and validity than was previously possible with
measures that confounded these 2 constructs. Measurement of self-reported
nonadherence consistent with psychometric principles will enable reliable, valid
evaluation of interventions to reduce nonadherence.
http://journals.lww.com/lwwmedicalcare/Abstract/2012/12000/Initial_Validation_of_a_Self_Report_Measure_of_the.2.as
px
42. Comparison of pharmacy-based measures of medication adherence
WM Vollmer, M Xu, A Feldstein, D Smith, A Waterbury, C Rand
BMC Health Services Research 12 Jun 2012;12:155
Background: Pharmacy databases are commonly used to assess medication usage,
and a number of measures have been developed to measure patients' adherence to
medication. An extensive literature now supports these measures, although few
studies have systematically compared the properties of different adherence
measures.
Methods: As part of an 18-month randomised clinical trial to assess the impact of
automated telephone reminders on adherence to inhaled corticosteroids (ICS) among
6903 adult members of a managed care organisation in the USA, we computed eight
pharmacy-based measures of ICS adherence using outpatient pharmacy dispensing
records obtained from the health plan's electronic medical record. We used simple
descriptive statistics to compare the relative performance characteristics of these
measures.
25
Results: Comparative analysis found a relative upward bias in adherence estimates
for those measures that require at least one dispensing event to be calculated.
Measurement strategies that require a second dispensing event evidence even
greater upward bias. These biases are greatest with shorter observation times.
Furthermore, requiring a dispensing event to be calculated meant that these
measures could not be defined for large numbers of individuals (17-32 % of
participants in this study). Measurement strategies that do not require a dispensing
event to be calculated appear least vulnerable to these biases and can be calculated
for everyone. However they do require additional assumptions and data (e.g. preintervention dispensing data) to support their validity.
Conclusions: Many adherence measures require one, or sometimes two, dispensings
in order to be defined. Since such measures assume all dispensed medication is
used as directed, they have a built in upward bias that is especially pronounced when
they are calculated over relatively short timeframes (less than 9 months). Less
biased measurement strategies that do not require a dispensing event are available,
but require additional data to support their validity.
Trial Registration: The study was funded by grant R01HL83433 from the US National
Heart, Lung and Blood Institute (NHLBI) and is filed as study NCT00414817 in the
ClinicalTrials.gov database.
43. A new taxonomy for describing and defining adherence to medications
B Vrijens, S De Geest, DA Hughes, K Przemyslaw, J Demonceau, T Ruppar, F Dobbels, E
Fargher, V Morrison, P Lewek, M Matyjaszczyk, C Mshelia, W Clyne, JK Aronson, J Urquhart
(ABC Project Team)
British Journal of Clinical Pharmacology May 2012;73(5):691-705
Interest in patient adherence has increased in recent years, with a growing literature
that shows the pervasiveness of poor adherence to appropriately prescribed
medications. However, four decades of adherence research has not resulted in
uniformity in the terminology used to describe deviations from prescribed therapies.
The aim of this review was to propose a new taxonomy, in which adherence to
medications is conceptualised, based on behavioural and pharmacological science,
and which will support quantifiable parameters. A systematic literature review was
performed using MEDLINE, EMBASE, CINAHL, the Cochrane Library and PsycINFO
from database inception to 1 Apr 2009. The objective was to identify the different
conceptual approaches to adherence research. Definitions were analysed according
to time and methodological perspectives. A taxonomic approach was subsequently
derived, evaluated and discussed with international experts. More than 10 different
terms describing medication-taking behaviour were identified through the literature
review, often with differing meanings. The conceptual foundation for a new,
transparent taxonomy relies on three elements, which make a clear distinction
between processes that describe actions through established routines ('Adherence to
medications', 'Management of adherence') and the discipline that studies those
processes ('Adherence-related sciences'). 'Adherence to medications' is the process
by which patients take their medication as prescribed, further divided into three
quantifiable phases: 'Initiation', 'Implementation' and 'Discontinuation'. In response
to the proliferation of ambiguous or unquantifiable terms in the literature on
medication adherence, this research has resulted in a new conceptual foundation for
a transparent taxonomy. The terms and definitions are focused on promoting
consistency and quantification in terminology and methods to aid in the conduct,
analysis and interpretation of scientific studies of medication adherence.
26
44. Validity and reliability of a self-reported measure of medication adherence in
patients with Type 2 diabetes mellitus in Singapore
Y Wang, J Lee, MPHS Toh, WE Tang, Y Ko
Diabetic Medicine Sep 2012;29(9):e338-e344
Aims: A reliable and valid measure is essential for the assessment of medication
adherence. Until now, no patient-reported medication adherence measure has been
validated in Singapore. The aim of this study was to validate a modified 4-item
Morisky-Green-Levine Medication Adherence Scale in patients with Type 2 diabetes in
Singapore.
Methods: A cross-sectional survey was conducted in a sample of outpatients with
Type 2 diabetes in Singapore from Sep to Dec 2009. Respondents completed either
an English or Chinese version of the modified 4-item Morisky-Green-Levine
Medication Adherence Scale. The scale scores ranged from 0 to 4, with higher scores
indicating better medication adherence. Reliability was assessed using Cronbach's
alpha. Content validity was assessed by expert review. Construct validity was
examined using factor analysis and hypothesis testing.
Results: Of the 294 respondents who completed the modified Morisky-Green-Levine
Medication Adherence Scale, 13.3, 21.4, 35.7 and 29.6% had a score of 0-1, 2, 3
and 4, respectively. The internal consistency of the scale was moderate (Cronbach's
alpha = 0.62). Principal component analysis showed that the four items loaded onto
one factor (eigenvalue = 1.95). Respondents with higher scores were older (P less
than 0.001), had lower HbA1c levels (P less than 0.001) and had better adherence to
physician-recommended diet (P less than 0.001) and physical exercise (P = 0.02).
Conclusions: The psychometric properties of the modified Morisky-Green-Levine
Medication Adherence Scale were less than satisfactory. A ceiling effect was
observed. The scale may not be an adequate measure to assess medication
adherence in patients with Type 2 diabetes in Singapore. Future research could
target refining the scale and investigating its use in other patient populations.
45. Adherence to antiretroviral therapy in HIV-positive adolescents in Uganda
assessed by multiple methods: a prospective cohort study
MO Wiens, S MacLeod, V Musiime, M Ssenyonga, R Kizza, S Bakeera-Kitaka, R Odoi-Adome,
F Ssali
Pediatric Drugs Oct 2012;14(5):331-335
Background: The effectiveness of traditional adherence measurements used in
adolescent populations is difficult to assess. Antiretroviral (ARV) adherence research
among adolescents living with HIV in resource-constrained countries is particularly
challenging and little evidence is available.
Objectives: The primary objective of this study was to determine the feasibility of a
large-scale, long-term study using electronic adherence monitoring in Uganda. The
secondary objective was to compare accuracy of pill count (PC) and self-report (SR)
adherence with electronic medication vials (eCAPs (TM)).
Methods: Adolescents receiving ARV therapy at the Joint Clinical Research Centre in
Kampala, Uganda, were recruited. ARVs were dispensed in eCAPs for 1 year.
Person-pill-days (PPDs) (1 day where adherence was measured for one medication in
one patient) were calculated and a weighted paired t-test was used to compare the
levels of adherence among subjects for three different adherence measurement
methods.
27
Results: 15 patients were included: 40% were female, mean age was 14 years,
mean baseline CD4+ cell count was 244 cells/microL and average treatment duration
was 9 months at study entry. Overall, 4721 PPDs were observed. Some eCAPs
required replacement during the study resulting in some data loss. Consent rate was
high (94%) but was slow due to age limit cut-points. Overall adherence for SR was
99%, PC was 97% and eCAP was 88% (p less than 0.05 for all comparisons). 93%,
67% and 23% of patients had an adherence of greater than 95% as measured by
SR, PC and eCAP methods, respectively.
Conclusions: A large-scale adherence study in Uganda would be feasible using a
more robust electronic monitoring system. Adherence measurements produced by
pill counts and self-reporting methods appear to overestimate adherence measured
electronically.
http://link.springer.com/article/10.1007/BF03262238
46. Methotrexate polyglutamates as a marker of patient compliance and clinical
response in psoriasis: a single-centre prospective study
RT Woolf, SL West, M Arenas-Hernandez, N Hare, AM Peters van Ton, CM Lewis, AM
Marinaki, JNWN Barker, CH Smith
British Journal of Dermatology Jul 2012;167(1):165-173
Background: Methotrexate is activated by the sequential addition of glutamic acid
residues to form methotrexate polyglutamates (MTXPG1-5). MTXPG1-5 inhibit
enzymes of the folate-purine-pyrimidine pathways, and longer-chain MTXPG3-5
species are more active.
Objectives: To determine the pattern of erythrocyte MTXPG1-5 in patients initiated
on oral methotrexate for psoriasis and to investigate the potential utility of MTXPGs
as markers of compliance and/or clinical response.
Methods: This was a single-centre, prospective study of 55 adult patients with
chronic plaque psoriasis initiated on weekly oral methotrexate. Erythrocyte MTXPG15 concentrations were measured (at weeks 4, 8, 12, 24 and 52) using highperformance liquid chromatography. Methotrexate responders achieved a 50% or
greater improvement in Psoriasis Area and Severity Index or physician's global score
of 'clear'/'nearly clear' at 24 weeks.
Results: MTXPG levels were measured in 14 to 33 patients at each time point. All
MTXPG1-5 species were detected at week 4 of therapy. Steady state for long-chain
MTXPG3-5 and total MTXPG1-5 was achieved by week 24. MTXPG3 emerged as the
predominant MTXPG species (from week 12 onwards) and reflected overall
polyglutamate status (correlating strongly with MTXPG2-5, MTXPG3-5 and MTXPG45; R = 0.76-0.95, P less than 1.55 x 10-5). Age, renal function and sex were not
significant determinants of MTXPG3 concentration. No significant association was
identified between MTXPG and adverse events or responder status.
Conclusions: This is the first study to demonstrate the prospective accumulation of
MTXPG1-5 in patients with psoriasis. The detection of MTXPGs early in therapy and
the establishment of a steady state with continuous treatment may offer measuring
of MTXPG as a test to monitor patient compliance with therapy. Larger studies are
required to determine the role of MTXPG as a potential biomarker of clinical
response.
28
Adherence Levels in Practice
Studies referring to a wide range of countries, health care systems,
diseases, patients and medications suggest that problems of lack of
adherence and lack of persistence are pervasive.
47. Adherence to oral antidiabetic medications in the pediatric population with
Type 2 diabetes: a retrospective database analysis
AO Adeyemi, KL Rascati, KA Lawson, SA Strassels
Clinical Therapeutics Mar 2012;34(3):712-719
Background: Little has been done in assessing adherence to oral antidiabetic (OAD)
medications in the paediatric population presenting with type 2 diabetes. This study
provided information on adherence rates in the Texas (USA) Medicaid paediatric
population with type 2 diabetes, which is rare in the literature. The knowledge of
adherence rates in the paediatric population with type 2 diabetes might help improve
the care given to paediatric patients with type 2 diabetes.
Objective: To describe OAD medication use, and assess trends in medication
adherence and persistence among Texas paediatric Medicaid patients.
Methods: Texas Medicaid prescription claims data of patients between 10 and 18
years of age, with at least 2 prescriptions of the same OAD medication from 1 Jan
2006 to 31 Dec 2009 were analysed. Adherence was assessed using the medication
possession ratio (MPR) as a proxy.
Results: A total of 3109 patients met the study's inclusion criteria. The mean (SD)
age of the 3109 eligible patients was 14.2 (2.3) years; 60% were Hispanics, 14%
were blacks, 13% were whites and another 13% were other minority races; 67% of
the population were females; and 91% were on metformin of the 6 OAD medications
included in the study. The overall mean (SD) MPR for patients was 44.69%
(27.06%). Adherence differed by gender (P less than 0.0001), race (P less than
0.0001) and age category (P less than 0.0001). Males had higher mean (SD) MPR
(47.47% (27.42%)) compared with females (43.29% (26.78%)). Mean MPR for
whites (50.04% (29.65%)) was significantly higher compared with blacks (44.24%
(26.16%)) and Hispanics (42.50% (26.10%)). Patients 12 years of age or younger
had significantly higher mean MPR (48.82% (27.37%)) compared with those in older
age categories. Logistic regression analysis suggested that age was significantly
related (odds ratio (OR) = 0.91; 95% CI, 0.87 to 0.95) to being adherent (MPR 80%
or above). Males were 25% (OR = 1.25; 95% CI, 1.02 to 1.53; P = 0.034) more
likely to be adherent (MPR 80% or above) compared with females, and whites were
twice as likely to be adherent (MPR 80% or above) compared with Hispanics (OR =
2.02; 95% CI, 1.54 to 2.66; P = 0.0012). Overall, mean (SD) days to
nonpersistence was 108 (86) days. Persistence was significantly and negatively
associated with age (P less than 0.0001). White race was significantly related to
longer persistence.
Conclusions: Adherence and persistence to OAD medications in the selected Texas
Medicaid paediatric population between 10 and 18 years was generally suboptimal,
especially in adolescents.
48. Adherence to medication for the treatment of psychosis: rates and risk factors
in an Ethiopian population
29
M Alene, M Wiese, MT Angamo, BV Bajorek, EA Yesuf, NT Wabe
BMC Clinical Pharmacology 18 Jun 2012;12:10
Background: Medication-taking behaviour, specifically non-adherence, is significantly
associated with treatment outcome and is a major cause of relapse in the treatment
of psychotic disorders. Non-adherence can be multifactorial; however, the rates and
associated risk factors have not yet been elucidated in an Ethiopian population. The
aim of this study was primarily to evaluate adherence rates to antipsychotic
medications, and secondarily to identify potential factors associated with nonadherence, among psychotic patients at a tertiary care teaching hospital in
Southwest Ethiopia.
Methods: A cross-sectional study was conducted over a 2-month period in 2009 (15
Jan to 20 Mar) at the Jimma University Specialized Hospital. Adherence was
computed using both a compliant fill rate method and self-reporting via a structured
patient interview (focusing on how often regular medication doses were missed
altogether, and whether they missed taking their doses on time). Data were
analysed using SPSS for Windows version 16.0, and chi-squared and Pearson's r
tests were used to determine the statistical significance of the association of
variables with adherence.
Results: 336 patients were included in the study. A total of 75.6% were diagnosed
with schizophrenia, while the others were diagnosed with other psychotic disorders.
Most (88.1%) patients were taking only antipsychotics, while the remainder took
more than one medication. Based upon the compliant fill rate, 57.5% of prescription
fills were considered compliant, but only 19.6% of participants had compliant fills for
all of their prescriptions. In contrast, on the basis of patients' self-report, 52.1% of
patients reported that they had never missed a medication dose, 32.0% sometimes
missed their daily doses, 22.0% only missed taking their dose at the specific
scheduled time, and 5.9% missed both taking their dose at the specific scheduled
time and sometimes missed their daily doses. The most common reasons provided
for missing medication doses were: forgetfulness (36.2%); being busy (21.0%); and
insufficient information about the medication (10.0%). Pill burden, side-effects of
the medication, social drug use and duration of maintenance therapy each had a
statistically significant association with medication adherence (P = 0.05 or less).
Conclusions: The observed rate of antipsychotic medication adherence in this study
was low, and depending upon the definition used to determine adherence, it is either
consistent or low compared with previous reports, which highlights its pervasive and
problematic nature. Adherence must therefore be considered when planning
treatment strategies with antipsychotic medications, particularly in countries such as
Ethiopia.
49. Capecitabine non-adherence: exploration of magnitude, nature and
contributing factors
D Bhattacharya, C Easthall, KA Willoughby, M Small, S Watson
Journal of Oncology Pharmacy Practice Sep 2012;18(3):333-342
Objectives: The prescribing of oral chemotherapy agents previously available only in
the intravenous formulation, such as capecitabine, has afforded many benefits
including reduced administration costs and improved patient acceptability. However,
it has introduced the new challenge of ensuring patient adherence to therapy. It is
therefore necessary to quantify adherence, and with a view to improving services,
explore factors that may impact on medication taking behaviour.
Methods: Patients with a diagnosis of breast or colorectal cancer and prescribed
capecitabine were recruited from a UK teaching hospital. Data regarding self-
30
reported adherence, beliefs about medicines, side effects, and satisfaction with
information received about capecitabine were recorded.
Results: Non-adherence was reported by 23.3% of the 43 participants. Capecitabine
therapy was perceived necessary by 97.6%, but almost one-third of participants had
strong concerns. Side effects were reported by 80% of participants, with PalmarPlantar erythrodysaesthesia and fatigue most troubling participants. Complete
satisfaction with information received was reported by 65% of participants; however,
dissatisfaction about how to tell if capecitabine is working and the proposed duration
of therapy was expressed by 42.9% and 37.3% of participants, respectively.
Conclusions: Adherence to capecitabine is high with a strong conviction that the
therapy is necessary. However, concerns were expressed regarding the experience
of side effects. Patients have unmet information needs regarding the processes
involved with monitoring capecitabine efficacy and determination of therapy
duration. Healthcare professionals may therefore wish to consider a greater focus on
involving patients in the monitoring of their care with respect to efficacy and planned
treatment schedules.
http://opp.sagepub.com/content/18/3/333.abstract
50. Adherence patterns in patients with type 2 diabetes on basal insulin
analogues: missed, mistimed and reduced doses
M Brod, A Rana, AH Barnett
Current Medical Research and Opinion Dec 2012;28(12):1933-1946
Objective: To describe basal insulin analogue dosing irregularities, the effect of these
events on patient functioning, well-being and diabetes management, and the
identification of patients most at risk.
Design and Methods: The GAPP2 (Global Attitude of Patients and Physicians 2) study
was an online multinational cross-sectional study of patients with type 2 diabetes
currently treated with basal insulin, and healthcare professionals (HCPs) involved in
the care of such patients. Basal insulin adherence patterns were evaluated with
respect to three types of dosing irregularity: missed, mistimed (+/- 2 hours from
prescribed time) and reduced dose over the last 30 days.
Results: A total of 3042 patients treated with basal insulin analogues and 1222
prescribers completed the full survey; 38% of patients reported any type of basal
insulin dosing irregularity in the last 30 days. Patients reported missing (22% on 3
+/- 0.16 occasions), mistiming (24% on 4.2 +/- 0.21 occasions) or reducing (14%
on 4.2 +/- 0.24 occasions) basal insulin doses, with 15% of patients reporting
multiple types of dosing irregularities. For most patients, missed (83%) and
mistimed doses (82%) were unintentional, whereas the majority (87%) of patients
reducing doses did so intentionally. Patients who intentionally missed or reduced a
dose of basal insulin were significantly more likely to have performed this dosing
irregularity on multiple occasions. 53% of patients increased the frequency of blood
glucose monitoring, and 17% of patients extended the duration of more frequent
blood glucose monitoring by one or more days as a result of unintentional missed
doses. Reduced dosing was highest in a subset of patients reporting self-treated
hypoglycaemia.
Conclusions: Basal insulin dosing irregularities including missed, mistimed and
reduced doses are common. A significant proportion of patients also report
undertaking these irregular dosing behaviours at a frequency that would be
considered by prescribers to negatively impact diabetes management. This is
despite the potential under-reporting due to recall or social bias that may be a
limitation of a self-reported survey around these behaviours.
31
51. Adherence to medication in adults with attention deficit hyperactivity
disorder and pro re nata dosing of psychostimulants: a systematic review
H Caisley, U Muller
European Psychiatry Jul 2012;27(5):343-349
Adherence to a regular medication regimen may be challenging for adults with
attention deficit hyperactivity disorder (ADHD). Some report taking
psychostimulants on a pro re nata (PRN) basis. This review aims to establish the
rate of adherence, and reasons for and consequences of non-adherence to
medication for ADHD in adults, and to review literature on PRN dosing of
psychostimulants in these patients. A systematic literature search was conducted.
Four primary research studies have investigated the rate of adherence to medication
in adults with ADHD. Mean adherence rate in two studies ranged from 52% to 87%.
A number of possible reasons for poor adherence have been suggested. Prospective
studies are needed to further define the rate of adherence and causes of poor
adherence. Evidence examining whether differences in adherence affect clinical
outcomes is equivocal. Therefore, caution should be applied to the assumption that
maximising adherence to regular medication regimens will improve clinical outcomes.
Two articles acknowledge that patients take medication on a PRN basis. Studies
comparing the effectiveness of a regular and PRN regimen of psychostimulants are
needed. If PRN dosing is as effective as a regular regimen, advantages might
include enhanced doctor-patient communication, reduced side effects and cost
savings.
52. Adherence to HIV post-exposure prophylaxis in victims of sexual assault: a
systematic review and meta-analysis
L Chacko, N Ford, M Sbaiti, R Siddiqui
Sexually Transmitted Infections Aug 2012;88(5):335-341
Objective: To assess adherence to post-exposure prophylaxis (PEP) for the
prevention of HIV infection in victims of sexual assault.
Methods: The authors carried out a systematic review, random effects meta-analysis
and meta-regression of studies reporting adherence to PEP among victims of sexual
violence. Seven electronic databases were searched. Our primary outcome was
adherence; secondary outcomes included defaulting, refusal and side effects.
Results: 2159 titles were screened, and 24 studies matching the inclusion criteria
were taken through to analysis. The overall proportion of patients adhering to PEP
(23 cohort studies, 2166 patients) was 40.3% (95% CI, 32.5% to 48.1%) and the
overall proportion of patients defaulting from care (18 cohorts, 1972 patients) was
41.2% (95% CI, 31.1% to 51.4%). Adherence appeared to be higher in developing
countries compared with developed countries.
Conclusions: Adherence to PEP is poor in all settings. Interventions are needed to
support adherence.
http://sti.bmj.com/content/88/5/335.abstract
53. Adherence patterns with first- versus second-generation antipsychotics for
newly diagnosed schizophrenia in Taiwan
C-M Chang, K-Y Wu, H-Y Liang, EC-H Wu, C-Y Chen, C-S Wu, S-J Chen, T-K Chang, H-J Tsai
Psychiatric Services May 2012;63(5):504-507
Objective: The aim of this study was to compare the early adherence patterns for
first-generation antipsychotics and second-generation antipsychotics during the first
month of treatment for patients newly diagnosed as having schizophrenia.
32
Methods: With a random sample from the Taiwan national health insurance
database, persons with a schizophrenia diagnosis (ICD-9-CM code 295.X) and a
concurrent initial antipsychotic prescription from 1998 to 2006 were defined as being
newly treated for schizophrenia. Adherence patterns within 1 month of diagnosis
were categorised into four independent groups: refill, switch, admission and
discontinuation.
Results: Treatment initiated with first-generation or second-generation
antipsychotics resulted in similar rates of refill (57% vs 59%). However, patients
who started with first-generation antipsychotics were significantly less likely to
switch (9% vs 14%) but more likely to discontinue (34% vs 26%) medications than
those whose treatment was initiated with second-generation antipsychotics.
Conclusions: The data substantiated previous observations of the magnitude of
adherence problems in Asian populations and highlight the importance of developing
new strategies for intervention.
http://ps.psychiatryonline.org/article.aspx?articleid=1109171
54. Understanding Statin Use in America and Gaps in Patient Education (USAGE):
an internet-based survey of 10,138 current and former statin users
JD Cohen, EA Brinton, MK Ito, TA Jacobson
Journal of Clinical Lipidology May 2012;6(3):208-215
Background: Statins substantially reduce the risk of cardiovascular disease and are
generally well-tolerated. Despite this, many patients discontinue therapy. A better
understanding of the characteristics of current and former statin users may be
helpful for formulating strategies to improve long-term adherence.
Objective: The Understanding Statin Use in America and Gaps in Education (USAGE)
survey assessed the attitudes, beliefs, practices and behaviour of current and former
statin users.
Methods: Individuals 18 years or older who reported a history of high cholesterol and
current or former statin use were identified within a registered consumer panel
cohort in the United States and invited to participate in an Internet survey.
Results: Of the 10,138 respondents, 8918 (88%) were current statin users and 1220
(12%) were former users. Participants (mean age 61 years) were predominantly
white (92%), female (61%), of middle income (median US$44,504/year) and had
health insurance (93%). Among current users, 95% took a statin alone and 70%
had not missed a dose in the past month. Although approx 70% reported that their
physicians had explained the importance of cholesterol levels for their heart health,
former users were less satisfied with the discussions (65% vs 83%, P less than
0.05). Muscle-related side effects were reported by 60% and 25% of former and
current users, respectively (P less than 0.05). Nearly half of all respondents
switched statins at least once. The primary reason for switching by current users
was cost (32%) and the primary reason for discontinuation was side effects (62%).
Conclusions: This survey provides important insights into behaviour and attitudes
among current and former statin users and the results suggest that more effective
dialogue between healthcare providers and patients may increase persistence of
statin use, particularly when the patient has concerns about side effects and drug
costs.
http://www.lipidjournal.com/article/S1933-2874(12)00082-7/abstract
55. Adherence to antiparkinsonian medication: an in-depth qualitative study
N Drey, E Mckeown, D Kelly, D Gould
International Journal of Nursing Studies Jul 2012;49(7):863-871
33
Background: Adherence to prescribed medication is low. It is a major problem as
following practitioners' recommendations is strongly associated with good patient
outcomes. Little research has been undertaken with people in the early stages of
Parkinson's disease although achieving symptom control depends on regularly timing
doses.
Research Questions: How do people with Parkinson's disease adhere to prescribed
medication, and what are the antecedents of non-adherence to antiparkinsonian
medication?
Design: Exploratory qualitative study using semi-structured interviews.
Setting: Specialist Parkinson's disease clinic in one National Health Service hospital
in England.
Participants: 15 consecutive patients not yet in the advanced stages of Parkinson's
disease living at home and responsible for managing their own medication or
managing medication with the help of their carer.
Methods: Semi-structured interviews with open questions.
Findings: Each respondent demonstrated at least one type and in most cases several
different types of non-adherent behaviour. Inadvertent minor non-adherence
occurred because patients forgot to take tablets or muddled doses. Minor deliberate
deviations occurred when patients took occasional extra tablets or brought forward
doses to achieve better symptom control, often to cater for situations that were
anticipated as especially demanding. Deliberate major non-adherence was very
common and always related to over-use of medication. The experiences of
parkinsonism were particular to the individual. The specific circumstances that
prompted an episode of non-adherence varied between patients. Nevertheless there
was evidence of negotiation between respondents and the Parkinson's disease nurse
specialist; medication regimens were altered in conjunction with the patient during
formal consultations and by telephone.
Conclusions: Non-adherence to prescribed medication for people with chronic
conditions is complex and for people with Parkinson's disease it was possible to
identify different types of non-adherence. The possible existence of a typology of
non-adherence for people with other chronic conditions merits investigation. Further
research is needed to establish whether the findings of this small scale qualitative
study can be replicated with a larger, more representative sample and establish how
people with Parkinson's disease might be encouraged to adhere to medication
regimens to improve symptom control.
http://www.journalofnursingstudies.com/article/S0020-7489(12)00041-7/abstract
56. First-fill medication discontinuations and nonadherence to antihypertensive
therapy: an observational study
CD Evans, DT Eurich, AJ Remillard, YM Shevchuk, D Blackburn
American Journal of Hypertension Feb 2012;25(2):195-203
Background: Medication nonadherence is a barrier to successfully managing
hypertension, but little is known about the contribution that immediate
discontinuations have on antihypertensive (AHT) nonadherence. The purpose of this
study was to determine the proportion of new AHT users who discontinue after a
single dispensation, and to examine potential predictors of these discontinuations.
Methods: This retrospective cohort study utilising linked administrative data from
Saskatchewan, Canada. Subjects were 40 years of age or older and received a new
AHT between 1994-2002. The primary end point was the proportion of subjects who
discontinued their AHT after the first dispensation (first-fill discontinuation). The
proportion of nonadherence attributed to first-fill discontinuations was then
34
calculated. Multivariate regression identified factors associated with first-fill
discontinuations.
Results: 52,039 subjects were included in the analyses. Mean age was 59.4 (sd
12.5) years, and 42% were male. Overall, 25,812/52,039 (50%) subjects were
nonadherent at 1 year; first-fill discontinuations accounted for 39.1%
(10,081/25,812) of this nonadherence. Approximately 20% (10,081/52,039) of all
subjects discontinued all AHT therapy after the first fill. A higher chronic disease
score (adjusted odds ratio (OR) 1.09; 95% CI, 1.08 to 1.11) and antidepressant
medication usage during the observation year (adjusted OR 1.17; 95% CI, 1.09 to
1.26) was associated with increased risk for first-fill discontinuations. Older age,
starting AHT therapy after 1994, frequent physician visits, or use of a statin,
acetylsalicylic acid, warfarin or antihyperglycaemic during the observation year was
associated with a lower risk for first-fill discontinuations.
Conclusions: A substantial proportion of nonadherence to AHT medications is due to
discontinuations after only a single dispensation.
57. Gaps in treatment, treatment resumption, and cost sharing
TB Gibson, AM Fendrick, J Gatwood, ME Chernew
American Journal of Pharmacy Benefits Nov-Dec 2012;4(6):e159-e165
Objectives: To describe the rate of return to statin therapy after an observed
stoppage and to examine whether patient cost sharing plays a role in the resumption
of therapy.
Study Design: We conducted a retrospective, observational study of a cohort of
commercially insured patients in the USA with a treatment gap in statin therapy.
Methods: The 2006 to 2009 prescription drug and medical claims experience of
individuals aged 18 to 64 years who filled at least 2 statin prescriptions was included.
Treatment gaps were defined as at least 90 days without statin medications. To
analyse the association between cost sharing and filling behaviour within 1 year of
discontinuation we estimated an alternative-specific conditional logit model, including
cost-sharing prices faced for alternatives (brand, generic, no fill). Models controlled
for sociodemographic characteristics, health status and time.
Results: Nearly half (42.5%) of patients with at least a 90-day gap in statin therapy
did not return to treatment within the next year. Patients discontinuing branded
statins were more likely to return to treatment (61.6%) than patients discontinuing
generic statins (54.4%) (P less than 0.01). Most patients reinitiating treatment
returned to the type of medication (brand or generic) initially discontinued. Higher
patient cost sharing, for both brand and generic medications, was associated with
lower odds of a subsequent prescription fill (adjusted odds ratio = 0.989; 95% CI,
0.987 to 0.991).
Conclusions: Intermittent treatment stoppages with statins are common, they may
last for several months, and only half of patients return to treatment. Assistance or
interventions by providers and pharmacists to help reconnect patients with needed
treatment may lead to improvements in the persistence of therapy.
This research was funded by Pfizer, Inc.
http://www.ajpblive.com/media/pdf/AJPB_12novdec_Gibson_e159to165.pdf
58. Persistence with therapy among patients treated with warfarin for atrial
fibrillation
T Gomes, MM Mamdani, AM Holbrook, JM Paterson, DN Juurlink
Archives of Internal Medicine 26 Nov 2012;172(21):1687-1689
35
Research letter reporting a study of persistence with warfarin therapy in newly
treated patients aged 66 years or older with atrial fibrillation (AF), using multiple
linked administrative data sets from Ontario, Canada. Drug therapy discontinuation
was characterised by Kaplan-Meier curves. Patients were followed for a maximum of
5 years.
Of the 125,195 patients who started warfarin therapy for AF, 8.9% did not fill a
second prescription, 31.8% discontinued within 1 year, 43.2% within 2 years and
61.3% within 5 years. Men tended to discontinue treatment sooner than women
(2.6 vs 3.2 years). Older patients and those with a higher stroke risk were less likely
to discontinue treatment.
See also editorial commentary by W Maxwell and CL Bennett, Archives of Internal
Medicine 26 Nov 2012;172(21):1689-1690.
http://archinte.jamanetwork.com/article.aspx?articleid=1384249
59. Anti-androgen prescribing patterns, patient treatment adherence and
influencing factors; results from the nationwide PCBaSe Sweden
B Grundmark, H Garmo, B Zethelius, P Stattin, M Lambe, L Holmberg
European Journal of Clinical Pharmacology Dec 2012;68(12):1619-1630
Purpose: Adherence has not been studied in male oncology populations. The aim of
this study on both the prescriber and user perspectives in prostate cancer treatment
was to analyse real-life prescribing patterns of anti-androgens (AA), primarily
bicalutamide, and factors influencing the patients' adherence to treatment.
Methods: A nationwide clinical cohort of incident prostate cancer, PCBaSe, was linked
to the Swedish Prescribed Drug Register. Men with a planned first-line monotherapy
AA treatment were identified; dosages and extent of off-label treatment were
investigated. Cumulative incidence proportions for reasons for drug discontinuation
were calculated. Factors potentially influencing adherence were explored using the
medical possession ratio based on the individual prescribed daily dose.
Results: First-line monotherapy AA was planned in 4.4% of all incident cases and in
2.1% of low-risk disease cases. Among 1406 men prescribed bicalutamide, 1109
(79%) received the approved daily dose of 150 mg. Discontinuation reasons differed
with disease severity. Off-label, low-dose prescription associated with age above 75
years and disease categorised as low risk was noted in 297 men (21%). 60% of the
men adhered well, i.e. 80% or higher. Age above 75 years and less severe disease
were both negatively associated with adherence.
Conclusions: Patient age and tumour risk group influenced the prescriber's choice of
dose, pointing to important issues for critical reflection. Possible over-treatment was
noted in low-risk disease. Interventions to increase adherence in older men and in
men with less severe disease are worth considering after critically reviewing the
appropriateness of the treatment indication, especially in the latter case.
http://link.springer.com/article/10.1007%2Fs00228-012-1290-x
60. Adherence, persistence, healthcare utilization, and cost benefits of guidelinerecommended hepatitis B pharmacotherapy
S-H Han, W Jing, E Mena, M Li, B Pinsky, H Tang, T Hebden, T Juday
Journal of Medical Economics Dec 2012;15(6):1159-1166
Objective: To compare pharmacotherapy adherence, persistence and healthcare
utilisation/costs among US patients with chronic hepatitis B (CHB) initiated on an
oral antiviral monotherapy recommended as first-line treatment by current national
(US) guidelines vs an oral antiviral not recommended as first-line monotherapy.
Research Design and Methods: In this retrospective cohort study, patients aged 1864 with medical claims for CHB who initiated an oral antiviral monotherapy for CHB
36
between 1 Jul 2005 and 31 Jan 2010 were identified from a large US commercial
health insurance claims database. Patients were continuously enrolled for a 6-month
baseline period and 90 days or longer follow-up. They were assigned to 'currently
recommended first-line therapy' (RT: entecavir or tenofovir) or not currently
recommended first-line therapy' (NRT: lamivudine, telbivudine or adefovir) cohorts.
Main Outcome Measures: Multivariate analyses were conducted to compare
treatment adherence, persistence, healthcare utilisation and costs for RT vs NRT
cohorts.
Results: Baseline characteristics were similar between RT (n = 825) and NRT (n =
916) cohorts. In multivariate analyses, RT patients were twice as likely as NRT
patients to be adherent (OR = 2.09; p less than 0.01) and persistent (mean: RT =
361 days, NRT = 298 days; p less than 0.01) and half as likely to have an inpatient
stay (OR = 0.527; p less than 0.01). Between the two oral antivirals recommended
as first-line treatment, even though pharmacy cost was higher for entecavir, mean
total healthcare costs for entecavir and tenofovir were similar (US$1214 and $1332
per patient per month, respectively). Similar results were also observed with regard
to adherence, persistence and healthcare use for entecavir and tenofovir.
Conclusions: A limitation associated with analysis of administrative claims data is
that coding errors can be mitigated but are typically not fully eradicated by careful
study design. Nevertheless, the current findings clearly indicate the benefits of
initiating CHB treatment with an oral antiviral monotherapy recommended as firstline treatment by current guidelines.
Some of the authors are with Bristol-Myers Squibb.
61. Problems with non-adherence to antipsychotic medication in Samoan New
Zealanders: a literature review
I Ioasa-Martin, LJ Moore
International Journal of Mental Health Nursing Aug 2012;21(4):386-392
This paper explores what is known about adherence to antipsychotic medications in
general and the possible reasons for non-adherence in Samoan New Zealanders.
Samoan New Zealanders are either Samoan-born immigrants or their descendents
born in New Zealand. Clinicians recognise a high prevalence of non-adherence
among Samoan New Zealanders. The authors hypothesise that traditional Samoan
beliefs play a prominent role in problems with adherence. To investigate this
hypothesis, a review of the literature on adherence in Samoan New Zealanders was
undertaken. Documents from the Ministry of Health support the hypothesis. To
investigate this issue, the Ministry of Health initiated a qualitative research project to
examine the nature of Samoan traditional beliefs. The results of this study are
summarised. No research had previously been undertaken on adherence in Samoan
New Zealanders. In general, there is a lack of research on all aspects of the mental
health of Pacific peoples in New Zealand. Literature reviews of adherence research
consistently show that interventions that improve adherence address the beliefs,
behaviours and relationships surrounding adherence. This finding supports the
authors' hypothesis that traditional beliefs play an important role in the problem of
adherence. Further definitive study with Samoan New Zealanders is required.
62. Discontinuation and long-term adherence to beta interferon therapy in patients
with multiple sclerosis
(Discontinuación y adherencia a largo plazo en la terapia con interferón beta en pacientes
con esclerosis multiple)
37
CV Iturbe, JR Ara Callizo, R Huarte Lacunza, H Navarro Aznarez, N Serrano Mislata, MJ
Rabanaque Hernandez
Farmacia Hospitalaria Mar-Apr 2012;36(2):77-83
Objective: To determine discontinuation rate and degree of adherence to first-line
treatment with interferon-beta (INF-beta) in patients with multiple sclerosis (MS),
identifying causes and associated factors.
Material and Methods: A retrospective observational study that included patients with
MS treated with INF-beta during 2001. The patients were followed-up from the
beginning of treatment until the end of 2006. The data sources used were a
computer database compiled in the outpatients' area, medical records and
application protocols for beginning and monitoring treatment for MS. Patient
characteristics at baseline, treatment and continuity were included in the information
collected.
Results: The study included 131 patients. Mean follow-up was 7.4 +/- 2.6 years.
64.1% of the patients were treated with only one drug during the study. At 2 years
follow-up 9.9% of patients had discontinued INF-beta therapy and at 5 years 41.2%
had done so. Men, patients with relapsing-remitting MS and those treated with INFbeta1a i.m. continued treatment for a longer period, but this was statistically
significant only in patients with 10 years or less of disease progression at the
beginning of therapy. Main causes of discontinuation were lack of efficacy (38.8%)
and adverse effects (32.8%). Compliant patients presented lower discontinuation
rates (55.8% vs 75%).
Conclusions: Treatment of MS patients with IFN-beta is discontinued mainly due to
lack of efficacy and adverse effects. Greater understanding of patients' views can
help to identify those at greatest risk of poor adherence, thereby helping to improve
treatment.
63. Comparative persistence and adherence to overactive bladder medications in
patients with and without diabetes
S Johnston, SW Janning, GP Haas, KL Wilson, DM Smith, G Reckard, S-P Quan, S Bukofzer
International Journal of Clinical Practice Nov 2012;66(11):1042-1051
Aims: This retrospective administrative claims-based study evaluated comparative
persistence and adherence to overactive bladder (OAB) medications in US patients
with and without diabetes.
Methods: Patients aged 18 years or older who initiated OAB medications between 1
Jan 2005 and 30 Jun 2008 were analysed from the Truven Health MarketScan
Commercial and Medicare Supplemental databases. A 12-month baseline period
prior to OAB medication initiation was used to classify patients into diabetes and
non-diabetes cohorts, and measure demographic and clinical characteristics.
Patients in each cohort were directly matched 1 : 1 based on index year, age, gender
and geographical region. Multiple logistic regression was used to compare cohorts
on outcomes of 80% or higher adherence to OAB medications and refilling a second
OAB medication prescription. Cox's proportional hazards model compared time to
non-persistence with OAB medications between both cohorts.
Results: In total, 36,560 patients were included in each cohort. Compared with the
non-diabetes cohort, the diabetes cohort had 21.5% higher odds of 80% or above
adherence to OAB medications, 16.6% higher odds of filling a second OAB
medication prescription and 10.3% lower hazard of non-persistence with OAB
medications during a 12-month evaluation period.
Conclusions: Patients with diabetes were more persistent and adherent to OAB
medications and had higher odds of filling a second medication prescription than
38
patients without diabetes. Further research is needed to identify factors responsible
for these findings.
64. Medication adherence among recipients with chronic diseases enrolled in a
state Medicaid program
R Khanna, PF Pace, R Mahabaleshwarkar, R Sankar Basak, M Datar, BF Banahan
Population Health Management Oct 2012;15(5):253-260
Limited information is currently available about medication adherence for common
chronic conditions among the US Medicaid population.
The primary objective of this study was to assess medication adherence among
Medicaid recipients with depression, diabetes, epilepsy, hypercholesterolaemia and
hypertension. Factors influencing adherence were determined. The authors also
assessed whether adherence influences the utilisation of acute care services.
The target population included nonelderly adult recipients (aged 21-64 years) who
were continuously enrolled in the Mississippi (MS) Medicaid fee-for-service
programme from 1 Jan 2006 to 31 Dec 2007. Recipients were identified who had a
medical services claim with a diagnosis of depression, diabetes, epilepsy,
hypercholesterolaemia or hypertension in calendar year 2006. Within each chronic
disease sample, medication adherence was determined using calendar year 2007
data for recipients who met inclusion and exclusion criteria. Recipients with
adherence of 80% or above were classified as adherent. Logistic regression analyses
were used to determine the factors that predict medication adherence and the effect
of adherence on concurrent all-cause acute care service (i.e. hospitalisation,
emergency room visit) utilisation.
Approximately 24% of recipients with depression, 35.9% with diabetes, 53.6% with
epilepsy, 32% with hypercholesterolaemia and 42.2% with hypertension were
adherent. Within each chronic disease sample, males and whites had higher
adherence than females and blacks. After controlling for demographic and diseaserelated covariates, recipients who were adherent had lower concurrent acute care
service utilisation than nonadherent recipients.
Given the inverse relationship between adherence and acute care service utilisation,
policy makers should consider implementing educational interventions aimed at
improving adherence in this underprivileged population.
http://online.liebertpub.com/doi/abs/10.1089/pop.2011.0069
65. Adherence with antiosteoporosis medications: a primary-care study
B McGowan, K Bennett
Prescriber Jan 2012;23(1-2):34-37
Describes the results of a study of adherence (as medication possession ratio, MPR)
and persistence in all and new users of anti-osteoporosis therapies in general
practice in Ireland using the Health Service Executive Primary Care Reimbursement
Services (HSE-PCRS) national primary care prescribing database.
The findings suggest that a significant proportion of patients initiating antiosteoporosis therapy were non-persistent by 1, 2 and 3 years post-treatment.
Women were more likely to persist than men but men were slightly better adherers
to treatment.
http://onlinelibrary.wiley.com/doi/10.1002/psb.854/pdf
66. Adherence with intravenous zoledronate and intravenous ibandronate in the
United States Medicare population
R Matthews, KG Saag, E Delzell
39
Arthritis Care and Research Jul 2012;64(7):1054-1060
Objective: To evaluate adherence to drug therapy among new users of zoledronate
and intravenous (IV) ibandronate among US Medicare enrollees.
Methods: We used data from the Medicare 5% random sample to evaluate new users
of IV zoledronate and IV ibandronate with continuous Part A and Part B fee-forservice coverage. The outcome was adherence as quantified by the proportion of
days covered (PDC) measured continuously and dichotomously (80% or above).
Followup time extended from 18-27 months for all individuals. Factors associated
with low adherence to zoledronate were evaluated with logistic regression.
Results: We identified 775 new users of zoledronate and 846 new users of IV
ibandronate. For both drugs, 30-48% of the first infusions were given in an
outpatient infusion centre, not in a physician's office. The mean PDC for zoledronate
users was 82%, which was greater than the mean PDC for the IV ibandronate users
(58-62% depending on the time period; P less than 0.0001). Approximately 30% of
zoledronate users did not receive a second infusion. Factors associated with low
adherence to zoledronate included older age and receipt of the first infusion in an
outpatient infusion centre rather than a physician's office.
Conclusions: Less frequently dosed IV bisphosphonates have not resolved the
problem of suboptimal adherence with prescription osteoporosis medications.
Interventions continue to be warranted to improve long-term adherence to
osteoporosis treatments.
http://onlinelibrary.wiley.com/doi/10.1002/acr.21638/abstract
67. Immunosuppressant treatment adherence, barriers to adherence and quality of
life in renal and liver transplant recipients in Spain
JM Morales, E Varo, P Lazaro
Clinical Transplantation Mar-Apr 2012;26(2):369-376
To assess the adherence to immunosuppressant therapy (IST) and perceived barriers
affecting IST adherence and quality of life (QOL) in patients who had received a renal
(RT) or liver transplant (LT), a questionnaire was sent to more than 9000 RT and LT
recipients in Spain. Questionnaire comprised questions about the patient's sociodemographic, organ transplant and medication characteristics; IST adherence and
patient's perceived barriers to adherence; and patient's QOL using the EuroQol.
Data from 1983 RT patients and 1479 LT patients were analysed. Self-reported
adherence to IST in RT (92.6%) and LT (88.5%) recipients was high. Daily
medication intake (mean of 2-3 doses/day per patient) was considered a lifestyle
restriction in about 25% of transplant recipients and was the most common barrier
to adherence perceived by over 30% of RT and LT patients. Overall, high-intensity
treatment regimens were associated with poorer QOL (EuroQol below 70) compared
with low-intensity treatment regimens. Most RT (71.0%) and LT (61.4%) patients
would prefer to suppress the evening dose if they were able to. Although high
adherence rates to IST were reported in this first large Spanish survey in RT and LT
patients, adjustment of daily treatment intensity by less frequent dosing may be an
adequate strategy to minimise barriers to adherence and improve QOL.
68. Adherence to drugs that prevent cardiovascular disease: meta-analysis on
376,162 patients
SH Naderi, JP Bestwick, DS Wald
American Journal of Medicine Sep 2012;125(9):882-887.e1
Objective: Combination therapy, specifically with aspirin, cholesterol and blood
pressure-lowering drugs, substantially reduces the risk of coronary heart disease,
40
but the full preventive effect is only realised if treatment continues indefinitely. Our
objective was to provide a summary estimate of adherence to drugs that prevent
coronary heart disease, according to drug class and use in people who have had a
myocardial infarction (secondary prevention) and people who have not (primary
prevention).
Methods: A meta-analysis of data on 376,162 patients from 20 studies assessing
adherence using prescription refill frequency for the following 7 drug classes was
performed: aspirin, ACE inhibitors, angiotensin receptor blockers, beta-blockers,
calcium-channel blockers, thiazides and statins. Meta-regression was used to
examine the effects of age, payment and treatment duration.
Results: The summary estimate for adherence across all studies was 57% (95% CI,
50 to 64) after a median of 24 months. There were statistically significant
differences in adherence between primary and secondary prevention: 50% (95% CI,
45 to 56) and 66% (95% CI, 56 to 75), respectively (P = .012). Adherence was
lower for thiazides (42%) than for angiotensin receptor blockers (61%) in primary
prevention (P = 0.02). There were no other statistically significant differences
between any of the drug classes in primary or secondary prevention studies.
Adherence decreased by 0.15% points/month (P = 0.07) and was unrelated to age
or whether patients paid for their pills.
Conclusions: Adherence to preventive treatment is poor and little related to class of
drug, suggesting that side effects are not the main cause. General, rather than
class-specific, measures at improving adherence are needed.
See also editorial referring to this paper, p.841-842.
http://www.amjmed.com/article/S0002-9343(12)00018-6/abstract
69. Long-term use of antiplatelet drugs by stroke patients: a follow-up study based
on prescription register data
K Ostergaard, J Hallas, S Bak, R dePont Christensen, D Gaist
European Journal of Clinical Pharmacology Dec 2012;68(12):1631-1637
Purpose: Treatment with antiplatelet drugs is a key element of secondary stroke
prevention. We investigated long-term antiplatelet drug use in stroke patients with a
focus on non-persistence.
Methods: Population-based prescription register data were used to determine
antiplatelet drug use in a cohort of stroke patients discharged from a Danish
neurology department. The antiplatelet drugs comprised acetylsalicylic acid (ASA),
clopidogrel and dipyridamole (if combined with ASA use). Non-persistence was
defined as failure to present a prescription for antiplatelet drugs within 180 days
after the dosage of a previous prescription had run out, or within 180 days after
discharge. Cox regression was used to identify risk factors for non-persistence.
Results: The cohort comprised 503 patients with ischaemic stroke discharged in
1999-2001. During follow-up (median 2.8 years, interquartile range 0.8-7.8 years),
486 of the subjects presented prescriptions for antiplatelets. Most subjects used a
dual regimen of ASA and dipyridamole (N = 320). Of 110 non-persistent subjects in
this group, 64 stopped using ASA, but continued to use dipyridamole in
monotherapy. Overall, 181 patients (36%) were non-persistent. Stroke severity
was inversely associated with the risk of non-persistence [NIHSS score on admission
0-3 (reference); 4-6: hazard risk (HR) 0.87; 95% CI, 0.61 to 1.25; 7+: HR 0.47;
95% CI, 0.29 to 0.74).
Conclusions: Long-term non-persistence with antiplatelet treatment was high and
more pronounced in our patients with less severe stroke. Our findings on the use of
ASA and dipyridamole indicate that non-persistence may in part be amenable to
simple intervention measures.
41
70. Women's views on and adherence to low-molecular-weight heparin therapy
during pregnancy and the puerperium
JP Patel, V Auyeung, RK Patel, MS Marsh, B Green, R Arya, JG Davies
Journal of Thrombosis and Haemostasis Dec 2012;10(12):2526-2534
Background: Non-adherence to prescribed medication represents a significant factor
associated with treatment failure. Pregnant women identified at risk of venous
thromboembolism are increasingly being prescribed low-molecular-weight heparin
(LMWH) during pregnancy and the puerperium. It is important to understand
women's views on and adherence to LMWH during pregnancy and the puerperium, so
that women gain maximum benefit from the treatment.
Objectives: To monitor women's adherence to enoxaparin, when prescribed during
pregnancy and the puerperium, and explore their beliefs about the enoxaparin
therapy prescribed.
Patients/Methods: A prospective cohort study involving 95 nullparous and
multiparous women prescribed enoxaparin for recognised antenatal indications.
Adherence to enoxaparin was assessed through self-completion of a diary,
additionally verified through laboratory tests. An adapted beliefs about medication
questionnaire was administered to women during their pregnancy.
Results: Women were highly adherent to enoxaparin: antenatally, mean percentage
adherence 97.92%; postnatally, mean percentage adherence 93.37% (paired t-test,
P = 0.000). In the cohort of women we followed, their perceived necessity for
enoxaparin therapy outweighed any concerns they had regarding enoxaparin
antenatally, necessity-concerns differential 2.20. In some women, however, this
perceived necessity does decrease postnatally.
Conclusions: Our results suggest that most women prescribed enoxaparin are highly
adherent to their therapy during the antenatal period and that women's antenatal
beliefs about enoxaparin are able to predict a decrease in postnatal adherence. Our
results have important clinical implications, particularly when women are initiated on
LMWH just during the postnatal period.
http://onlinelibrary.wiley.com/doi/10.1111/jth.12020/abstract
71. Preschool children with high adherence to inhaled corticosteroids for asthma
do not show behavioural problems
W Quak, T Klok, AA Kaptein, EJ Duiverman, PLP Brand
Acta Paediatrica Nov 2012;101(11):1156-1160
Aim: To assess prevalence of behavioural problems in preschool children with
asthma with electronically verified exposure to inhaled corticosteroids (ICS).
Methods: Cross-sectional study of 81 children 2-5 years of age in the Netherlands
using daily ICS for persistent asthma. During 3 months’ follow-up, adherence to ICS
treatment was recorded by an electronical logging device (Smartinhaler (R)).
Parents completed the Child Behavior Checklist 1.5-5 years (CBCL 1.5-5) to assess
behavioural problems; results were compared to a published reference group of
healthy children.
Results: The median (interquartile range) adherence to ICS was 92 (78-97) %.
There was no difference in total CBCL score between children with asthma on ICS
(mean, (SD) 32.10 (1.99)) and the reference group (33.30 (1.87); 95% CI for
difference, -6.62 to 4.22). Children with asthma were more likely to have somatic
complaints (95% CI for difference, 0.64 to 1.96) and less likely to have
anxious/depressive symptoms (95% CI for difference, -1.57 to -0.25) than the
42
reference group. CBCL scores were not significantly related to the electronically
measured adherence rates.
Conclusions: Maintenance treatment with ICS, taken daily as prescribed, is not
associated with an increased risk of behavioural problems in preschool children.
72. Short and long term retention in antiretroviral care in health facilities in rural
Malawi and Zimbabwe
F Rasschaert, O Koole, R Zachariah, L Lynen, M Manzi, W Van Damme
BMC Health Services Research 5 Dec 2012;12:444
Background: Despite the successful scale-up of ART services over the past years,
long term retention in ART care remains a major challenge, especially in high HIV
prevalence and resource-limited settings. This study analysed the short-term (less
than 12 months) and long-term (more than 12 months) retention on ART in two ART
programmes in Malawi (Thyolo district) and Zimbabwe (Buhera district).
Methods: Retention rates at 6-month intervals are reported separately among (1)
patients since ART initiation and (2) patients who had been on ART for at least 12
months, according to the site of ART initiation and follow-up, using the Kaplan Meier
method. 'Retention' was defined as being alive on ART or transferred out, while
'attrition' was defined as dead, lost to follow-up or stopped ART.
Results: In Thyolo and Buhera, a total of 12,004 and 9721 patients respectively were
included in the analysis. The overall retention among the patients since ART
initiation was 84%, 80% and 77% in Thyolo and 88%, 84% and 82% in Buhera at 6,
12 and 18 months, respectively. In both programmes the largest drop in ART
retention was found during the initial 12 months on ART, mainly related to a high
mortality rate in the health centres in Thyolo and a high loss to follow-up rate in the
hospital in Buhera. Among the patients who had been on ART for at least 12
months, the retention rates levelled out, with 97%, 95% and 94% in both Thyolo
and Buhera, at 18, 24 and 30 months respectively. Loss to follow-up was identified
as the main contributor to attrition after 12 months on treatment in both
programmes.
Conclusions: To better understand the reasons of attrition and adapt the ART
delivery care models accordingly, it is advisable to analyse short- and long-term
retention separately, in order to adapt intervention strategies accordingly. During
the initial months on ART more medical follow-up, especially for symptomatic
patients, is required to reduce mortality. Once stable on ART, however, the ART care
delivery should focus on regular drug refill and adherence support to reduce loss to
follow up. Hence, innovative life-long retention strategies, including use of new
communication technologies, community based interventions and drug refill outside
the health facilities are required.
73. Adherence with bisphosphonate therapy in US veterans with rheumatoid
arthritis
JS Richards, GW Cannon, CL Hayden, RL Amdur, D Lazaro, TR Mikuls, AM Reimold, L
Caplan, DS Johnson, P Schwab, BN Cherascu, GS Kerr
Arthritis Care and Research Dec 2012;64(12):1864-1870
Objective: Pharmacy Benefits Management programme data for patients enrolled in
the Veterans Affairs Rheumatoid Arthritis (VARA) registry were linked with clinical
data to determine bisphosphonate adherence and persistence among US veterans
with rheumatoid arthritis (RA) and to determine factors associated with adherence.
43
Methods: The primary outcome measures were the duration of bisphosphonate
therapy and the medication possession ratio (MPR). Patients with an MPR of less
than 0.80 were classified as nonadherent. Potential covariates considered in the
analysis included patient demographics, RA disease activity and severity parameters,
and factors associated with osteoporosis risk. Associations of patient factors with
duration of therapy and adherence were examined using multivariable regression
modelling.
Results: Bisphosphonates were prescribed to 573 (41.5%) of 1382 VARA subjects.
The mean +/- SD duration of therapy for bisphosphonates was 39.2 +/- 31.4
months. A longer duration of therapy correlated with older age, more years of
education and dual x-ray absorptiometry testing. The mean +/- SD MPR of VARA
subjects for bisphosphonate therapy was 0.69 +/- 0.28; 302 (52.7%) were
nonadherent. In multivariate analyses, nonadherence with bisphosphonate therapy
was associated with a longer duration of RA disease (odds ratio (OR), 1.02; 95% CI,
1.00 to 1.04) and duration of bisphosphonate therapy longer than 32 months (OR
1.63; 95% CI, 1.04 to 2.57). Whites were less likely to have a low MPR compared
with nonwhites (OR 0.52; 95% CI, 0.30 to 0.88).
Conclusions: Nonadherence with bisphosphonates was common in this cohort of RA
patients and was associated with nonwhite ethnicity, a longer duration of RA disease,
and a greater duration of bisphosphonate therapy.
http://onlinelibrary.wiley.com/doi/10.1002/acr.21777/abstract
74. Persistence, adherence, and toxicity with oral CMF in older women with earlystage breast cancer (Adherence Companion Study 60104 for CALGB 49907)
KJ Ruddy, BN Pitcher, LE Archer, HJ Cohen, EP Winer, CA Hudis, HB Muss, AH Partridge
Annals of Oncology Dec 2012;23(12):3075-3081
Background: Cyclophosphamide-methotrexate-5-fluorouracil (CMF) is often selected
as adjuvant chemotherapy for older patients with early-stage breast cancer due to
perceived superior tolerability. We sought to measure persistence with CMF,
adherence to oral cyclophosphamide, and the association of these with toxic effects.
Patients and Methods: CALGB 49907 was a randomized trial comparing standard
chemotherapy (CMF or AC, provider/patient choice) with capecitabine in patients
aged 65 or older with stage I-IIIB breast cancer. Those randomised to standard
therapy and choosing CMF were prescribed oral cyclophosphamide 100 mg/m2 for 14
consecutive days in six 28-day cycles. Persistence was defined as being prescribed
six cycles of at least one of the three CMF drugs. Adherence was the number of
cyclophosphamide doses that women reported they had taken divided by the number
prescribed. Persistence and adherence were based on case report forms and
medication calendars.
Results: Of 317 randomised to standard chemotherapy, 133 received CMF. Median
age was 73 years (range 65-88). 71% submitted at least one medication calendar;
65% persisted with CMF. Non-persistence was associated with node negativity (P =
0.019), febrile neutropenia (P = 0.002) and fatigue (P = 0.044). Average adherence
was 97% during prescribed cycles.
Conclusions: Self-reported adherence to cyclophosphamide was high, but persistence
was lower, which may be attributable to toxic effects.
http://annonc.oxfordjournals.org/content/23/12/3075
75. Suboptimal adherence to treatment in multiple sclerosis
(Adherencia subóptima al tratamiento en la esclerosis multiple)
R Santolaya Perrin, M Fernandez-Pacheco Garcia Valdecasas, L Arteche Eguizabal, I Gema
Perez Perez, N Munoz Munoz, O Ibarra Barrueta, G Callejon Callejon
44
Farmacia Hospitalaria May-Jun 2012;36(3):124-129
Objective: To find out if patients with multiple sclerosis adhere to treatment with
beta interferons and glatiramer acetate, the percentage of withdrawal and its causes.
Methods: Observational, longitudinal, prospective, national, multicentre study which
selected multiple sclerosis patients who attended a hospital pharmacy department in
Spain to collect their medication. The main variable was the percentage adherence
during a year, measured as the ratio between the doses dispensed and those
prescribed. Treatment withdrawals and their causes were then measured.
Results: 543 patients from 39 pharmacy departments were included over a 6-month
period, The average time exposed to the drugs during the study period was 312
days and the average adherence in this period was 61.5% (95% CI, 59.4 to 63.5).
34 (6.26%) of the 543 study participants withdrew from treatment, which in most
cases was decided by the doctor.
Conclusions: Multiple sclerosis patients' treatment adherence over a period of 1 year
was lower than the ideal. The causes should therefore be analysed and corrective
measures established.
76. Primary nonadherence to medications in an integrated healthcare setting
J Shin, JS McCombs, RJ Sanchez, M Udall, MC Deminski, TC Cheetham
American Journal of Managed Care Aug 2012;18(8):426-434
Objectives: To measure rates of primary nonadherence (PNA) - when patients fail to
pick up a newly prescribed prescription from the pharmacy - for 10 therapeutic drug
groups and identify factors associated with PNA to chronic and acute medications.
Study Design: Retrospective cohort study.
Methods: New prescriptions written for study drugs in an integrated healthcare
system in southern California, USA, were identified between 1 Dec 2009 and 28 Feb
2010. PNA was defined as the failure to fill a prescription within 14 days of when it
was written. PNA rates were calculated by drug group and descriptive statistics were
performed. Multivariable logistic regression was used to identify significant patient,
provider, and prescription characteristics associated with PNA. Results were
stratified by acute versus chronic treatment.
Results: A total of 569,095 new prescriptions were written during the 3-month
period. Across all drug groups, the PNA rate was 9.8%. PNA rates for individual
drug groups varied and were highest for osteoporosis medications (22.4%) and
antihyperlipidaemics (22.3%). Patients who filled at least 1 prescription in the prior
year (odds ratio (OR); 95% CI) for acute = 0.06 (0.06 to 0.07), for chronic = 0.11
(0.10 to 0.12)) or had a prescription for a symptomatic disease (OR = 0.51; 95% CI,
0.48 to 0.53) were more likely to fill their prescription. Patients were more likely to
be primary nonadherent if they were black (OR acute = 1.30 (1.25 to 1.36), chronic
= 1.26 (1.18 to 1.33)) or treatment-naive to therapy (OR acute = 2.52 (2.36 to
2.7), chronic = 1.07 (1.03 to 1.120).
Conclusions: Overall PNA was 9.8% but individual PNA rates varied by therapeutic
drug group. Factors of PNA were mostly consistent across drug groups, but some
depended on whether the treatment was acute or chronic.
http://www.ajmc.com/publications/issue/2012/2012-8-vol18-n8/Primary-Nonadherence-toMedications-in-an-Integrated-Healthcare-Setting
77. High prevalence of medication non-adherence in a sample of communitydwelling older adults with Adult Protective Services-validated self-neglect
A Turner, A Hochschild, J Burnett, A Zulfiqar, CB Dyer
Drugs and Aging Sep 2012;29(9):741-749
45
Background: Medication non-adherence can exacerbate disease severity, leading to
impairments that interfere with self-care activities in older adults, and, ultimately,
death. Elder self-neglect is the most common report to Adult Protective Services
(APS) across the USA and is a significant risk factor for early mortality. These
individuals often suffer from multiple comorbid diseases that require careful
management, but for various reasons they are unwilling or unable to provide
themselves with the self-care resources necessary for maintaining health and safety.
No studies have assessed whether medication adherence is associated with elder
self-neglect.
Objective: The purpose of this study was to assess and describe medication
adherence in this population, as well as evaluate associations between medication
adherence and cognitive impairment, depression, physical function, and abilities to
perform basic and instrumental activities of daily living (BADLs and IADLs).
Methods: A cross-sectional study of 100 community-dwelling adults aged 65 years or
older with APS-substantiated elder self-neglect. In-home comprehensive geriatric
assessments (CGAs) were completed and included medication reviews. Information
on each medication, including the amount taken from the date dispensed, was
collected and used to determine adherence. The criteria for non-adherence were
taking less than 80 or more than 110% of at least one medication. The sample was
also split into groups of low adherence (29% or less), moderate adherence (29-86%)
and high adherence (86% or above). Scores on the CGA measures Mini-Mental
State Examination, Geriatric Depression Scale, Physical Performance Test (PPT) and
Kohlman Evaluation of Living Skills were assessed to determine whether cognitive
impairment, depression, physical function, and/or ability to perform BADLs and
IADLs were associated with non-adherence or low, moderate or high levels of
adherence.
Results: 25% of the sample was taking more than 7 medications daily. The average
rate of adherence was 59%. Only 8 participants (10%) were adherent to their entire
medication regimen, and thus, 90% were considered non-adherent to at least one
medication. The mean number of medications to which individuals were nonadherent was 3.4. The cognitive impairment, depression, physical function and
BADL/IADL measures were not statistically associated with medication nonadherence
using the cut points of less than 80% or above 110%. However, when split into
tertiles, the lowest medication adherence level (29% or below) was significantly
associated with a greater number of medications being consumed and lower
objective physical function levels as measured by the PPT.
Conclusions: Medication non-adherence is a very prevalent problem among older
adults who are self-neglecting, and higher non-adherence levels were associated
with the number of medications being consumed as well as lower physical function.
Physicians who find high rates of medication non-adherence in their patients should
consider barriers to adherence, including a large number of medications, lower
physical function and the possibility of elder self-neglect. Future efforts should focus
on studying the underlying reasons for medication non-adherence in larger samples
of older adults who are self-neglecting. This would facilitate the development of
interventions to reduce medication non-adherence in this population.
http://link.springer.com/article/10.1007/s40266-012-0007-2
78. A retrospective database analysis on persistence with inhaled corticosteroid
therapy: comparison of two dry powder inhalers during asthma treatment in
Germany
T Voshaar, K Kostev, J Rex, D Schroder-Bernhardi, J Maus, U Munzel
International Journal of Clinical Pharmacology and Therapeutics Apr 2012;50(4):257-264
46
Background: Asthma is one of the most common chronic diseases worldwide.
Patient persistence with treatment is essential to achieve sufficient outcomes, in
particular to avoid exacerbations.
Objective: To investigate inhaled corticosteroid (ICS) therapy with two different
inhalers (Novolizer® and Turbuhaler®) by comparing persistence, concomitant use
of additional asthma medication and occurrence of exacerbations in real life.
Study Design: A retrospective analysis of prescription data from outpatient treatment
was performed using the IMS Disease Analyzer. It provides longitudinal anonymised
patient data from approx 3000 office-based physicians in Germany. Treatment
persistence of asthma patients (ICD 10 code: J45) using 200 microg budesonide
either via Novopulmon®/Budecort® (Novolizer group = NOV) or Pulmicort®
(Turbuhaler group = TUR) was compared. Eligible patients had the first prescription
of ICS medication (index day) between Jun 2001 and Sep 2007 and a data history
available for at least 12 months before and after the index day.
Results: Analysis of 1780 NOV and 664 TUR patients revealed that 1 year after index
day, 89% NOV patients remained on their ICS compared to 85% TUR patients. NOV
patients changed significantly less often and later to another ICS (p = 0.0108; logrank test). Significantly fewer NOV patients switched temporarily or permanently to
another ICS during the observation time (NOV group: 14.7%; TUR group: 20.8%; p
= 0.0002, log-rank test). On average, NOV and TUR patients received comparable
prescriptions of short acting medication (NOV more SABA, TUR more formoterol).
There was a trend towards fewer prescriptions of systemic corticosteroids in NOV
patients.
Conclusions: These results suggest better therapy persistence with NOV compared
with TUR during asthma treatment in Germany. This can be a marker of better
compliance and may contribute to prevent exacerbations. However, the number of
exacerbations per patient year in the NOV group (0.12) compared to the TUR group
(0.18) was not statically significantly lower (p = 0.4096).
http://www.dustri.com/nc/journals-in-english/mag/int-journal-of-clinical-pharmacologyand-therapeutics/vol/volume-50/issue/april-33.html
79. Implementation of a simple age-based strategy in the prevention of
cardiovascular disease: the Polypill approach
DS Wald, NJ Wald
Journal of Evaluation in Clinical Practice Jun 2012;18(3):612-615
Background: A combination of medications that simultaneously reduce several
cardiovascular risk factors in people above a specified age, without selection based
on risk factor measurement, has been proposed as a simple strategy for reducing the
risk of cardiovascular disease and shown to be effective in randomised trials (the
Polypill approach).
Aims: To assess acceptance of the Polypill approach and adherence to preventive
treatment among individuals taking part in a cardiovascular disease prevention
service.
Methods: Daily treatment with simvastatin (40mg), amlodipine (2.5 mg),
bendroflumethiazide (1.25 mg), lisinopril (5 mg) (or candesartan (4 mg) if cough
was reported) and folic acid (0.8 mg) was offered, as separate components, to
people aged 55 years or older with no history of cardiovascular, renal or liver
disease. An audit of adverse effects, adherence and requests for blood pressure and
cholesterol measurement was determined by telephone consultation.
Results: Between 2006 and 2010, 269 participants started treatment with the Polypill
components. Follow-up ranged from 3 to 48 months (mean 20). A total of 222
participants (83%) adhered to treatment, including 30 (11%) who switched from the
47
ACE inhibitor (lisinopril) to the angiotensin receptor blocker (candesartan) because of
cough. Ten participants (4%) continued to take treatment but stopped taking one or
more drugs because of other symptoms, and 37 (14%) stopped all treatment, 8
because of adverse effects and 29 for non-medical reasons. No one requested a
blood pressure or cholesterol measurement.
Conclusion: This is the first demonstration of the application of the Polypill approach
in practice. The method was accepted and the Polypill components were well
tolerated, with good adherence and no demand for information about risk factors.
80. Medication use patterns and predictors of nonpersistence and nonadherence
with oral 5-aminosalicylic acid therapy
L Yen, J Wu, P Hodgkins, RD Cohen, MB Nichol
Journal of Managed Care Pharmacy Nov-Dec 2012;18(9):701-712
Background: 5-aminosalicylic acid (5-ASA) is the recommended first-line treatment
for active mild-to-moderate ulcerative colitis (UC) and for maintenance of UC
remission. However, persistence and adherence to prescribed 5-ASAs are often
suboptimal.
Objective: To evaluate 5-ASA medication use patterns and assess risk factors
associated with nonpersistence and nonadherence to oral 5-ASA medications in UC
patients.
Methods: IMS LifeLink Health Plan claims data (Jan 2007 to Jun 2011) were
analysed. We identified adult patients (18 years or older) with at least 1 diagnosis of
UC (ICD-9-CM code = 556.x (ulcerative colitis)) and at least 1 pharmacy claim for an
oral 5-ASA (balsalazide disodium, sulfasalazine, mesalamine delayed-release, and
Multi-Matrix System mesalamine) during the study period. Patients were required to
have continuous eligibility on both health and pharmacy plans for 6 months pre- and
12 months post-initial pharmacy claim (index date). Medication use patterns
(discontinuation, time to discontinuation (days), switch, and nonadherence) in the 12
months following the index date were evaluated. Nonpersistence or discontinuation
with the index medication was defined as a treatment gap of 60 days or longer.
Switch was identified as patients changing to another 5-ASA product after
discontinuing the index medication. Nonadherence to index medication was
determined by medication possession ratio (MPR) less than 0.8 for the index
medication. Nonadherence to any 5-ASA treatment was determined by a proportion
of days covered (PDC) less than 0.8 for any 5-ASA. A Cox model was used to assess
the relative hazards associated with discontinuation. Multiple logistic regression
models were used to assess risk factors associated with nonadherence to either the
index or any 5-ASA medications.
Results: A total of 5664 patients met selection criteria. The median time to
discontinuation of index drug differed significantly across index medications (range,
98.5 days (sulfasalazine) to 177.5 days (Multi-Matrix System mesalamine), P less
than 0.0001). Patients on Multi-Matrix System mesalamine were less likely to
discontinue (63.3% vs 68.6%, P = 0.001) and more likely to adhere to their
medication (MPR = 0.8 or higher; 23.1% vs 17.4%, P less than 0.0001) than
patients on other medications. Patients on mesalamine delayed-release (13.8%) or
Multi-Matrix System mesalamine (14.3%) had lower switch rates than the patients
on balsalazide (17.2%) or sulfasalazine (17.8%), P = 0.01. Significant predictors of
nonpersistence included index medication versus Multi-Matrix System mesalamine
(balsalazide disodium: HR = 1.21, 95% CI, 1.07 to 1.36; mesalamine delayedrelease: HR = 1.21; CI, 1.11 to 1.32; sulfasalazine: HR = 1.40; CI, 1.25 to 1.57),
48
female gender (HR = 1.16; CI, 1.09 to 1.23), never receiving specialist care
(HR = 1.14; CI, 1.07 to 1.21), preferred provider organisation (PPO) versus health
maintenance organisation (HR = 1.14; CI, 1.04 to 1.24) and Medicare fee for service
or self-insured health plan versus commercial plan (HR = 1.29; CI, 1.10 to 1.52).
Significant variables associated with nonadherence with 5-ASA treatment (PDC less
than 0.8) included not switching medication (OR = 1.90; CI, 1.58 to 2.29), age
younger than 65 (OR = 1.90; CI, 1.56 to 2.31), index medication as compared with
Multi-Matrix System mesalamine (balsalazide disodium: OR = 1.43; CI, 1.10 to 1.85;
mesalamine delayed-release: OR = 1.41; CI, 1.19 to 1.68; sulfasalazine: OR = 1.66;
CI, 1.30 to 2.12), female gender (OR = 1.33; CI, 1.17 to 1.52), residing in different
regions as compared with the Midwest region (the South (OR = 1.40; CI, 1.20 to
1.64) and Northeast (OR = 1.29; CI, 1.05 to 1.58)), no use of rectal forms during
the post-index period (OR = 1.28; CI, 1.08 to 1.50), no use of
immunosuppressive/biological agents during the post-index period (OR = 1.70; CI,
1.35 to 2.14), never receiving specialist care (OR = 1.25; CI, 1.08 to 1.44), and
Medicaid/Medicare versus commercial plan (OR = 1.48; CI, 1.03 to 2.13).
Conclusions: Patients on once-daily dosed Multi-Matrix System mesalamine had the
lowest risk of discontinuation and the highest adherence rate. Multiple factors were
associated with either nonpersistence or nonadherence, including multiple-daily
dosed index medication, younger age, female gender, residing in the South region,
PPO plan, noncommercial payer, not using immunosuppressive/biologic agents, not
using rectal 5-ASA and never receiving specialist care.
Sponsored by Shire Development LLC and some of the authors are Shire employees.
http://www.amcp.org/WorkArea/DownloadAsset.aspx?id=15874
81. Persistence and compliance of medications used in the treatment of
osteoporosis - analysis using a large scale, representative, longitudinal German
database
V Ziller, K Kostev, I Kyvernitakis, J Boeckhoff, P Hadji
International Journal of Clinical Pharmacology and Therapeutics May 2012;50(5):315-322
Objective: Osteoporosis can be effectively treated with a number of medications.
However, high persistence and compliance are required to assure efficacy. This
study analyses persistence and compliance with a variety of medical interventions
including p.o., i.v. and s.c. administrations in Germany.
Methods: This retrospective cohort study used a representative longitudinal database
(IMS LRx) comprising longitudinal prescription data for Germany from almost 80% of
all German prescriptions of members of the German statutory health insurance
system. Persistence is defined as the proportion of patients who remained on their
initially prescribed therapy at 1 year. Compliance is measured indirectly based on
the medication possession ratio (MPR).
Results: A total of more than 1 million patients (1,107,482) for the period 07/2007
to 06/2009 was identified in the database who received a prescription for a
bisphosphonate, strontium or PTH. Of these, 268,568 patients fulfilled further
inclusion criteria and were included in the persistence and compliance analysis. At
12 months the proportion of patients that remained on treatment were 65.6% for
zoledronate 5mg; 56.6% for ibandronate i.v. 3mg; 54.7% for PTH (teriparatide and
49
1-84 PTH), 51.0% for ibandronate 150mg p.o.; 44.8% for alendronate 70mg; 43.4%
for etidronate. Other values were risedronate plus calcium 42.3%; alendronate plus
vitamin D 37.8%; risedronate 35mg 35.2%; risedronate 5mg 30.6%; strontium
ranelate 31.4% and alendronate 10mg 17.3%.
Conclusions: Persistence and compliance during the treatment of osteoporosis were
found to be insufficient. Treatment using the intravenous route and PTH showed the
highest persistence and compliance rates and daily oral bisphosphonates the lowest.
More effort to improve treatment compliance and persistence is needed to assure
clinical efficacy.
http://www.dustri.com/nc/journals-in-english/mag/int-journal-of-clinical-pharmacologyand-therapeutics/vol/volume-50/issue/may-23.html
50
Factors Affecting Adherence
A very wide range of factors have been identified which (in
some cases at least) affect adherence to medication and may
act as barriers to adherence. These may be grouped as related
to medication (e.g. adverse effects, taste, complexity of
regimen), to inherent characteristics of the patient (e.g. age,
gender, ethnic group), to comorbidity (e.g. anxiety, dementia,
depression), to the patient’s attitudes and beliefs (e.g. about
illness and medication) and to the patient’s social environment
(e.g. social support from family and friends, relationship with
health professionals).
The various factors are unlikely to be independent, but their
inter-relationships are poorly understood.
Some of these factors may be potentially modifiable, for
example by patient education, and others could be used to
target generalised interventions at groups at high risk of nonadherence.
82. Beliefs about antipsychotic versus hypoglycemic medications among
individuals with serious mental illness and type 2 diabetes
JM Aakre, DR Medoff, LB Dixon, JA Kreyenbuhl
Patient Preference and Adherence 9 May 2012;6:389-394
Background: This study compared the beliefs held by individuals with coexisting
serious mental illness and type 2 diabetes regarding the necessity and risks of taking
antipsychotic versus hypoglycaemic medications. We also investigated whether
nonadherent patients differed from adherent patients in their beliefs about
medications.
Methods: 44 individuals with type 2 diabetes and serious mental illness who were
prescribed hypoglycaemic and antipsychotic medications completed a cross-sectional
assessment of medication beliefs and adherence for both medication types.
Results: Patients perceived a greater need for hypoglycaemic versus antipsychotic
medications; however, their beliefs were not associated with nonadherence to either
medication type.
Conclusions: These results suggest that individuals with coexisting serious mental
illness and type 2 diabetes have stronger convictions regarding the necessity of their
diabetes medication for maintaining their health.
83. Health system factors and antihypertensive adherence in a racially and
ethnically diverse cohort of new users
AS Adams, C Uratsu, W Dyer, D Magid, P O'Connor, A Beck, M Butler, PM Ho, JA Schmittdiel
Archives of Internal Medicine 2012;doi: 10.1001/2013.jamainternmed.955 (published early
online Dec 2012)
Background: The purpose of this study was to identify potential health system
solutions to suboptimal use of antihypertensive therapy in a diverse cohort of
patients initiating treatment.
Methods: Using a hypertension registry at Kaiser Permanente Northern California
(USA), we conducted a retrospective cohort study of 44,167 adults (aged 18 years or
51
older) with hypertension who were new users of antihypertensive therapy in 2008.
We used multivariate logistic regression analysis to model the relationships between
race/ethnicity, specific health system factors and early nonpersistence (failing to
refill the first prescription within 90 days) and nonadherence (fewer than 80% of
days covered during the 12 months following the start of treatment), respectively,
controlling for sociodemographic and clinical risk factors.
Results: More than 30% of patients were early nonpersistent and 1 in 5 were
nonadherent to therapy. Nonwhites were more likely to exhibit both types of
suboptimal medication-taking behaviour compared with whites. In logistic regression
models adjusted for sociodemographic, clinical, and health system factors, nonwhite
race was associated with early nonpersistence (black: odds ratio, 1.56; 95% CI, 1.43
to 1.70; Asian: 1.40; 95% CI, 1.29 to 1.51; Hispanic: 1.46; 95% CI, 1.35 to 1.57)
and nonadherence (black: 1.55; 95% CI, 1.37 to 1.77; Asian: 1.13; 95% CI, 1.00 to
1.28]; Hispanic: 1.46, 95% CI, 1.31 to 1.63). The likelihood of early nonpersistence
varied between Asians and Hispanics by choice of first-line therapy. In addition,
racial and ethnic differences in nonadherence were appreciably attenuated when
medication co-payment and mail-order pharmacy use were accounted for in the
models.
Conclusions: Racial/ethnic differences in medication-taking behaviour occur early in
the course of treatment. However, health system strategies designed to reduce
patient co-payments, ease access to medications, and optimise the choice of initial
therapy may be effective tools in narrowing persistent gaps in the use of these and
other clinically effective therapies.
84. A systematic review of patient self-reported barriers of adherence to
antihypertensive medications using the World Health Organization
Multidimensional Adherence Model
SA AlGhurair, CA Hughes, SH Simpson, LM Guirguis
Journal of Clinical Hypertension Dec 2012;14(12):877-886
Multiple barriers can influence adherence to antihypertensive medications. The aim
of this systematic review was to determine what adherence barriers were included in
each instrument and to describe the psychometric properties of the surveys
identified.
Barriers were characterised using the World Health Organization (WHO)
Multidimensional Adherence Model with patient, condition, therapy, socioeconomic
and health care system/team-related barriers. Five databases (Medline, Embase,
Health and Psychological Instruments, CINHAL and International Pharmaceutical
Abstracts (IPA)) were searched from 1980 to Sep 2011.
Our search identified 1712 citations; 74 articles met inclusion criteria and 51 unique
surveys were identified. The Morisky Medication Adherence Scale was the most
commonly used survey. Only 20 surveys (39%) have established reliability and
validity evidence. According to the WHO Adherence Model domains, patient-related
barriers were most commonly addressed, while condition, therapy and socioeconomic
barriers were under represented.
The complexity of adherence behaviour requires robust self-report measurements
and the inclusion of barriers relevant to each unique patient population and
intervention.
http://onlinelibrary.wiley.com/doi/10.1111/j.1751-7176.2012.00699.x/pdf
85. Adherence to antidiabetic drug treatment among workers with type 2 diabetes
MA Amiche, L Guenette, JP Gregoire, J Moisan
52
Journal of Population Therapeutics and Clinical Pharmacology May 2012;19(2):e115-e116
Paper presented at the Canadian Association for Population Therapeutics meeting, Montreal,
Quebec, Canada, 6-8 May 2012.
Background: Adherence to the antidiabetic drug (AD) treatment may lessen
deleterious effects of Type 2 diabetes on productivity at work.
Objectives: In workers initiating an oral AD treatment, 1) to assess the proportion of
individuals persistent with their treatment 1 year after its initiation, 2) among those
persisting, to assess the proportion of compliant individuals, 3) to identify the
determinants of persistence and 4) of compliance.
Methods: We performed a cohort study using the RAMQ (Quebec, Canada)
databases. We included adults insured by the public drug plan who had initiated an
oral AD between 1 Jan 2000 and 31 Dec 2008. Retired individuals and those on
welfare were excluded. Individuals who had a claim for any AD in the 45 days
preceding the anniversary or their first claim were deemed persistent. Of these,
those were considered compliant who had a supply of AD for at least 80% of the
days. Multivariate logistic regression models were used to identify characteristics
associated with both outcomes.
Results: Among the 41,006 study individuals, 81.1% were persistent, and 69.7% of
those who persisted were compliant. Older individuals, those living in a rural area,
with a higher number of pharmacy visits or who had past compliance with
cardioprotective treatments were more likely to be both persistent and compliant,
whereas those initially on a sulfonylurea or who had consulted a physician 14 times
or more in the year before initiating treatment were less likely to be persistent and
compliant.
Conclusions: Identified determinants could help tailoring interventions aimed at
optimising the use of OAD treatments.
http://www.jptcp.com/jptcp_capt2012_e113_e149-r185248
86. Who forgot? The challenges of family responsibility for adherence in vulnerable
pediatric populations
BJ Anderson
Pediatrics May 2012;129(5):e1324-e1325
Commentary referring to a paper by Buchanan et al. (Pediatrics May
2012;129(5):e1244-e1251)99 on barriers to medication adherence in HIV-infected
children and youth.
http://pediatrics.aappublications.org/content/129/5/e1324.extract
87. Adherence and dosing frequency of common medications for cardiovascular
patients
JP Bae, PP Dobesh, DG Klepser, JD Anderson, AJ Zagar, PL McCollam, ME Tomlin
American Journal of Managed Care Mar 2021;18(3):139-146
Objectives: To compare adherence between once-daily (QD) and twice-daily (BID)
dosing with chronic-use prescription medications used by patients with
cardiovascular disease.
Study Design: Retrospective cohort database analysis.
Methods: Analysis consisted of 1,077,474 patients older than 18 years with a
prescription index date from 1 Jan to 31 Dec 2007, for an antidiabetic,
antihyperlipidaemic, antiplatelet or cardiac agent with QD or BID dosing. Adherence
(medication possession ratio, MPR) was the number of days of medication supplied
between the first prescription fi ll date and the subsequent 365 days divided by 365
days. Overall mean MPR and comparisons between dosing frequency groups were
assessed with a generalised estimating equation. Covariates included age at index
53
date, gender, Charlson comorbidity index, therapeutic class, dosing frequency and
the interaction between therapeutic class and dosing frequency group.
Results: Overall, the adjusted mean MPR +/- standard error (SE) value for QD
agents was 13.6% greater than BID agents (0.66 +/- 0.0006 vs 0.57 +/- 0.0016; P
less than 0.01). The adjusted mean MPR values for QD agents were 2.9%, 17.5%
and 29.4% greater than BID agents in the antidiabetic, antihyperlipidaemic and
antiplatelet therapeutic classes, respectively. For cardiac agents, the adjusted mean
MPR value was similar between QD and BID agents. Carvedilol represented
approximately 80% of the cardiac agents in the BID group. The adjusted mean MPR
+/- SE for carvedilol phosphate QD was 0.73 +/- 0.0024 and 0.65 +/- 0.0027 for
carvedilol BID (11% difference; P less than 0.01).
Conclusions: In this large analysis, the QD dosing regimen was related to greater
adherence versus a BID regimen.
http://www.ajmc.com/publications/issue/2012/2012-3-vol18-n3/Adherence-and-DosingFrequency-of-Common-Medications-for-Cardiovascular-Patients
88. Prescribing for children - taste and palatability affect adherence to antibiotics:
a review
D Baguley, E Lim, A Bevan, A Pallet, SN Faust
Archives of Disease in Childhood Mar 2012;97(3):293-297
The taste of an antibiotic is often not taken into account by practitioners, although
there is significant evidence to show palatability correlates strongly with adherence.
Many parents will be familiar with the difficulties of convincing young children to take
bitter, unfamiliar medicine. Certain drugs, for example flucloxacillin, are so
unpalatable that they should not be prescribed as syrups without prior 'taste testing'
in an individual child, while others, such as oral cephalosporins, are accepted very
well although they are more expensive with a broader antimicrobial spectrum than
may be strictly necessary. Palatability is important in the broader context of global
child health as regards the successful treatment of malaria, HIV and dehydration.
The hidden cost of poor adherence resulting treatment failure, complications and the
development of drug resistance cannot be over-emphasised. Prescribing should
involve parents, children and practitioners in an open discussion around the most
suitable, palatable formulations for successful treatment outcomes.
http://adc.bmj.com/content/97/3/293.abstract
89. Effects of depression and anxiety improvement on adherence to medication
and health behaviors in recently hospitalized cardiac patients
LK Bauer, MA Caro, SR Beach, CA Mastromauro, E Lenihan, JL Januzzi, JC Huffman
American Journal of Cardiology 1 May 2012;109(9):1266-1271
Impaired adherence to medications and health behaviours may mediate the
connection between psychiatric symptoms and mortality in cardiac patients. This
study assessed the association between improvements in depression/anxiety and
self-reported adherence to health behaviours in depressed cardiac patients in the 6
months after cardiac hospitalisation. Data were analysed from depressed patients on
inpatient cardiac units who were hospitalised for acute coronary syndrome, heart
failure or arrhythmia and enrolled in a randomised trial of collaborative care
depression management (n = 134 in primary analysis). Measurements of depression
(Patient Health Questionnaire-9), anxiety (Hospital Anxiety and Depression Scale,
Anxiety subscale) and adherence to secondary prevention behaviours (Medical
Outcomes Study-Specific Adherence Scale items) were obtained at baseline, 6 weeks
12 weeks, and 6 months. The association between improvement in
depression/anxiety and adherence was assessed by linear regression after
54
accounting for the effects of multiple relevant covariates. At all time points
improvement in the Patient Health Questionnaire-9 was significantly and
independently associated with self-reported adherence to medications and secondary
prevention behaviours. In contrast, improvement in the Hospital Anxiety and
Depression Scale, Anxiety subscale was associated with improved adherence only at
6 weeks. In conclusion, in a cohort of depressed cardiac patients, improvement in
depression was consistently and independently associated with superior self-reported
adherence to medications and secondary prevention behaviours across a 6-month
span, whereas improvement in anxiety was not.
http://www.ajconline.org/article/S0002-9149(12)00054-9/abstract
90. Symptoms of depression and anxiety and adherence to antihypertensive
medication
LE Bautista, LM Vera-Cala, C Colombo, P Smith
American Journal of Hypertension Apr 2012;25(4):505-511
Background: Nonadherence to drug treatment is a major contributor to
antihypertensive treatment failure. Mood disorders could impair the patient's desire
and ability to follow physician's recommendations. We evaluated the role of
symptoms of depression and anxiety on adherence to antihypertensive drug
treatment.
Methods: We conducted a longitudinal cohort study in 20- to 70-year-old patients
starting antihypertensive drug treatment, without other chronic conditions, and not
taking mood-modifying drugs. Severity of symptoms of depression and anxiety were
evaluated at enrollment and 3, 6, 9 and 12 months of follow-up, using the Beck
depression inventory-II (BDI-II) and the psychological general well-being index
(PGWB), respectively. Treatment adherence was measured by pill count.
Nonadherence was defined as taking fewer than 80% of the prescribed number of
pills. Poisson regression was used to model the association of the exposures with
adherence.
Results: We enrolled 178 patients (58% male; mean age: 50 years; 508 follow-up
visits). The risk of nonadherence was 52.6% in 12 months (95% CI, 46.1 to 59.1).
After adjusting for other risk factors, individuals with at least mild depression (BDI-II
14 or above) and those with at least mild anxiety (PGWB anxiety score below 22)
were 2.48 (95% CI, 1.47 to 4.18) and 1.59 (95% CI, 0.99 to 2.56) times more likely
to become nonadherent in the following 3 months, respectively.
Conclusions: Patients with at least mild anxiety and depression symptoms are at
increased risk of becoming nonadherent to antihypertensive medication. Screening
for depression and anxiety symptoms could be used to identify high-risk patients.
Further evidence is needed to elucidate whether interventions targeting these
conditions improve adherence.
http://ajh.oxfordjournals.org/content/25/4/505.abstract
91. An ecological perspective on medication adherence
L Berben, F Dobbels, S Engberg, MN Hill, S De Geest
Adherence to a prescribed medication regimen is influenced not only by
characteristics of the individual patient, but also by factors within the patient's
environment, or so-called system level factors. Until now, however, health care
system factors have received relatively little attention in explaining medication
nonadherence. Ecological models might serve as a framework to help explain the
influence of health care system factors on patient behaviour (e.g. adherence). In an
ecological model, different levels of factors influence patients' behaviour, i.e. factors
55
at the patient-level, micro- (provider and social support), meso- (health care
organisation) and macro (health policy) -levels. In order to understand medication
adherence and implement interventions to improve medication adherence, factors at
these different levels should be taken into consideration. This paper describes an
ecological model comprising the most important factors at the patient-, micro-,
meso- and macro-levels.
92. Predicting persistent medication non-adherence
M Berger, J Cox, SG Imershein, RA Jackson
American Diabetes Association 72nd Scientific Sessions, Philadelphia, PA, 8-12 Jun 2012,
poster abstract 693-P
In a low-literacy diabetes education and outreach programme delivered in mostly
rural areas of the USA (n = 1705; 64% self-report diabetes at baseline), medications
were presented as an important tool, along with physical activity and nutrition, to
improve biomarkers. The programme was a collaboration between Joslin Diabetes
Center and Pennsylvania field Extension agents of the National Institute for Food and
Agriculture, a division of the US Department of Agriculture. Programmes were
delivered to small groups in non-medical settings, and included point-of-care testing
of biomarkers, emphasising positive outcomes that could be achieved by knowing
and understanding biomarker values. We identified 989 participants taking at least
one diabetes-related medication both at baseline and at 3-month follow-up. A
participant was 'adherent' if (s)he self-reported taking a prescription medication on
each of the previous 7 days, and 'non-adherent' otherwise. At baseline, 164 (17%)
participants were non-adherents, of whom 81 (49%) remained not adherent at
follow-up. People who remained non-adherent had consistently higher baseline
biomarker values (all p less than 0.05 except for LDL cholesterol).
In addition to their higher baseline biomarker values, persistent non-adherers were
more likely than participants who became adherent to be female (79% vs 67%),
have an income of US$ 25,000 per year or less (41% vs 31%) have less than a
college degree (91% vs 79%), be in poor/fair health (47% vs 39%) and agree with
the statements 'Sometimes I am careless about taking my medicines' (41% vs 29%)
and 'If I eat a little better or exercise a little more, I won’t need medicines (36% vs
26%).
http://www.reeis.usda.gov/web/crisprojectpages/0222094-diabetes-detection-andprevention-program.html
93. Challenges to physician-patient communication about medication use: a
window into the skeptical patient's world
T Bezreh, MB Laws, T Taubin, DE Rifkin, IB Wilson
Patient Preference and Adherence 30 Dec 2011;6:11-18
Patients frequently do not take medicines as prescribed and often do not
communicate with their physicians about their medication-taking behaviour. The
movement for 'patient-centred' care has led to relabelling of this problem from
'noncompliance' to 'nonadherence' and later to a rhetoric of 'concordance' and
'shared decision making' in which physicians and patients are viewed as partners
who ideally come to agreement about appropriate treatment. We conducted a
qualitative content analysis of online comments to a 'New York Times' article on low
rates of medication adherence. The online discussion provides data about how a
highly selected, educated sample of patients thinks about medication use and the
doctor-patient relationship. Our analysis revealed patient empowerment and selfreliance, considerable mistrust of medications and medical practice, and frequent
56
noncommunication about medication adherence issues. We discuss how these
observations can potentially be understood with reference to Habermas's theory of
communicative action, and conclude that physicians can benefit from better
understanding the negative ways in which some patients perceive physicians'
prescribing practices.
94. The feasibility of antibiotic dosing four times per day: a prospective
observational study in primary health care
T Bjerve Eide, VC Hippe, M Brekke
Scandinavian Journal of Primary Health Care Mar 2012;30(1):16-20
Objective: To investigate whether the increase in the number of doses of penicillin V
from 3 times daily to 4 times daily for common infections, as recommended in the
new Norwegian guidelines for antibiotic treatment in primary health care, would lead
to reduced patient compliance.
Design: Prospective observational study.
Setting and Subjects: Six general practitioners included all patients who were
prescribed systemic antibiotic treatment regardless of indication during a 10-month
period. A total of 270 patients provided data for the study.
Methods: Telephone interview focusing on omitted antibiotic doses.
Results: Some 17% of patients had poor compliance, defined as failing to take 5% or
more of total antibiotic doses. Neither level of poor compliance nor number of
omitted doses differed significantly when the number of daily doses increased from
three to four. There were significantly fewer omitted doses in the group given two
doses per day when compared with three doses (p = 0.04) and four doses per day (p
= 0.01).
Conclusions: We found no difference in compliance or omitted doses between
antibiotic regimens of 3 and 4 doses per day. The new Norwegian guidelines for
antibiotic treatment in primary health care appear feasible with regard to patient
compliance.
http://informahealthcare.com/doi/pdf/10.3109/02813432.2012.654196
95. Neurocognition, insight and medication nonadherence in schizophrenia: a
structural equation modeling approach
L Boyer, M Cermolacce, D Dassa, J Fernandez, M Boucekine, R Richieri, F Vaillant, R Dumas,
P Auquier, C Lancon
PLoS ONE 29 Oct 2012;7(10):e47655
Objective: The aim of this study was to examine the complex relationships among
neurocognition, insight and nonadherence in patients with schizophrenia.
Methods:
Design: Cross-sectional study. Inclusion criteria: Diagnosis of schizophrenia
according to the DSM-IV-TR criteria. Data collection: Neurocognition was assessed
using a global approach that addressed memory, attention and executive functions;
insight was analysed using the multidimensional 'Scale to assess Unawareness of
Mental Disorder'; and nonadherence was measured using the multidimensional
'Medication Adherence Rating Scale' (MARS). Analysis: Structural equation modeling
(SEM) was applied to examine the non-straightforward relationships among the
following latent variables: neurocognition, 'awareness of positive symptoms' and
'negative symptoms', 'awareness of mental disorder' and nonadherence.
Results: 169 patients attending a day hospital in France were enrolled. The final
testing model showed good fit, with normed chi2 = 1.67, RMSEA = 0.063, CFI =
0.94 and SRMR = 0.092. The SEM revealed significant associations between (1)
57
neurocognition and 'awareness of symptoms', (2) 'awareness of symptoms' and
'awareness of mental disorder' and (3) 'awareness of mental disorder' and
nonadherence, mainly in the 'attitude toward taking medication' dimension. In
contrast, there were no significant links between neurocognition and nonadherence,
neurocognition and 'awareness of mental disorder', and 'awareness of symptoms'
and nonadherence.
Conclusions: Our findings support the hypothesis that neurocognition influences
'awareness of symptoms', which must be integrated into a higher level of insight (i.e.
the 'awareness of mental disorder') to have an impact on nonadherence. These
findings have important implications for the development of effective strategies to
enhance medication adherence
http://www.plosone.org/article/info:doi/10.1371/journal.pone.0047655
96. Real-life treatment patterns, compliance, persistence, and medication costs in
patients with hypertension in Germany
L Breitscheidel, B Ehlken, K Kostev, MSA Oberdiek, A Sandberg, RE Schmieder
Journal of Medical Economics Feb 2012;15(1):155-165
Objective: This retrospective patient data analysis was initiated to describe current
treatment patterns of patients in Germany with arterial hypertension, with a special
focus on compliance, persistence and medication costs of fixed-dose and unfixed
combinations of angiotensin receptor blockers (ARBs), amlodipine (AML) and
hydrochlorothiazide (HCT) in Germany.
Methods: The study analyzed prescription data collected by general practitioners,
using the IMS Disease Analyzer database. The database was searched for patients
with the diagnosis hypertension (ICD-10 code I10) and treatment data in the period
Sep 2009 to Aug 2010. Compliance was measured indirectly based on the
medication possession ratio (MPR), and persistence was defined as the duration of
time from initiation to discontinuation of therapy. Medication costs were assessed
from the statutory health insurance perspective in Germany.
Results: In the IMS DA 406,888 observable patients in Germany were encoded with
the diagnosis I10 essential hypertension. In total, 88,716 patients received
prescriptions including ARBs, monotherapy (18.6%) or unfixed combinations with
other anti-hypertensives (19.3%). The compliance with fixed-dose combinations of
ARB with HCT, either dual or with one other anti-hypertensive drug, was significantly
better, compared to unfixed combinations (mean compliance 78.1% for fixed-dose
vs 71.5% for unfixed combinations of ARB with HCT, p less than 0.0001; mean
compliance 79.4% vs 72.0%, p less than 0.0001 if an additional anti-hypertensive
medication was added). Fixed-dose combinations of ARB with HCT, ARB with AML,
dual only or prescribed with another anti-hypertensive medication resulted in a
substantial increase of persistence, especially for patients on fixed-dose dual
combinations (225.7 vs 163.6 days for ARB with HCT; 232.9 vs 178.4 days for ARB
with AML, respectively). Fixed-dose combinations (varying from Euro 1.38 to Euro
2.20 per patient per day) were on average cheaper than unfixed combinations.
Limitations: Persistence and compliance could be under- or over-estimated because
their assessment was based on prescription information. For two-thirds of 69,060
patients, data on compliance and persistence were missing.
Conclusions: The study shows considerable variations in ARB treatment patterns
among patients, with the majority of patients treated with fixed-dose or semi-fixed
combination therapy. Fixed-dose combinations of ARBs with HCT and/or AML seem
to result in better compliance and persistence compared to unfixed regimens of these
drug classes, leading to reduction in all-cause hospitalisations, emphasising the
58
benefit and potential cost-savings of using fixed-dose regimens in a real-life general
practice setting in Germany.
The study was supported financially by Daiichi Sankyo Europe GmbH.
97. Characteristics of persons who complied with and failed to comply with annual
ivermectin treatment
WR Brieger, JC Okeibunor, AO Abiose, R Ndyomugyenyi, S Wanji, E Elhassan, UV Amazigo
Tropical Medicine and International Health Jul 2012;17(7):920-930
Objective: To assess individual compliance with annual ivermectin treatment in
onchocerciasis-endemic villages.
Methods: Multi-site study in eight APOC-sponsored projects in Cameroon, Nigeria
and Uganda to identify the socio-demographic correlates of compliance with
ivermectin treatment. A structured questionnaire was administered on 2305 persons
aged 10 years and above. Two categories of respondents were purposively selected
to obtain both high and low compliers: people who took ivermectin 6-8 times and 02 times previously. Simple descriptive statistics were employed in characterising the
respondents into high and low compliers, while some socio-demographic and key
perceptual factors were employed in regression models constructed to explain levels
of compliance among the respondents.
Results: Some demographic and perceptual factors associated with compliance were
identified. Compliance was more common among men (54.4%) (P less than 0.001).
Adults (54.6%) had greater rates of high compliance (P less than 0.001. The mean
age of high compliers (41.5 years) was significantly older (35.8 years) (t = 8.46, P
less than 0.001). Perception of onchocerciasis and effectiveness of ivermectin
influenced compliance. 81.4% of respondents saw benefits in annual ivermectin
treatment, high compliance among those who saw benefits was 59.3% compared to
13.3% of those who did not (P less than 0.001).
Conclusions: Efforts to increase compliance with ivermectin treatment should focus
on providing health education to youth and women. Health education should also
highlight the benefits of taking ivermectin.
98. Development of a conceptual model of adherence to oral anticoagulants to
reduce risk of stroke in patients with atrial fibrillation
TM Brown, K Siu, D Walker, M Pladevall-Vila, S Sander, M Mordin
Journal of Managed Care Pharmacy Jun 2012;18(5):351-362
Background: Oral anticoagulant (OA) medication is the recommended therapy for
reducing the risk of thromboembolic complications in patients with atrial fibrillation
(AF), and warfarin is the medication most frequently used. However, nonadherence
associated with OA medications may lead to considerable health risks. A conceptual
model of OA medication adherence in patients with AF could clarify factors affecting
adherence, thereby assisting in the development and structuring of adherencepromotion programmes. To our knowledge, such a model, driven by information
obtained directly from patients, has never been developed.
Objective: To develop a conceptual model of adherence to OA medication based on a
literature review and patient feedback via qualitative research among patients with
AF.
Methods: A literature search was conducted of English-language articles published
between the years 2005 and 2010 that related to factors affecting OA medication
adherence, excluding articles pertaining to AF associated with mechanical heart valve
replacement. To expand on the literature review findings, four focus groups totalling
59
38 participants aged 60 years or older, diagnosed with nonvalvular AF, and currently
taking any OA medication were conducted in 2011 in two cities on the east coast of
the USA. Participants completed the Modified Morisky Scale (MMS), with subscales
measuring motivation and knowledge, and were asked about daily processes and
behaviours related to taking OA medication. The identification of focus group themes
was based on the frequency of participant report and endorsement; themes were
spontaneously mentioned or supported by at least two people in each of at least
three focus groups. Model concepts, based on focus group themes and factors
identified in the literature review, were determined by the consensus of three
authors.
Results: 181 publications were identified; 30 were selected for full-text review. The
focus group participants had a mean age of 69.9 years. Most participants reported a
diagnosis of hypertension (86.8%, n = 33), high cholesterol (50.0%, n = 19), heart
disease or chronic heart failure (31.6%, n = 12) or diabetes (28.9%, n = 11). Most
(89.5%, n = 34) were taking warfarin. About one-half (52.6%, n = 20) had been
taking an OA medication for less than 5 years. On the MMS, 78.9% of participants
reported high levels of motivation, and 100% reported high levels of knowledge.
Four concepts emerged from the focus groups and were supported by the literature
for inclusion in the model: (a) knowledge base of the disease and continued
reinforcement (i.e. health care professional reinforcement); (b) short-term and longterm motivation (e.g. avoidance of negative health consequences); (c) personalised
system, habit formation and system adaptation (e.g. developing a routine or external
reminders); and (d) self-efficacy loop (i.e. the personalised system and its
adaptability are reinforced as patients become more consistent, confident and
adherent). The literature review also suggested other factors that may also affect
patient adherence (e.g. demographic, psychosocial, cognitive).
Conclusions: Adherence in patients with AF is complex and involves multiple factors,
some specific to each individual and others more general. This model identifies an
adherence process that can guide opportunities for effective interventions, such as
educational and behavioural programmes targeted at these processes, to improve
patient adherence to OA medication.
99. Barriers to medication adherence in HIV-infected children and youth based on
self- and caregiver report
AL Buchanan, G Montepiedra, PA Sirois, B Kammerer, PA Garvie, DS Storm, SL Nichols
Objective: Nonadherence to antiretroviral therapy among children/youth with HIV
often is associated with disease progression. This study examined the agreement
between child and caregiver perceptions of barriers to adherence and factors
associated with these barriers.
Methods: Children/youth with perinatally acquired HIV and their parents/caregivers
(n = 120 dyads) completed a questionnaire about 19 potential barriers to adherence
to the child's antiretroviral therapy regimen. Agreement between the two reports
was measured via the kappa statistic. Factors associated with the barriers were
assessed by using multiple logistic regression.
Results: Of the 120 children, 55% were African-American, 54% were boys, and the
average age was 12.8 years. The most frequently reported barrier by either the
caregiver or youth was 'forgot'. There were varying degrees of agreement between
child and caregiver on the following barriers: 'forgot', 'taste', 'child was away from
home', 'child refused' and 'child felt good'. Children who knew their HIV status were
more likely to report logistical barriers, such as scheduling issues. Children with a
60
biological parent as their caregiver were more likely to report regimen or fear of
disclosure as a barrier.
Conclusions: Lack of agreement was observed for more than half of the studied
barriers, indicating discrepancies between children's and caregivers' perceptions of
factors that influence medication-taking. The findings suggest a need for
interventions that involve both child and caregiver in the tasks of remembering when
to administer the child's medications, sustaining adherence and appropriately
transitioning medication responsibility to the youth.
http://pediatrics.aappublications.org/content/129/5/e1244.abstract
100. Adherence to lipid-lowering treatment: the patient perspective
M Casula, E Tragni, AL Catapano
Patient Preference and Adherence Nov 2012;6:805-814
Despite the widespread prescription of highly effective lipid-lowering medications,
such as the HMG-CoA reductase inhibitors (statins), a large portion of the population
has lipid levels higher than the recommended goals. Treatment failures have been
attributed to a variety of causes but the most important is likely to be poor
adherence to therapy in the form of irregular or interrupted intake and the high
frequency of discontinuation or lack of persistence. Adherence is a multidimensional
phenomenon determined by the interplay of patient factors, physician factors and
health care system factors. Patients' knowledge and beliefs about their illness,
motivation to manage it, confidence in their ability to engage in illness-management
behaviours, and expectations regarding the outcome of treatment and the
consequences of poor adherence interact to influence adherence behaviour. Patientrelated factors account for the largest incremental explanatory power in predicting
adherence. This article provides an overview of this critical issue, focusing on patient
role in determining adherence level to lipid-lowering therapy.
101. Predictors of antiretroviral medication adherence among a diverse cohort of
adolescents with HIV
S Chandwani, LJ Koenig, AM Sill, S Abramowitz, LC Conner, L D'Angelo
Journal of Adolescent Health Sep 2012;51(3):242-251
Purpose: To compare prevalence and describe predictors of antiretroviral treatment
adherence among adolescents with HIV acquired perinatally (PIY) or through risk
behaviours (BIY).
Methods: Data were obtained from the baseline assessment of Adolescent Impact,
an intervention for HIV-infected adolescents receiving care in three US cities.
Patients self-reported missed medication doses as well as medication factors, HIV
knowledge, disclosure, substance use, mental health and social support through
face-to-face or computer-assisted interviews.
Results: Of 104 participants, 68 (65.4%) reported full adherence. Compared with
BIY, PIY were younger, had greater HIV disease severity and had more structural
supports. Adjusting for transmission mode (PIY vs BIY), nonadherence by self-report
was associated with higher viral load (VL) (adjusted odds ratio (AOR) = 1.5, CI, 1.03
to 2.18). Nonadherent adolescents were significantly likely to have had AIDS,
discussed HIV disease with providers, reported difficulty with medication routine,
experienced internalising behaviour problems and used drugs. In multivariate
analyses, independent predictors of nonadherence included acquiring HIV
behaviourally (AOR = 4.378; CI, 1.055 to 18.165), ever having AIDS (AOR = 4.78;
CI, 1.31 to 17.49), perceiving difficult medication routine (AOR = 1.84; CI, 1.07 to
3.16), discussing disease indicators with provider (AOR = 4.57; CI, 1.74 to 11.98)
61
and missing doses because of forgetting (AOR = 2.53; CI, 1.29 to 4.96). Adjusting
for transmission mode, detectable VL was associated with lower recent CD4+
lymphocyte counts, discussing disease indicators with providers and missing doses
because of forgetting or being depressed. Low recent CD4+ lymphocyte counts
(AOR = 0.988; p = 0.024) but fewer HIV symptoms (AOR = 0.466, p = 0.032) and
missing doses because of forgetting (AOR = 1.76, p = 0.05) were independently
associated with detectable VL in multivariate analysis.
Conclusions: Despite differences between groups, nonadherence was associated with
severity of illness, difficult medication routine and forgetfulness. Beyond individual
needs, both groups of adolescents had suboptimal adherence and would benefit from
simplified medication routines and organisational skills.
http://www.sciencedirect.com/science/article/pii/S1054139X11006768
102. Improved antiretroviral refill adherence in HIV-focused community
pharmacies
JM Cocohoba, P Murphy, G Pietrandoni, BJ Guglielmo
Journal of the American Pharmacists Association Sep-Oct 2012;52(5):e67-e73
Objective: To determine differences in patient characteristics, antiretroviral therapy
(ART) regimen characteristics and regimen refill adherence for human
immunodeficiency virus (HIV)-focused pharmacy (HIV-P) versus traditional
pharmacy (TP) users.
Design: Retrospective cohort study.
Setting: California, USA, Walgreens pharmacies from May 2007 to Aug 2009.
Participants: HIV-positive patients with more than 30 days of antiretroviral
prescription claims.
Intervention: Deidentified prescription records for patients filling any ART
prescription at any California Walgreens pharmacy during the study period were
assessed.
Main Outcome Measures: ART regimen refill adherence (calculated by modified
medication possession ratio (mMPR)) and dichotomous measure of optimal
adherence of 95% or greater.
Results: 4254 HIV-P and 11,679 TP users were included. Compared with TP users,
HIV-P users travelled farther to pharmacies (5.03 vs 1.26 miles, P less than 0.01). A
greater proportion of HIV-P users filled prescriptions for chronic diseases (35% vs
30%) and received fixed-dose combination antiretroviral tablets (92% vs 83%) (all P
less than 0.01). Median mMPR was higher for HIV-P users (90% vs 77%, P less than
0.0001). After adjusting for age, gender, insurance, medication use and distance
from pharmacy, use of HIV-P (odds ratio 1.90; 95% CI, 1.72 to 2.08) and fixed-dose
combination antiretroviral tablets (3.34; 2.84 to 3.96) were most strongly associated
with having 95% or greater ART regimen refill adherence.
Conclusions: For HIV-positive patients struggling with antiretroviral adherence,
clinicians may consider minimising pill burden with combination tablets and referral
to an HIV-focused pharmacy.
http://japha.org/article.aspx?articleid=1363590
103. Predictors of medication adherence postdischarge: the impact of patient age,
insurance status, and prior adherence
MJ Cohen, S Shaykevich, C Cawthon, S Kripalani, MK Paasche-Orlow, JL Schnipper
Journal of Hospital Medicine Jul-Aug 2012;7(6):470-475
Background: Optimising post-discharge medication adherence is a target for avoiding
adverse events. Nevertheless, few studies have focused on predictors of
postdischarge medication adherence.
62
Methods: The Pharmacist Intervention for Low Literacy in Cardiovascular Disease
(PILL-CVD) study used counselling and follow-up to improve post-discharge
medication safety. In this secondary data analysis, we analysed predictors of selfreported medication adherence after discharge. Based on an interview at 30 days
post-discharge, an adherence score was calculated as the mean adherence in the
previous week of all regularly scheduled medications. Multivariable linear regression
was used to determine the independent predictors of post-discharge adherence.
Results: The mean age of the 646 patients included was 61.2 years, and they were
prescribed an average of 8 daily medications. The mean post-discharge adherence
score was 95% (standard deviation (SD) = 10.2%). For every 10-year increase in
age, there was a 1% absolute increase in post-discharge adherence (95% CI, 0.4%
to 2.0%). Compared to patients with private insurance, patients with Medicaid were
4.5% less adherent (95% CI, -7.6% to -1.4%). For every 1-point increase in
baseline medication adherence score, as measured by the 4-item Morisky score,
there was a 1.6% absolute increase in post-discharge medication adherence (95%
CI, 0.8% to 2.4%). Surprisingly, health literacy was not an independent predictor of
post-discharge adherence.
Conclusions: In patients hospitalised for cardiovascular disease, predictors of lower
medication adherence post-discharge included younger age, Medicaid insurance and
baseline nonadherence. These factors can help predict patients who may benefit
from further interventions.
http://onlinelibrary.wiley.com/doi/10.1002/jhm.1940/abstract
104. Dosing frequency and medication adherence in chronic disease
CI Coleman, B Limone, DM Sobieraj, S Lee, MS Roberts, R Kaur, T Alam
Journal of Managed Care Pharmacy Sep 2012;18(7):527-539
Background: Prior research has shown a decrease in medication adherence as dosing
frequency increases; however, meta-analyses have not been able to demonstrate a
significant inverse relationship between dosing frequency and adherence when
comparing twice-daily versus once-daily dosing.
Objective: To determine the effect of scheduled dosing frequency on medication
adherence in patients with chronic diseases.
Methods: A systematic literature search of Medline and Embase from Jan 1986 to
Dec 2011 and a hand search of references were performed to identify eligible
studies. Randomised and observational studies were included if they utilised a
prospective design, assessed adult patients with chronic diseases, evaluated
scheduled oral medications taken 1 to 4 times daily, and measured medication
adherence for at least 1 month using an electronic monitoring device. Manual
searches of reference sections of identified studies and systematic reviews were also
performed to find other potentially relevant articles. Standard definitions for
medication taking, regimen and timing adherence were used and evaluated. Studies
were pooled using a multivariate linear mixed-model method to conduct metaregression accounting for both random and fixed effects, weighted by the inverse
of the variance of medication adherence.
Results: 51 studies, comprising 65, 76 and 47 dosing frequency arms for the taking,
regimen and timing adherence endpoints were included. Unadjusted adherence
estimates were highest when the least stringent definition, taking adherence, was
used (range for dosing frequencies: 80.1%-93.0%) and lowest when the most
stringent definition, timing adherence, was used (range for dosing frequencies:
18.8%-76.9%). In multivariate meta-regression analyses, the adjusted weighted
mean percentage adherence rates for all regimens dosed more frequently than once
per day were significantly lower compared with once-daily regimens (for 2-times, 3-
63
times and 4-times daily regimens, respectively: differences for taking adherence: 6.7%, -13.5% and -19.2%; regimen adherence: -13.1%, -24.9% and -23.1%; and
timing adherence: -26.7%, -39.0% and -54.2%).
Conclusions: Patients with chronic diseases appear to be more adherent with oncedaily compared with more frequently scheduled medication regimens. The use of
more stringent definitions of adherence magnified these findings.
105. Antidiabetic therapy in real practice: indicators for adherence and treatment
cost
GL Colombo, E Rossi, M De Rosa, D Benedetto, AV Gaddi
Patient Preference and Adherence 14 Sep 2012;6:653-661
Background: Type 2 diabetes has become a disease with a high economic and social
impact. The ARNO Observatory is a clinical data warehouse consisting of a network
of local health care units (ASL) scattered throughout the Italian territory which
collects data on health care consumption for about 10.5 million people. The purpose
of this study was to evaluate the use of antidiabetic drugs with particular reference
to type of treatment. The analyses were carried out on a sample of 169,375 patients
treated with oral blood glucose-lowering drugs in 2008 from a total population of
4,040,624 health care beneficiaries at 12 local health care units in the ARNO
Observatory.
Methods: Patients were considered 'on treatment with oral blood glucose-lowering
drugs' if they had received at least one prescription of an antidiabetic drug
(Anatomical Therapeutic Chemical code A10B) during 2008. The patients were
divided into three treatment groups, i.e. monotherapy, fixed-combination drugs and
dual therapy. The following indicators were assessed: number of patients treated
with an oral antidiabetic drug, mean number of hospitalisations, mean number of
specialist examinations, and mean expenditure per treated patient. Adherence was
assessed using the medication possession ratio indicator (MPR).
Results: Patients treated with oral blood glucose-lowering drugs comprised 4.2% of
the investigated population, and had an average age of 68.9 years. The mean
annual number of hospitalisations was lower in the dual therapy group (298 vs 328
per 1000 patients in the sample), while the average number of specialist
examinations was lower in the fixed-combination group (30.1 vs 35.1). Patients on
monotherapy showed a better percentage of adherence for glimepiride (70.5%) and
pioglitazone (70.4%), whereas the best adherence in the fixed-combination therapy
group was recorded for metformin plus pioglitazone (75.5%). The average annual
cost per diabetic patient was Euro 2388, with differences between the monotherapy
(Euro 2321), fixed-combination (Euro 2270) and dual therapy (Euro 2465) groups.
Fixed combination therapy involved a lower mean expenditure for insulin, other
drugs, and specialist and diagnostic care. Thiazolidinediones (such as pioglitazone)
showed the lowest average annual cost per patient among the monotherapies, with a
marked decrease in costs for hospitalisation, specialist care and diagnostics.
Conclusions: The results of our study should be extended to other regional/national
reference local health care units in order to define and compare average standard
costs per pathology throughout the wide sample considered in this research work.
Appropriate drug prescribing is of critical importance in order to achieve therapeutic
objectives and to optimise the use of resources in modern health care systems.
106. Duration and compliance with antidepressant treatment in immigrant and
native-born populations in Spain: a four year follow-up descriptive study
64
I Cruz, C Serna, M Rue, J Real, J Soler-Gonzalez, L Galvan
BMC Public Health 2 Apr 2012;12:256
Background: Non-compliance with antidepressant treatment continues to be a
complex problem in mental health care. In immigrant populations non-compliance is
one of several barriers to adequate management of mental illness; some data
suggest greater difficulties in adhering to pharmacological treatment in these groups
and an increased risk of therapeutic failure. The aim of this study is to assess
differences in the duration and compliance with antidepressant treatment among
immigrants and natives in a Spanish health region.
Methods: Population-based (n = 206,603), retrospective cohort study including all
subjects prescribed ADT between 2007 and 2009 and recorded in the national
pharmacy claims database. Compliance was considered adequate when the duration
was longer than 4 months and when patients withdrew more than 80% of the packs
required.
Results: 5334 subjects (8.5% of them being immigrants) initiated ADT. Half of the
immigrants abandoned treatment during the second month (median for natives = 3
months). Of the immigrants who continued, only 29.5% presented good compliance
(compared with 38.8% in natives). The estimated risk of abandoning/ending
treatment in the immigrant group compared with the native group, adjusted for age
and sex, was 1.28 (95% CI, 1.16 to 1.42).
Conclusions: In the region under study, immigrants of all origins present higher
percentages of early discontinuation of ADT and lower median treatment durations
than the native population. Although this is a complex, multifactor situation, the
finding of differences between natives and immigrants in the same region suggests
the need to investigate the causes in greater depth and to introduce new strategies
and interventions in this population group.
107. Systematic review on factors associated with medication non-adherence in
Parkinson's disease
DJ Daley, PK Myint, RJ Gray, KH O'Leary Deane
Parkinsonism and Related Disorders Dec 2012;18(10):1053-1061
Background: Medication non-adherence is prevalent in Parkinson's disease (PD) and
results in substantial motor dysfunction. Although various approaches have been
suggested to address non-adherence in PD, good quality evidence of associated
factors is limited.
Objective: To review systematically the literature on clinical and demographic factors
associated with medication non-adherence in PD.
Methods: We searched 5 online databases in Apr 2011 (updated in Jan 2012):
MEDLINE, EMBASE, AMED, PsycINFO and CINAHL for studies reporting data on
factors associated with medication non-adherence in people with idiopathic PD.
Bibliographies were hand searched to acquire records not identified electronically.
Two reviewers independently assessed identified articles for potential inclusion. Data
extraction was undertaken using a standardised data extraction form.
Methodological quality was assessed against a specially designed quality indicator
tool emphasising the detection of threats to internal validity.
Results: We identified 1880 records of which 6 met inclusion criteria. A total of 772
PD patients were included (mean age 62 years, males 61%). We identified 11
factors (6 clinical and 5 demographic) associated with non-adherence. We ranked
each factor in order by weight of overall evidence: mood disorders, cognition, poor
symptom control/QoL, younger age/longer disease duration, regimen
65
complexity/polypharmacy, risk taking behaviours, poor knowledge of PD/education,
lack of spouse/partner, low income, maintaining employment and gender.
Conclusions: Clinicians should be aware of factors associated with medication nonadherence in PD. Targeted interventions should be developed and investigated to
establish whether addressing factors associated with non-adherence in PD leads to
greater medication adherence.
http://www.prd-journal.com/article/S1353-8020(12)00345-8/abstract
108. Demographic, socioeconomic, and psychological factors related to medication
non-adherence among emergency department patients
DP Davis, MD Jandrisevits, S Iles, TR Weber, LC Gallo
Journal of Emergency Medicine Nov 2012;43(5):773-785
Background: Many Emergency Department (ED) visits are related to medication nonadherence; however, the contributing factors are poorly understood.
Objectives: To explore the relative contributions of demographic, socioeconomic and
psychological factors to medication non-adherence in an ED population in the USA.
Methods: This was a cross-sectional analysis enrolling patients with one of three
illnesses requiring chronic medication usage (hypertension, diabetes or seizures).
Trained research associates administered a 60-item survey that assessed
demographic and socioeconomic information, as well as a variety of psychological
factors potentially relevant to adherence (health attitudes, health beliefs, depression,
anxiety, social support and locus of control). Patients rated their overall prescription
medication adherence and estimated the number of days in the preceding month on
which doses were missed. In addition, treating physicians estimated the degree to
which the ED visit was related to medication non-adherence; clinical data were
abstracted to help validate patient and physician assessments. The relationships
between non-adherence and demographic, socioeconomic, and psychological
variables were explored using multivariate statistics and logistic regression.
Covariance analysis was performed to validate subscales, and receiver-operator
curves were used to define optimal threshold values.
Results: A total of 472 patients consented to participate, with good representation
for various demographic and socioeconomic groups. Each psychological factor
related significantly to both patient and physician ratings of non-adherence (p less
than 0.05). Of all demographic and socioeconomic factors examined, only current or
historical drug use predicted non-adherence.
Conclusions: Psychological factors seem to be important determinants of medication
non-adherence among ED patients. These data may help define future research
directions and interventions.
109. Influence of socioeconomic factors on the adherence of alendronate
treatment in incident users in Norway
HM Devold, K Furu, S Skurtveit, A Tverdal, JA Falch, AJ Sogaard
Pharmacoepidemiology and Drug Safety Mar 2012;21(3):297-304
Purpose: To examine whether socioeconomic factors influence adherence to
alendronate drug treatment among incident users in Norway during 2005 to 2009.
Methods: The study included 7610 incident alendronate users in 2005 (40-79 years),
followed until 31 Dec 2009. Mean age was 66.6 years, and 86.7% of the patients
were women. Data were drawn from the Norwegian Prescription Database and
linked to marital status, education and income. Adherence was measured by the
medication possession ratio (MPR). MPR was defined as the number of dispensed
defined daily doses divided by the number of days each patient was included in the
66
study. A patient was adherent if MPR = 80% or higher. ORs with 95% CI were
estimated using logistic regression.
Results: Among all patients, 45.5% were adherent throughout 4.2 years. A slightly
higher proportion of women than men were adherent. Adjusted for all covariates,
women aged 70-79 years had an OR of 1.27 (95% CI, 1.10 to 1.45) for adherence
compared with those 40-59 years. In women, high household income predicted
adherence of alendronate use. In men, a middle educational level compared with a
low level, predicted adherence (adjusted OR = 1.47; 95% CI, 1.10 to 1.96). After
adjustments, previous marriage reduced the odds of being adherent compared with
present marriage, in both men and women.
Conclusions: In women, the most important factors for being adherent were older
age and high income. In men, a middle educational level predicted adherence.
Previous marriage reduced the odds of being adherent in both women and men.
http://onlinelibrary.wiley.com/doi/10.1002/pds.2344/abstract
110. A literature review to explore the link between treatment satisfaction and
adherence, compliance, and persistence
C Dias Barbosa, M-M Balp, K Kulich, N Germain, D Rofail
Patient Preference and Adherence 13 Jan 2012;6:39-48
Purpose: To explore the published evidence on the link between treatment
satisfaction and patients' compliance, adherence and/or persistence.
Methods: Articles published from Jan 2005 to Nov 2010 assessing compliance,
adherence, or persistence and treatment satisfaction were identified through
literature searches in Medline, Embase and PsycInfo. Abstracts were reviewed by
two independent researchers who selected articles for inclusion. The main attributes
of each study examining the link between satisfaction and adherence, compliance or
persistence were summarised.
Results: The database searches yielded 1278 references. Of the 281 abstracts that
met the inclusion criteria, 20 articles were retained. In the articles, adherence and
compliance were often used interchangeably and various methods were used to
measure these concepts. All showed a positive association between treatment
satisfaction and adherence, compliance or persistence. 16 studies demonstrated a
statistically significant link between satisfaction and compliance or persistence. Of
these, 10 demonstrated a significant link between satisfaction and compliance, two
showed a significant link between satisfaction and persistence and 8 demonstrated a
link between either a related aspect or a component of satisfaction (e.g. treatment
convenience) or adherence (e.g. intention to persist). An equal number of studies
aimed at explaining compliance or persistence according to treatment satisfaction (n
= 8) and treatment satisfaction explained by compliance or persistence (n = 8).
Four studies only reported correlation coefficients, with no hypothesis about the
direction of the link. The methods used to evaluate the link were varied: two studies
reported the link using descriptive statistics, such as percentages, and 18 used
statistical tests, such as Spearman's correlation or logistic regressions.
Conclusions: This review identified few studies that evaluate the statistical
association between satisfaction and adherence, compliance or persistence. The
available data suggested that greater treatment satisfaction was associated with
better compliance and improved persistence, and with lower regimen complexity or
treatment burden.
111. Trust, medication adherence, and hypertension control in Southern African
American men
67
K Elder, Z Ramamonjiarivelo, J Wiltshire, C Piper, WS Horn, KL Gilbert, S Hullett, J Allison
American Journal of Public Health Dec 2012;102(12):2242-2245
The authors examined the relationship between trust in the medical system,
medication adherence, and hypertension control in Southern African-American men.
The sample included 235 African-American men aged 18 years and older with
hypertension. African-American men with higher general trust in the medical system
were more likely to report better medication adherence (odds ratio (OR), 1.06) and
those with higher self-efficacy were more likely to report better medication
adherence and hypertension control (OR, 1.08 and OR, 1.06, respectively).
http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2012.300777
112. Identifying patient-specific beliefs and behaviours for conversations about
adherence in asthma
JM Foster, L Smith, SZ Bosnic-Anticevich, T Usherwood, SM Sawyer, CS Rand, HK Reddel
Internal Medicine Journal Jun 2012;42(6):e136-e144
Background: Asthma guidelines advise addressing adherence at every visit, but no
simple tools exist to assist clinicians in identifying key adherence-related beliefs or
behaviours for individual patients.
Aims: To identify potentially modifiable beliefs and behaviours that predict
electronically recorded adherence with controller therapy.
Methods: Patients aged 14 years or older with doctor-diagnosed asthma who were
prescribed inhaled corticosteroid/long-acting beta2-agonist (ICS/LABA) completed
questionnaires on medication beliefs/behaviours, side-effects, Morisky adherence
behaviour score and Asthma Control Test (ACT), and recorded spirometry.
Adherence with ICS/LABA was measured electronically over 8 weeks. Predictors of
adherence were identified by univariate and multivariate analyses.
Results: 99/100 patients completed the study (57 female; forced expiratory volume
in 1s mean +/- standard deviation 83 +/- 23% predicted; ACT 19.9 +/- 3.8). Mean
electronically recorded adherence (n= 85) was 75% +/- 25 and mean self-reported
adherence was 85% +/- 26%. Factor analysis of questionnaire items significantly
associated with poor adherence identified seven themes: perceived necessity, safety
concerns, acceptance of asthma chronicity/medication effectiveness, advice from
friends/family, motivation/routine, ease of use and satisfaction with asthma
management. Morisky score was moderately associated with actual adherence (r = 0.45, P less than 0.0001). In regression analysis, 10 items independently predicted
adherence (adjusted R2= 0.67; P less than 0.001). Opinions of friends/family about
the patient's medication use were strongly associated with poor adherence. Global
concerns about ICS/LABA therapy were more predictive of poor adherence than were
specific side-effects; the one-third of patients who reported experiencing side-effects
from their steroid inhaler had lower adherence than others (mean 62% vs 81%; P =
0.015).
Conclusions: This study identified several specific beliefs and behaviours which
clinicians could use for initiating patient-centred conversations about medication
adherence in asthma.
113. Association between depressive and anxiety disorders and adherence to
antihypertensive medication in community-living elderly adults
L Gentil, HM Vasiliadis, M Preville, C Bosse, D Berbi
Journal of the American Geriatrics Society Dec 2012;60(12):2297-2301
Objectives: To identify the determinants of antihypertensive medication adherence in
community-living elderly adults.
68
Design: Longitudinal observational study.
Setting: Population-based health survey in the province of Quebec, Canada.
Participants: Data from a representative sample (N = 2811) of community-dwelling
adults in Quebec aged 65 and older participating in the Etude sur la Sante des Aînes
study. The final study sample analysed consisted of 926 participants taking
antihypertensive drugs during the 2 years of the study.
Measurements: Adherence to antihypertensive medication was measured using days
of supply obtained during a specified time period. Depression and anxiety disorders
were assessed using Diagnostic and Statistical Manual of Mental Disorders, 4th
Edition, criteria, and physical health status was measured using the Charlson
Comorbidity Index. Other factors considered were age, education, marital status,
annual family income and number of antihypertensive drugs that participants used.
Results: Mean antihypertensive proportion (percentage) of days supplied in was
92.5% in Year 1 and 59.4% in Year 2. The presence of depression and anxiety
disorders and the number of antihypertensive medications significantly predicted
medication adherence. The sex by depression and anxiety disorders interaction term
was significant.
Conclusions: Adherence to antihypertensive medication was significantly associated
with depression and anxiety disorders in men but not women. The treatment of
depression and anxiety disorders in individuals with hypertension may be helpful in
improving medication adherence rates and healthcare outcomes.
114. Comparative adherence to oxybutynin or tolterodine among older patients
T Gomes, DN Juurlink, MM Mamdani
European Journal of Clinical Pharmacology Jan 2012;68(1):97-99
Purpose: To compare persistence of oxybutynin or tolterodine therapy among older
patients newly prescribed one of these drugs.
Methods: We conducted a retrospective cohort study of residents of Ontario, Canada,
aged 66 years and older who were newly prescribed either drug between 1 Jan 2000
and 31 Dec 2007. Persistence with treatment was defined on the basis of refills for
the drug within a grace period equal to 50% of the prescription duration.
Results: We identified 31,996 patients newly treated with oxybutynin and 24,855
newly treated with tolterodine. After 2 years of follow-up, persistence on oxybutynin
(9.4%) was significantly lower than that on tolterodine (13.6%, p less than 0.0001).
The median time to discontinuation of oxybutynin and tolterodine was 68 and 128
days, respectively.
Conclusions: The authors conclude that their findings suggest that the tolerability of
these drugs differs substantially.
115. Predictors of antihypertensive medication adherence in two urban health-care
systems
L Grigoryan, VN Pavlik, DJ Hyman
American Journal of Hypertension Jul 2012;25(7):735-738
Background: Most studies on patient-related predictors of adherence used selfreported measures or pharmacy databases to measure adherence. We identified
predictors of antihypertensive medication adherence measured by Medication Event
Monitoring System (MEMS), the gold standard for adherence assessment, in
uncontrolled, predominantly African-American (AA) hypertensives from large urban
public and private primary care clinics in the USA.
69
Methods: As part of the baseline data collection of a cluster-randomised trial for
hypertension control, we measured adherence in a random sample of 124
participants using MEMS caps. We also included the data of 52 patients in
intervention clinics who subsequently completed MEMS monitoring on referral from
their provider. Participants were classified as adherent if they took 80% or more of
all prescribed doses. Multivariate logistic regression was used to predict adherence.
Results: Of 176 patients monitored, 61 (34.6%) took fewer than 80% of prescribed
doses. AA ethnicity (odds ratio (OR) AA vs Hispanic = 0.36; 95% CI, 0.15 to 0.86),
female sex (OR = 0.38; 95% CI, 0.15 to 0.91) and public clinics as source of care
(OR public clinics vs private clinics = 0.45; 95% CI, 0.20 to 0.97) were
independently associated with lower adherence. Higher adherence was seen in
patients monitored by clinician order in the intervention clinics (OR intervention
sample vs random baseline sample = 2.15; 95% CI, 0.96 to 4.81) and diabetic
patients (OR = 2.05; 95% CI, 1.01 to 4.15). All analyses were adjusted for
education, employment status and other potentially confounding factors.
Conclusions: African-American ethnicity, female gender and attending a publicly
funded primary care clinic were associated with lower adherence. Whether targeting
these groups for special interventions would improve overall adherence needs further
study.
116. Relationship of adherence determinants and parental spirituality in cystic
fibrosis
DH Grossoehme, L Opipari-Arrigan, Rhonda VanDyke, S Thurmond, M Seid
Pediatric Pulmonology Jun 2012;47(6):558-566
The course of cystic fibrosis (CF) progression in children is affected by parent
adherence to treatment plans. The Theory of Reasoned Action (TRA) posits that
intentions are the best behavioural predictors and that intentions reasonably follow
from beliefs ('determinants'). Determinants are affected by multiple 'background
factors', including spirituality. The purpose of this study was to understand whether
two parental adherence determinants (attitude towards treatment and self-efficacy)
were associated with spirituality (religious coping and sanctification of the body). We
hypothesised that parents' attitudes toward treatment adherence are associated with
these spiritual constructs. A convenience sample of parents of children with CF aged
3 to 12 years (n = 28) participated by completing surveys of adherence and
spirituality during a regular outpatient clinic visit. Type and degree of religious
coping was examined using principal component analysis. Adherence measures were
compared based on religious coping styles and sanctification of the body using
unpaired t-tests. Collaborative religious coping was associated with higher selfefficacy for completing airway clearance (M = 1070.8; SD = 35.8; P = 0.012), for
completing aerosolised medication administration (M = 1077.1; SD = 37.4; P = 0.018)
and for attitude towards treatment utility (M = 38.8; SD = 2.36; P = 0.038). Parents
who attributed sacred qualities to their child's body (e.g. 'blessed' or 'miraculous')
had higher mean scores for self-efficacy (airway clearance, M = 1058.6; SD = 37.7;
P = 0.023; aerosols M = 1070.8; SD = 41.6; P = 0.020). Parents for whom God was
manifested in their child's body (e.g. 'My child's body is created in God's image') had
higher mean scores for self-efficacy for airway clearance (M = 1056.4; SD = 59.0;
P = 0.039), aerosolised medications (M = 1068.8; SD = 42.6; P = 0.033) and treatment
70
utility (M = 38.8; SD = 2.4; P = 0.025). Spiritual constructs show promising
significance and are currently undervalued in chronic disease management.
http://onlinelibrary.wiley.com/doi/10.1002/ppul.21614/abstract
117. Influence of package inserts on adherence to medication in primary care
patients
(Der Einfluss des Beipackzettels auf die medikamentöse Adhärenz bei hausärztlichen
Patienten)
D Grober-Gratz, U-M Waldmann, W Knaus, M Gulich, H-P Zeitler
Deutsche Medizinische Wochenschrift Jul 2012;137(27):1395-1400
Background: German legislation requires a package insert (PI) to be attached to any
prescribed drug to inform patients about its use, indications, dosage and possible
side effects. This PI is often blamed for deliberate deviations from the patient's
prescribed medication regimen. It is unknown to what extent patients take the
opportunity to inform themselves from the PI and what are the potential
consequences for medication adherence.
Methods: In semi-structured interviews patients were asked about their use of
package inserts, their opinion about PI and potential consequences of PI. Patients
with newly prescribed drugs were included in the study. Data analysis was carried
according to the qualitative content analysis of Mayring.
Results: 71 interviews were analysed. PIs are used in very different ways and
extents. PIs are predominantly associated with negative connotations. Reading the
PI seems to have hardly any immediate impact on medication adherence. Patients
stated that they feel confident in the pharmaceutical industry and in particular they
rely on the expertise of their general practitioner.
Conclusions: These results indicate that the use of PIs may have less impact than is
often assumed. In these patients, reading the package insert hardly affected
medication adherence.
https://www.thieme-connect.com/ejournals/abstract/10.1055/s-0032-1305084
118. Impact of out-of-pocket expenses on discontinuation of statin therapy: a
cohort study in Finland
A Helin-Salmivaara, MJ Korhonen, T Alanen, R Huupponen
Journal of Clinical Pharmacy and Therapeutics Feb 2012;37(1):58-64
Objective: Out-of-pocket expenses of drug therapy may negatively affect adherence.
We aimed to analyse 1-year discontinuation rates between cohorts initiating therapy
with either generic simvastatin or non-generic atorvastatin.
Methods: Statin-naive initiators of atorvastatin and generic simvastatin in Apr-Jun
2003, and corresponding cohorts in 2005, were identified through the nationwide
Finnish prescription register. Persistence with statin therapy was followed for 365
days, considering the treatment to have been discontinued when the tablet-free gap
between two consecutive refills exceeded 90 days. Using multivariate-adjusted
logistic regression, odds ratios (OR) for discontinuation associated with initiating with
simvastatin vs atorvastatin were estimated separately for each year.
Results and Discussion: In the year 2003, 5838 persons initiated treatment with
atorvastatin and 5644 with generic simvastatin. In the year 2005, the respective
numbers were 5228 and 10 987. Soon after the introduction of generic substitution
in 2003, there was no difference in the risk of discontinuation between the
comparator groups (OR 0.97; 95% CI, 0.89 to 1.05). Two years later, persons
initiating with generic simvastatin were 20% less likely to discontinue statin therapy
(OR 0·80; 95% CI, 0.74 to 0.83). Among persons whose medicinal costs were
71
almost completely reimbursed towards the end of the initiation year, the OR was
1.14 (95% CI, 0.76 to 1.64; P = 0.033 for interaction).
Conclusions: We found that lower out-of-pocket expenses associated with the
initiating statin had a positive impact on persistence with therapy. The finding does
not seem to apply to persons with minor copayments towards the end of the
initiation year.
119. Adherence and medication management by the elderly
MA Henriques, MA Costa, J Cabrita
Journal of Clinical Nursing Nov 2012;21(21-22):3096-3105
Aims and Objectives: The purpose of this study was to explore the strategies used
for medication management by elderly who live at home.
Background: Non-adherence to chronic medication is a common problem among the
elderly with chronic conditions. Many studies have been developed, but have not
progressed solving this multidisciplinary health care problem. The causes of nonadherence by the elderly are multiple and complex.
Design: Descriptive, qualitative study.
Methods: Data were collected by two focus groups in Portugal. The content of
discussion was analysed from verbatim transcripts and by identifying categories and
sub-categories which emerged, leading to the construction of a diagram analysis.
Results: The finding indicated the strategies and the interpretation of people aged 65
or more and with chronic illness, managing their medication. Four content
categories emerged: living with drugs, taking medication, belief about drugs and
relationship with health professionals.
Conclusions: The study enabled us to identify and understand, by giving a 'voice' to
the elderly, that living with drugs is a dynamic and complex process and that taking
medication is perceived by older people as a consequence of their ageing, which
requires them to include that process in their lives as a habit implying changes in
their daily routines. The elderly suggest that the relationship with health
professionals is essential in medication management and they reported that the
information given by nurses during consultations is very important.
Relevance to Clinical Practice: The relationship with nurses in particular is an
important issue for older people. Understanding the factors of adherence and
helping people are important areas of research in nursing. The quality of this
relationship may be the key to increasing adherence in this group of people.
120. Influences on blood pressure medication adherence in diabetic patients
AR Herron, CS Barnes, CW Tsui, JM Caudle, DC Ziemer
Empowered patients are essential to effective diabetes self-management and
adherence. Recommended blood pressure target levels are more stringent for
people with diabetes and medication adherence is vital to maintaining control. In
order to understand factors that influence patient adherence to prescribed blood
pressure (BP) medication, researchers administered questionnaires to 343 type 2
diabetes patients with initially uncontrolled hypertension, recruited for the
Empowerment for Vascular Action (EVA) study in the Grady Primary Care Center, an
urban, public safety net outpatient clinic in Atlanta, GA, USA. Subjects answered
questions from the medication adherence self-efficacy scale (MASE). The MASE is a
72
scale that is used to identify situations in which patients could have low adherence to
their BP medication.
The population was mostly African-American (92%), female (66%), with mean age
56 and diabetes duration of 11 years; 29% had not completed high school. Initial
mean systolic BP was 141mm Hg. EVA intervention included feedback, coaching,
goal setting and problem-solving sessions. After 6-months subjects completed
follow-up questionnaires to yield a 6-month medication adherence score. Multivariable regression analysis showed education (p = 0.041) and baseline adherence
scores (p less than 0.001) as the strongest predictors of subsequent adherence.
Negative trends for empowerment intervention (p = 0.055) and for the number of BP
medications prescribed (p = 0.075) were seen. We speculate that intervention
sessions established trusting relationships that encouraged patient reporting of nonadherence.
Achieving BP goals is vital to preventing complications among persons with diabetes.
Empowering patients to follow medication and lifestyle regimens is key to achieving
those goals. Coaching sessions that promote more focused and goal oriented
patient-provider communication allow better communication of adherence to allow
providers to focus efforts on finding patient-friendly medication regimens.
http://www.abstractsonline.com/Plan/ViewAbstract.aspx?sKey=465c09cc-e66a-403c-a6190f648526bd73&cKey=d08bd740-3240-41fa-bdfd-946c192367d9&mKey=%7b0F70410F8DF3-49F5-A63D-3165359F5371%7d
121. Differences in asthma controller medication adherence by age and gender
LJ Hinyard, C Geremakis, J Temprano
Journal of Allergy and Clinical Immunology Feb 2012;129(2-Suppl.):AB66
Presented at the American Academy of Allergy, Asthma and Immunology annual meeting,
Orlando, Florida, USA, 2-6 Mar 2012.
Rationale: Adherence to asthma controller medication is thought to improve clinical
outcomes; however, literature examining the relationship between age and gender
and adherence is limited. This study investigated the relationship between controller
medication adherence and age and gender in an administrative claims database.
Methods: Asthmatics were identified from MarketScan medical claims from Jan 2006
to Dec 2008. Medication Possession Ratios (MPR) were calculated for controller
medications: mast cell-stabilising agents (MCSA), inhaled corticosteroids (ICS), longacting beta-agonists (LABA), ICS-LABA combinations (ICS-LABA), leukotriene
modifiers (LM), chronic oral steroids (COS) (continuous use 3 months or longer),
monoclonal antibodies (MA) and theophylline. Adherence was classified as low,
medium and high based on MPR tertile for each medication category. Age was
categorized as 18-34, 35-49, and 50-65. Linear associations between age and
adherence were calculated using the Mantel-Haenszel chi-squared test, and chisquared tests were conducted for gender and adherence categories.
Results: The study included 53,532 men and 92,418 women. Average MPR ranged
from 0.20 (women, MCSA) through 0.76 (men and women, COS). There was a
significant (p less than 0.0001) positive linear association between age and
adherence for all drug categories, except for COS. Men were more adherent with
MCSA (p = 0.014), ICS (p less than 0.0001), LABA (p less than 0.0001) and ICSLABA (p less than 0.0001). Women demonstrated better adherence with LM (p less
than 0.0001).
Conclusions: Overall, compliance with controller therapy was poor in this study.
Older and male asthmatics are more likely to be adherent to most controller
medications. Further studies examining barriers to adherence, particularly for
women and young adults, are needed.
73
http://www.jacionline.org/article/S0091-6749(11)02704-7/fulltext
122. Life events, coping, and antihypertensive medication adherence among older
adults: the Cohort Study of Medication Adherence among Older Adults
EW Holt, P Muntner, C Joyce, DE Morisky, LS Webber, M Krousel-Wood
American Journal of Epidemiology 1 Oct 2012;176(Suppl.7):S64-S71
The authors examined the association between life events and antihypertensive
medication adherence in older adults and the moderating role of coping. A crosssectional analysis was conducted by using data (n = 1817) from the Cohort Study of
Medication Adherence among Older Adults (recruitment conducted from Aug 2006 to
Sep 2007). Life events occurring in the 12 months preceding the study interview
were assessed via the Holmes Rahe Social Readjustment Rating Scale (SRRS), and
coping levels were assessed via an adapted version of the John Henry Active Coping
Scale. Low adherence to antihypertensive medication was defined as scores less
than 6 on the 8-item Morisky Medication Adherence Scale (known as 'MMAS-8'). Of
study participants, 13.2% had low adherence, and 27.2% and 5.0% had medium
(150-299) and high (300 or above) SRRS scores, respectively. After multivariable
adjustment, the odds ratios for low adherence associated with medium and high,
versus low, SRRS were 1.50 (95% CI, 1.11 to 2.02) and 2.11 (95% CI, 1.24 to
3.58), respectively. When multivariable models were stratified by coping level, the
association between life events and adherence was evident only among participants
with low coping levels.
http://aje.oxfordjournals.org/content/176/suppl_7/S64.abstract
123. Predictors of adherence to inhaled medications among veterans with COPD
JC Huetsch, JE Uman, EM Udris, DH Au
Journal of General Internal Medicine Nov 2012;27(11):1506-1512
Background: Factors contributing to medication nonadherence among patients with
chronic obstructive pulmonary disease (COPD) are poorly understood.
Objectives: To identify patient characteristics that are predictive of adherence to
inhaled medications for COPD and, for patients on multiple inhalers, to assess
whether adherence to one medication class was associated with adherence to other
medication classes.
Design: Cohort study using data from US Veteran Affairs (VA) electronic databases.
Participants: This study included 2730 patients who underwent pulmonary function
testing between 2003 and 2007 at VA facilities in the Northwestern United States,
and who met criteria for COPD.
Main Measures: We used pharmacy records to estimate adherence to inhaled
corticosteroids (ICS), ipratropium bromide (IP) and long-acting beta-agonists (LABA)
over two consecutive 6-month periods. We defined patients as adherent if they had
refilled medications to have 80% of drug available over the time period. We also
collected information on their demographics, behavioural habits, COPD severity and
comorbidities.
Key Results: Adherence to medications was poor, with 19.8% adherent to ICS,
30.6% adherent to LABA and 25.6% adherent to IP. Predictors of adherence to
inhaled therapies were highly variable and dependent on the medication being
examined. In adjusted analysis, being adherent to a medication at baseline was the
strongest predictor of future adherence to that same medication (ICS: OR, 4.79;
95% CI, 3.22 to 7.12; LABA: OR, 6.60; 95% CI, 3.92 to 11.11; IP: OR, 14.13; 95%
CI, 10.00 to 19.97), but did not reliably predict adherence to other classes of
medication.
74
Conclusions: Among patients with COPD, past adherence to one class of inhaled
medication strongly predicted future adherence to the same class of medication, but
only weakly predicted adherence to other classes of medication.
124. Comparison of statin adherence among beneficiaries in MA-PD plans versus
PDPs
K Jung, AM McBean, J-A Kim
Journal of Managed Care Pharmacy Mar 2012;18(2):106-115
Background: US Medicare Part D, which provides prescription drug coverage to
Medicare beneficiaries, is delivered through either Medicare Advantage prescription
drug (MA-PD) plans or stand-alone prescription drug plans (PDPs). MA-PD plans
cover both drug therapy and other medical services, whereas PDPs provide
prescription drug coverage only. Because of the potential substitutability between
prescription drugs and other medical services, MA-PD plans may make greater
efforts to improve enrollees' adherence to recommended medications than PDPs.
Prescription drug benefits are more generous in MA-PD plans than in PDPs.
Objective: To assess statin adherence, comparing Medicare beneficiaries in MA-PD
plans with those in PDPs.
Methods: We used records from the Chronic Condition Warehouse 2007 Prescription
Drug Event (PDE) file, associated Plan Characteristics files and the Beneficiary
Summary File (BSF) for a 5% random sample of Medicare beneficiaries. The study
sample comprised Medicare beneficiaries aged 65 years or older in 2006 who filled at
least 1 prescription for a statin during 2007, excluding beneficiaries with low-income
subsidy or end-stage renal disease and those without both Medicare Part A and Part
B enrollment in 2007. Medication adherence was measured by medication
possession ratio (MPR), defined as the sum of days supply for all statin prescriptions
filled in 2007 minus the days supply that would have carried over into 2008 from the
final 2007 prescription filled, divided by the total number of days from the fill date of
the first statin prescription to 31 Dec 2007. A binary indicator of good adherence
was defined as MPR exceeding 80%. Propensity-score matching was used to reduce
differences in observed characteristics of enrollees in MA-PD plans and PDPs. The
propensity score was based on sociodemographic characteristics and health risk
measures, including Hierarchical Condition Category (HCC) scores.
Results: In the unmatched sample, the mean MPR was 70.57% for MA-PD enrollees
vs 70.54% for PDP enrollees (P = 0.780), and the proportion of enrollees with good
adherence was 46.7% for MA-PD plans vs 46.9% for PDPs (P = 0.262). In the
matched sample, statin adherence was slightly better among MA-PD enrollees than
PDP enrollees. Mean MPRs were 70.80% and 69.44%, and the percentages of
enrollees with good adherence were 47.0% and 45.3% in MA-PD plans and PDPs,
respectively (both P less than 0.001).
Conclusions: During an early year of the Part D programme, MA-PD enrollees had
slightly better adherence to statin therapy than PDP enrollees. While the difference
was statistically significant, it was very small and unlikely to lead to clinically
meaningful consequences. Less than one-half of MA-PD and PDP enrollees had good
adherence in statin use, suggesting room for improvement in both types of Part D
plans. Continuing evaluations of adherence in diverse therapy classes are needed for
Medicare Part D beneficiaries.
125. Intentional non-adherence to medications among HIV positive alcohol
drinkers: prospective study of interactive toxicity beliefs
75
SC Kalichman , T Grebler, CM Amaral, M McNerey, D White, MO Kalichman, C Cherry, L
Eaton
Journal of General Internal Medicine 2012;doi: 10.1007/s11606-012-2231-1 (published
early online 12 Oct 2012)
Background: Antiretroviral therapy (ART) adherence is key to successful treatment of
HIV infection and alcohol is a known barrier to adherence. Beyond intoxication, ART
adherence is impacted by beliefs that mixing alcohol and medications is toxic.
Purpose: To examine prospective relationships of factors contributing to intentional
medication non-adherence when drinking.
Methods: People in Georgia, USA, who both receive ART and drink alcohol (N = 178)
were enrolled in a 12-month prospective cohort study that monitored beliefs about
the hazards of mixing ART with alcohol (interactive toxicity beliefs), alcohol
consumption using electronic daily diaries, ART adherence assessed by both
unannounced pill counts and self-report, and chart-abstracted HIV viral load.
Results: Participants who reported skipping or stopping their ART when drinking
(N = 90, 51%) demonstrated significantly poorer ART adherence, were less likely to
be viral suppressed, and more likely to have CD4 counts under 200/cc3. Day-level
analyses showed that participants who endorsed interactive toxicity beliefs were
significantly more likely to miss medications on drinking days.
Conclusions: Confirming earlier cross-sectional studies, the current findings from a
prospective cohort show that a substantial number of people intentionally skip or
stop their medications when drinking. Interventions are needed to correct alcoholrelated interactive toxicity misinformation and promote adherence among alcohol
drinkers.
126. Spillover adherence effects of fixed-dose combination HIV therapy
TL Kauf, KL Davis, SR Earnshaw, EA Davis
Patient Preference and Adherence 28 Feb 2012;6:155-164
The impact of fixed-dose combination (FDC) products on adherence to other, nonfixed regimen components has not been examined. We compared adherence to a
third antiretroviral (ART) component among patients receiving a nucleoside reverse
transcriptase inhibitor (NRTI) backbone consisting of the FDC Epzicom,
GlaxoSmithKline Inc, Research Triangle Park, NC (abacavir sulfate 600mg +
lamivudine 300mg; FDC group) vs NRTI combinations taken as two separate pills
(NRTI Combo group) using data from a US national sample of 30 health plans
covering approximately 38 million lives from 1997 to 2005. Adherence was
measured as the medication possession ratio (MPR). Multivariate logistic regression
compared treatment groups based on the likelihood of achieving 95% or higher
adherence, with sensitivity analyses using alternative thresholds. MPR was assessed
as a continuous variable using multivariate linear regression. Covariates included
age, gender, insurance payer type, year of study drug initiation, presence of mental
health and substance abuse disorders and third agent class. The study sample
consisted of 650 FDC and 1947 NRTI Combo patients. Unadjusted mean adherence
to the third agent was higher in the FDC group than the NRTI Combo group (0.92 vs
0.85; P less than 0.0001). In regression analyses, FDC patients were 48% and 39%
more likely to achieve 95% and 90% third agent adherence, respectively (P less than
0.03). None of the other MPR specifications achieved comparable results. Among
managed care patients, use of an FDC appears to substantially improve adherence to
a third regimen component and thus the likelihood of achieving the accepted
standard for adherence to HIV therapy of 95%.
The study was funded by GlaxoSmithKline.
76
127. Potential risk factors for medication non-adherence in patients with chronic
obstructive pulmonary disease (COPD)
MR Khdour, AF Hawwa, JC Kidney, BM Smyth, JC McElnay
European Journal of Clinical Pharmacology Oct 2012;68(10):1365-1373
Aims: To investigate the effect of a range of demographic and psychosocial variables
on medication adherence in chronic obstructive pulmonary disease (COPD) patients
managed in a secondary care setting.
Methods: A total of 173 patients with a confirmed diagnosis of COPD, recruited from
an outpatient clinic in Northern Ireland, participated in the study. Data collection
was carried out via face-to-face interviews and through review of patients' medical
charts. Social and demographic variables, co-morbidity, self-reported drug
adherence (Morisky scale), Hospital Anxiety and Depression (HAD) scale, COPD
knowledge, Health Belief Model (HBM) and self-efficacy scales were determined for
each patient.
Results: Participants were aged 67 +/- 9.7 (mean +/- SD) years, 56% female and
took a mean of 8.2 +/- 3.4 drugs. Low adherence with medications was present in
29.5% of the patients. Demographic variables (gender, age, marital status, living
arrangements and occupation) were not associated with adherence. A range of
clinical and psychosocial variables, on the other hand, were found to be associated
with medication adherence, i.e. beliefs regarding medication effectiveness, severity
of COPD, smoking status, presence of co-morbid illness, depressed mood, selfefficacy, perceived susceptibility and perceived barriers within the HBM (p less than
0.05). Logistic regression analysis showed that perceived ineffectiveness of
medication, presence of co-morbid illness, depressed mood and perceived barriers
were independently associated with medication non-adherence in the study (P less
than 0.05).
Conclusions: Adherence in COPD patients is influenced more by patients' perception
of their health and medication effectiveness, the presence of depressed mood and
co-morbid illness than by demographic factors or disease severity.
128. Opinions of a small sample of pharmacists about pharmacy setting and
patient adherence to antiretroviral therapy
J Kibicho, J Owczarzak, SD Pinkerton
Journal of Managed Care Pharmacy Jul-Aug 2012;18(6):446-452
Report summarising US pharmacists' opinions about similarities and differences in
adherence promotion practices for patients with HIV between specialty and
nonspecialty mail order pharmacies and between community-based specialty and
nonspecialty pharmacies.
A convenience sample of 31 pharmacists (28 from community-based pharmacies and
3 from a single mail order pharmacy) providing care to persons living with HIV
(PLWH) in 4 midwestern cities was recruited and pharmacists were interviewed
individually at their pharmacy locations between Aug and Oct 2009, using
semistructured interview guides.
Concludes that, although the choice of pharmacy is largely determined by insurance
benefits coverage, the effect of that choice on adherence may be more nuanced than
is captured by distinctions between community-based versus mail order pharmacy or
even between community-based settings (i.e. specialty versus nonspecialty
pharmacy). Although mail order pharmacies are convenient and less expensive than
community-based pharmacies, the lack of face-to-face patient interaction
77
(particularly for newly diagnosed PLWH), potential delays in receiving prescriptions
and identifying nonadherence, and lack of patient involvement in processing
prescriptions are concerns that could influence adherence outcomes.
Because of the significant growth in the use of mail order pharmacies and the lack of
evidence about their effects on adherence for PLWH, there is need for more research
that informs policy. The authors suggest 4 areas of research based on findings from
the present study: (1) how mail order pharmacists promote adherence for newly
diagnosed or poorly adherent PLWH; (2) the skills and systems needed to overcome
the lack of face-to-face encounters in a mail order pharmacy; (3) how to
appropriately target mail order pharmacy services without compromising care for
patients who could benefit from face-to-face interactions with a community-based
pharmacist; and (4) when to switch patients from community-based to mail order
settings. There is a need for more research that increases our understanding of mail
order adherence promotion activities and their impact on health outcomes for PLWH.
129. Socio-demographic differences in adherence to evidence-based drug therapy
after hospital discharge from acute myocardial infarction: a population-based
cohort study in Rome, Italy
U Kirchmayer, N Agabiti, V Belleudi, M Davoli, D Fusco, M Stafoggia, M Arcà, AP Barone, CA
Perucci
Journal of Clinical Pharmacy and Therapeutics Feb 2012;37(1):37-44
Objective: Adherence to evidence-based drug therapy after acute myocardial
infarction has increased over the last decades, but is still unsatisfactory. The
objectives are of this study were to analyse patterns of evidence-based drug therapy
after acute myocardial infarction (AMI), and evaluate socio-demographic differences.
Methods: A cohort of 3920 AMI patients discharged from hospital in Rome (2006-07)
was selected. Drugs claimed during the 12 months after discharge were retrieved.
Drug utilisation was defined as density of use (boxes claimed/individual follow-up;
chronic use = 6+ boxes/365 days) and therapeutic coverage, calculated through
Defined Daily Doses (chronic use: = 80% or more of individual follow-up). Patterns
of use of single drugs and their combinations were described. The association
between polytherapy and gender, age and socio-economic status (small-area
composite index based on census data) was analysed through logistic regression,
accounting for potential confounders.
Results and Discussion: Most patients used single drugs: 90.5% platelet aggregation
inhibitors (antiplatelets), 60.0% beta-blockers, 78.1% agents acting on the reninangiotensin system (ACEIs/ARBs), 77.8% HMG CoA reductase inhibitors (statins).
Percentages of patients with 80% or higher therapeutic coverage were 81.9% for
antiplatelets, 17.8% for beta-blockers, 64.4% for ACEIs/ARBs and 76.1% for statins.
The multivariate analysis showed gender and age differences in adherence to
polytherapy (females: OR = 0.84; 95% CI, 0.72 to 0.99; 71-80 years age-group: OR
= 0.82; 95% CI, 0.68 to 0.99). No differences were observed with respect to socioeconomic position.
Conclusions: The availability of information systems offers the opportunity to
monitor the quality of care and identify weaknesses in public health-care systems.
These results identify specific factors contributing to non-adherence and hence define
areas for more targeted health-care interventions. The results suggest that efforts
to improve adherence should focus on women and older patients.
78
130. Information about medication in HIV-infected patients and its relation to
adherence: an observational cross-sectional study
V Korb-Savoldelli, F Gillaizeau, T Caruba, P Prognon, P Durieux, B Sabatier
Swiss Medical Weekly 26 Jul 2012;142:w13642
Background: In HIV-infected patients, understanding of medication instructions is an
essential condition for adherence to Highly Active Antiretroviral Therapy (HAART). In
this study, we used a self-reported questionnaire to find which sources of medication
information were used by HIV-infected patients and their impact on adherence. In
secondary objectives, we determined profiles of non-adherent patients and specified
the role of the pharmacist.
Methods: A cross-sectional, observational study was conducted in one community
pharmacy and one French university hospital pharmacy, in patients naive or not to
HAART, from Apr to Jun 2009.
Results: 233 HIV-infected patients were included during the 3-month study period.
The majority of patients sought information about their HAART treatments from the
hospital physician (79.8%), the community physician (74.2%) and patient
information leaflets (73.8%). Community and hospital pharmacists were consulted
by 16.3% and 3.4% of patients, respectively. According to multivariate regression
analysis, adherence seemed to be associated with the sources of information
'community physician', 'hospital physician', 'internet', and the potential support of
patient associations. A total of 65.7% of patients were considered to be adherent.
Conclusions: In our study, among sources used by HIV-infected outpatients, their
physicians are the most helpful sources of information about HAART. Regarding
practice implications, the key role of the pharmacist is underutilised, indicating the
need for improved communication between the pharmacist and outpatients.
http://www.smw.ch/scripts/stream_pdf.php?doi=smw-2012-13642
131. Characteristics of HIV patients referred to a medication adherence program in
Switzerland
I Krummenacher, M Cavassini, O Bugnon, MP Schneider
International Journal of Clinical Pharmacy Jun 2012;34(3):426-431
Background: Since Aug 2004, HIV patients who experience - or are at risk of problems with their antiretroviral treatment (ART) are referred by their physician to
a medication adherence programme at the community pharmacy of the Department
of Ambulatory Care and Community Medicine in Lausanne (Switzerland). The
programme combines motivational interviewing and electronic drug monitoring.
Objective: To compare the demographic and clinical characteristics as well as ART of
HIV patients referred to the adherence programme versus those of the entire HIV
population followed in the same infection disease department in the same time
frame.
Method: Retrospective descriptive cross-sectional study. Study time frame was
defined according to the period with the highest number of HIV patients visiting the
adherence programme.
Results: Subjects included in the adherence programme were more likely to have a
protease inhibitor-based regimen (64%; 95% CI, 52 to 75% vs 37 %) and lower
CD4 cell counts (419 (252.0, 521.0); 95% CI, 305 to 472 vs 500 (351.0, 720.0))
than the entire HIV population. A majority of women were included in the adherence
programme (66%; 95% CI, 54 to 76 %, vs 39% in the entire HIV population).
Conclusions: Subjects referred to the adherence programme were different from the
entire HIV population and showed worse clinical outcomes and were more often
under salvage therapy. More women than men were included. Reasons for such a
difference need to be explored further.
79
http://link.springer.com/article/10.1007%2Fs11096-012-9638-y
132. A review of published studies of patients' illness perceptions and medication
adherence: lessons learned and future directions
SN Kucukarslan
Research in Social and Administrative Pharmacy Sep-Oct 2012;8(5):371-382
Background: Patients who seek medical care and who are prescribed medication may
choose to either accept or not accept the prescriber's recommendations to use the
prescribed medication. The Common Sense Model (CSM) is one behavioural model
that can help researchers and practitioners to identify patients' illness perceptions
that drive their decisions.
Objective: This article reviews published research that evaluated the impact of illness
representations (as defined in CSM) with medication adherence.
Methods: A narrative review of published research in illness representation and
medication adherence was conducted. Articles were searched using MEDLINE,
PreMEDLINE, evidence-based medicine reviews, and the International Pharmaceutical
Abstracts databases and using the search terms medication adherence, compliance,
illness perception, self-regulation theory, and common-sense model.
Results: 11 published studies were identified that compared illness representation
(or illness perception) and medication adherence. Each illness representation factor,
with the exception of illness coherence, directly or indirectly impacted medication
adherence. Illness identity, where symptoms are used to label a health condition,
can impact medication adherence, even with asymptomatic conditions such as
hypertension. Patient age, disease condition and culture may have an impact on
patient response to illness perceptions. Recommendations for future research are
(1) to use longitudinal studies to evaluate the cause-effect relationships between
illness perceptions and medication adherence, (2) to study patients' early
experiences with their illness, (3) to recruit patients who are nonadherent, (4) to use
clinical outcome measures in addition to the self-report medication adherence
measures and (5) to include patients' age and culture in the model.
Conclusions: Although the CSM is a well-known patient behaviour model, its use to
explain medication adherence has been limited to cross-sectional studies across
various health conditions. Further research is needed to elucidate the relationships
between illness perceptions and patient medication adherence, which can help
practitioners to engage and communicate better with patients.
133. Understanding rational non-adherence to medications. A discrete choice
experiment in a community sample in Australia
T-L Laba, J-A Brien, S Jan
BMC Family Practice 20 Jun 2012;13:61
Background: In spite of the potential impact upon population health and expenditure,
interventions promoting medication adherence have been found to be of moderate
effectiveness and cost effectiveness. Understanding the relative influence of factors
affecting patient medication adherence decisions and the characteristics of
individuals associated with variation in adherence will lead to a better understanding
of how future interventions should be designed and targeted. This study aims to
explore medication-taking decisions that may underpin intentional medication nonadherence behaviour amongst a community sample and the relative importance of
medication specific factors and patient background characteristics contributing to
those decisions.
80
Methods: A discrete choice experiment conducted through a web-enabled online
survey was used to estimate the relative importance of eight medication factors
(immediate and long-term medication harms and benefits, cost, regimen, symptom
severity, alcohol restrictions) on the preference to continue taking a medication. To
reflect more closely what usually occurs in practice, non-disease specific medication
and health terms were used to mimic decisions across multiple medications and
conditions. 161 general community participants, matching the national Australian
census data (age, gender) were recruited through an online panel provider
(participation rate: 10%) in 2010.
Results: Six of the eight factors (i.e. immediate and long-term medication harms and
benefits, cost, and regimen) had a significant influence on medication choice.
Patient background characteristics did not improve the model. Respondents with
private health insurance appeared less sensitive to cost then those without private
health insurance. In general, health outcomes, framed as a side-effect, were found
to have a greater influence over adherence than outcomes framed as therapeutic
benefits.
Conclusions: Medication-taking decisions are the subject of rational choices,
influenced by the attributes of treatments and potentially amenable to intervention
through education, strategic pricing and the altering of dosing characteristics.
Understanding individual treatment preferences is thus an important step to
improving adherence support provision in practice. Re-framing future interventions
and policies to support rational and informed individual patient choices, is the way
forward to realising the full potential health and economic benefits from the
efficacious use of medications.
134. The effect of cost on adherence to prescription medications in Canada
MR Law, L Cheng, IA Dhalla, D Heard, SG Morgan
Canadian Medical Association Journal 21 Feb 2012:184(3):297-302
Background: Many patients do not adhere to treatment because they cannot afford
their prescription medications, putting them at increased risk of adverse health
outcomes. We determined the prevalence of cost-related nonadherence and
investigated its associated characteristics, including whether a person has drug
insurance.
Methods: Using data from the 2007 Canada Community Health Survey, we analysed
the responses of 5732 people who answered questions about cost-related
nonadherence to treatment. We determined the national prevalence of cost-related
nonadherence and used logistic regression to evaluate the association between costrelated nonadherence and a series of demographic and socioeconomic variables,
including province of residence, age, sex, household income, health status and
having drug insurance.
Results: Cost-related nonadherence was reported by 9.6% (95% CI, 8.5% to 10.6%)
of Canadians who had received a prescription in the past year. In our adjusted
model, we found that people in poor health (odds ratio (OR) 2.64; 95% CI, 1.77 to
3.94), those with lower income (OR 3.29; 95% CI, 2.03 to 5.33), those without drug
insurance (OR 4.52; 95% CI 3.29 to 6.20) and those who live in British Columbia
(OR 2.56; 95% CI, 1.49 to 4.42) were more likely to report cost-related
nonadherence. Predicted rates of cost-related nonadherence ranged from 3.6%
(95% CI, 2.4 to 4.5) among people with insurance and high household incomes to
35.6% (95% CI, 26.1% to 44.9%) among people with no insurance and low
household incomes.
81
Interpretation: About 1 in 10 Canadians who receive a prescription report costrelated nonadherence. The variability in insurance coverage for prescription
medications appears to be a key reason behind this phenomenon.
http://www.cmaj.ca/content/184/3/297.full.pdf+html
135. Treatment acceptance and adherence in HIV disease: patient identity and the
perceived impact of physician-patient communication
MB Laws, GS Rose, T Bezreh, MC Beach, T Taubin, L Kogelman, M Gethers, IB Wilson
Studies have found that physician-patient relationships and communication quality
are related to medication adherence and outcomes in HIV care. Few qualitative
studies exist of how people living with HIV experience clinical communication about
their self-care behaviour.
Eight focus groups with people living with HIV in two US cities were conducted.
Participants responded to a detailed discussion guide and to reenactments of actual
physician-patient dialogue about antiretroviral adherence.
The 82 participants were diverse in age, sex and ethnicity. Most had been living with
HIV for many years and had stable relationships with providers. They appreciated
providers who knew and cared about their personal lives, who were clear and direct
about instructions, and who were accessible. Most had struggled to overcome
addiction, emotional turmoil and/or denial before gaining control over their lives and
becoming adherent to medications. They made little or no causal attribution for their
transformation to any outside agency, including their providers. They generally saw
medication adherence as a function of autonomous motivation.
Successful coping with HIV, with its prevalent behavioural comorbidities, stigma and
other challenges, requires a transformation of identity and internalisation of
motivation to maintain health. Effective methods for clinicians to support such
development are needed.
136. Utilization patterns of stimulants in ADHD in the Medicaid population: a
retrospective analysis of data from the Texas Medicaid program
KA Lawson, M Johnsrud, P Hodgkins, R Sasane, ML Crismon
Clinical Therapeutics Apr 2012;34(4):944-956.e4
Background: Some previously published research on treatment utilisation patterns in
patients with attention deficit/hyperactivity disorder (ADHD) in the USA has been
focused on data from commercial health plans, whereas research in the Medicaid
population is lacking. Thus, little is known about these utilisation patterns in
Medicaid populations, which typically have demographic and clinical characteristics
that differ from those of employer-based groups.
Objectives: The objectives of the present retrospective data analysis were to
evaluate the associations of medication groups (categorised by stimulant type
(methylphenidate or amphetamine) and duration of action (short-acting (SA) or
long-acting (LA))) with measures of stimulant utilisation patterns (adherence,
persistence, and switching) in children, adolescents and adults with ADHD enrolled in
the fee-for-service delivery model within the Texas Medicaid Program.
Methods: Texas Medicaid fee-for-service claims data were analysed retrospectively.
Data from enrollees with ADHD (aged 6-63 years) were included if patients were
newly initiated on medication from Jan 2006 to Sep 2007, had one or more medical
claim with a code for ADHD, and had continuous Medicaid eligibility 6 months before
and after treatment initiation. Adherence, persistence, and switching were compared
by initial stimulant medication group (SA methylphenidate (SA-M), LA-M, SA
82
amphetamine (SA-A) and LA-A). Rates were compared overall and by age group
(children, adolescents and adults). Multivariate models were used to control for
demographic, clinical and utilisation covariates.
Results: Of 15,055 eligible patients, mostly children, 71% were initiated on
methylphenidate; 90% received LA formulations (LA-M, 65%; LA-A, 25%). Most
children (66%) and adolescents (65%) were initiated on LA-M, followed by LA-A
(23% and 29%, respectively). Among adults, 38% each were initiated on LA-M and
LA-A. Overall adherence (measured using the days in possession ratio (DPR)) and
persistence were significantly greater with the LA versus the SA formulations (mean
DPR, 0.497-0.504 vs 0.407-0.418, respectively; mean persistence, 81 vs 66-67
days; both, P less than 0.001), and the rates of switching were lower with the LA
versus the SA formulations (12.3%-14% vs 27%-28%; P less than 0.001). On
multivariate analyses, the likelihoods of adherence and persistence were significantly
greater with the LA formulations, and the likelihood of being switched was
significantly greater with the SA formulations (P less than 0.001). These analyses
also showed that medication utilisation was significantly related to demographic and
clinical characteristics.
Conclusions: Based on the findings from this retrospective analysis, ADHD treatment
utilisation patterns varied by formulation in this Texas Medicaid population.
Persistence at 180 days was poor regardless of the stimulant used. Consideration of
stimulant formulations and demographic characteristics in patients in whom longterm ADHD management is being initiated may assist in optimum utilisation, perhaps
leading to better symptom control and more efficient resource utilisation.
http://www.clinicaltherapeutics.com/article/S0149-2918(12)00100-2/abstract
137. Effect of the Medicare Part D coverage gap on medication use among patients
with hypertension and hyperlipidemia
P Li, S McElligott, H Bergquist, JS Schwartz, JADoshi
Annals of Internal Medicine 5 Jun 2012;156(11):776-784
The US Medicare Part D coverage gap places financial burden on patients and could
influence decision making regarding prescriptions. In this study using Medicare Part
D administrative data, beneficiaries receiving prescriptions for antihypertensive or
antidyslipidaemia drugs who had no or generic-only gap coverage were less likely to
fill these prescriptions, had more continuous prescription gaps, and were less likely
to have prescription refills consistent with appropriate medication schedules than
those without a coverage gap. Prescription filling varied less by type of plan for
drugs used to treat symptomatic conditions. Unfavourable prescription-filling
patterns for some drugs may be associated with coverage gaps.
See also associated editorial by CL Roumie, p.834-835.
138. Factors related to medication non-adherence for patients with hypertension in
Taiwan
W-W Li, C-T Kuo, S-L Hwang, H-T Hsu
Journal of Clinical Nursing Jul 2012;21(13-14):1816-1824
Aims and Objective: To characterise a Taiwanese population and to examine the
prevalence of antihypertensive medication non-adherence and how the
cultural/clinical factors were associated with non-adherence in Taiwan.
Background: Antihypertensive medication non-adherence is a significant clinical issue
in the United States. However, little is known about hypertension (HTN) control and
cultural/clinical factors related to non-adherence in Taiwan.
Design: A convenience sample survey design was used.
83
Method: Data were gathered from a convenience sample of 200 subjects recruited
from a large teaching hospital. Medication non-adherence and cultural/clinical
factors were recorded using various self-administered questionnaires, and blood
pressure was taken twice for each participant.
Results: The mean age of the participants was 60.4 (SD 11.5 years) including 62%
men. Two-thirds had less than a high school education (64.5%), and the majority of
them were married (86.0%) and lived with family or close friends (93.5%). The
average length of HTN diagnosis was 8.6 years (SD 9.0 years). Medication nonadherence rate was 47.5% and uncontrolled HTN rate was 49.0%. Some
participants (17.0%) used Chinese herbs for treating their disease (e.g. cough) and
promoting health in addition to their regular antihypertensive medications. Two
factors were found to be statistically significant for predicting medication nonadherence: Lower Perceived Susceptibility to Specific Diseases (OR = 1.15; 95% CI,
1.01 to 1.31) and Longer Length of HTN Diagnosis [OR = 1.06; 95% CI, 1.01 to
1.12).
Conclusions: Taiwanese at risk of non-adherence included those who perceived lower
susceptibility to specific diseases and had been diagnosed with HTN for a longer
time. Those using herbs need to be studied for an impact of herbs on their
adherence behaviour.
Relevance to Clinical Practice: These findings can help guide the development of
culturally sensitive and clinically appropriate nursing interventions for HTN
management in Taiwan.
139. Relationship of health literacy to intentional and unintentional non-adherence
of hospital discharge medications
LA Lindquist, L Go, J Fleisher, N Jain, E Friesema, DW Baker
Journal of General Internal Medicine Feb 2012;27(2):173-178
Background: Inadequate health literacy is prevalent among seniors and is associated
with poor health outcomes. At hospital discharge, medications are frequently
changed and patients are informed of these changes via their discharge instructions.
Objectives: To explore the association between health literacy and medication
discrepancies 48 hours after hospital discharge and determine the causes of
discharge medication discrepancies.
Design: Face-to-face surveys assessing health literacy at hospital discharge using
the short form of the Test of Functional Health Literacy in Adults (sTOFHLA). We
obtained the medication lists from the written discharge instructions. At 48 hours
post-discharge, we phoned subjects to assess their current medication regimen, any
medication discrepancies, and the causes of the discrepancies.
Participants: 254 community-dwelling seniors 70 years or older, admitted to acute
medicine services for more than 24 hours at an urban hospital in the USA.
Results: Of 254 seniors [mean age 79.3 years; 53.1% female], 142 (56%) had a
medication discrepancy between their discharge instructions and their actual home
medication use 48 hours after discharge. Subjects with inadequate and marginal
health literacy were significantly more likely to have unintentional non-adherence meaning the subject did not understand how to take the medication (inadequate
health literacy 47.7% vs marginal 31.8% vs adequate 20.5%, p = 0.002).
Conversely, those with adequate health literacy were significantly more likely to have
intentional non-adherence - meaning the subject understood the instructions but
chose not to follow them as a reason for the medications discrepancy compared with
marginal and inadequate health literacy (adequate 73.3% vs marginal 11.1% vs
84
inadequate 15.6%; p less than 0.001). Another common cause of discrepancies was
inaccurate discharge instructions (39.3%).
Conclusions: Seniors with adequate health literacy are more inclined to purposefully
not adhere to their discharge instructions. Seniors with inadequate health literacy
are more likely to err due to misunderstanding their discharge instructions.
Together, these results may explain why previous studies have shown a lack of
association between health literacy and overall medication discrepancies.
140. Systematic review of consistency between adherence to cardiovascular or
diabetes medication and health literacy in older adults
YK Loke, I Hinz, X Wang, C Salter
Annals of Pharmacotherapy Jun 2012;46(6):863-872
Objective: To review the relationship between health literacy and adherence to
cardiovascular/diabetes medication.
Data Sources: We searched EMBASE (1974-Feb 2012) and MEDLINE (1948-Feb
2012). Search terms included health literacy, numeracy, health education and
related terms, health literacy measurement tools and medication adherence.
Study Selection and Data Extraction: English-language articles of all study designs
were considered. Articles were included if they had a measurement of health literacy
and medication adherence and if participants were older adults taking drugs for
cardiovascular illness or diabetes mellitus.
Data Synthesis: A total of 1310 citations were reviewed, including 9 articles that
reported on 7 research studies. Most studies were retrospective, and all were based
in the USA. Because there was considerable diversity in measurements, participant
characteristics and outcome measures, we conducted a narrative synthesis rather
than a meta-analysis. In assessing study validity, we looked at participant selection,
method of measuring health literacy and medication adherence, missing data or
losses and adjustment for confounders. Of the 7 studies included, only one found a
demonstrable association between health literacy and refill adherence. One clinical
trial failed to show significant improvements in medication adherence after an
intervention to improve health literacy.
Conclusions: The current evidence does not show a definite association between
health literacy and medication adherence in older adults with cardiovascular disease
or diabetes mellitus. In the absence of a definite link, efforts to develop
interventions to improve health literacy would not necessarily improve adherence to
cardiovascular medications. There is an urgent need for robust studies outside of
the US, with wider, generalised recruitment of participants.
http://www.theannals.com/content/46/6/863.abstract
141. Depressive traits in essential tremor: impact on disability, quality of life, and
medication adherence
ED Louis, ED Huey, M Gerbin, AS Viner
European Journal of Neurology Oct 2012;19(10):1349-1354
Background: There is growing study of the psychiatric features of essential tremor.
Depressive symptoms occur in a considerable number of patients. Yet their impact,
as a primary factor, has received almost no attention. We assessed whether,
independent of tremor severity, patients with more depressive symptoms have more
perceived tremor-related disability, lower tremor-related quality of life and poorer
compliance with tremor medication.
Methods: On the basis of their Center for Epidemiological Studies Depression Scale
score, we stratified 70 essential tremor patients into three groups: 41 with minimal
85
depressive symptoms, 24 with moderate depressive symptoms and 5 with severe
depressive symptoms. Importantly, the three groups had similar tremor severity on
neurological examination. We assessed self-reported tremor-related disability,
tremor-related quality of life (Quality of Life in Essential Tremor) (QUEST) score, and
medication compliance.
Results: Cases with minimal depressive symptoms had the lowest QUEST scores (i.e.
highest quality of life), cases with moderate depressive symptoms had intermediate
scores and those with severe depressive symptoms had the highest QUEST scores
(i.e. lowest quality of life) (P less than 0.001). Depressive symptoms were a
stronger predictor of tremor-related quality of life than was the main motor feature
of essential tremor (ET) itself (tremor). Self-reported medication compliance was
lowest in cases with severe depressive symptoms and highest in cases with minimal
depressive symptoms.
Conclusions: The physical disability caused by the tremor of ET has traditionally been
regarded as the most important feature of the disease that causes distress, and it
has received the most attention in the management of patients with this disease.
Our data indicate that this may not be the case.
142. Determinants of antiretroviral therapy adherence in northern Tanzania: a
comprehensive picture from the patient perspective
RA Lyimo, M de Bruin, J van den Boogaard, HJ Hospers, A vander Ven, D Mushi
BMC Public Health 30 Aug 2012;12:716
Background: To design effective, tailored interventions to support antiretroviral
therapy (ART) adherence, a thorough understanding of the barriers and facilitators of
ART adherence is required. Factors at the individual and interpersonal level, ART
treatment characteristics and health care factors have been proposed as important
adherence determinants.
Methods: To identify the most relevant determinants of adherence in northern
Tanzania, in-depth interviews were carried out with 61 treatment-experienced
patients from four different clinics. The interviews were ad-verbatim transcribed and
recurrent themes were coded.
Results: Coding results showed that the majority of patients had basic understanding
of adherence, but also revealed misconceptions about taking medication after alcohol
use. Adherence motivating beliefs were the perception of improved health and the
desire to live like others, as well as the desire to be a good parent. A de-motivating
belief was that stopping ART after being prayed for was an act of faith. Facilitators
of adherence were support from friends and family, and assistance of home based
care (HBC) providers. Important barriers to ART adherence were the use of alcohol,
unavailability of food, stigma and disclosure concerns, and the clinics dispensing too
few pills. Strategies recommended by the patients to improve adherence included
better Care and Treatment Centre (CTC) services, recruitment of patients to become
Home Based Care (HBC) providers and addressing the problem of stigma through
education.
Conclusions: This study underscores the importance of designing tailored, patientcentered adherence interventions to address challenges at the patient, family,
community and health care level.
143. Financial stress is associated with reduced treatment adherence in HIVinfected adults in a resource-rich setting
J McAllister, G Beardsworth, E Lavie, K MacRae, A Carr
86
HIV Medicine Feb 2013;14(2):120-124 (published early online 10 Jul 2012)
Objectives: Financial stress has been identified as a barrier to antiretroviral
adherence, but only in resource-limited settings. Almost half of HIV-infected
Australian adults earn no regular income and, despite highly subsidised antiretroviral
therapy and universal health care, 3% of HIV-infected Australians cease
antiretroviral therapy each year. We studied the relationship between financial
stress and treatment adherence in a resource-rich setting.
Methods: Outpatients attending the HIV clinic at St Vincent's Hospital, Sydney, NSW,
Australia, between Nov 2010 and May 2011 were invited to complete an anonymous
survey including questions relating to costs and adherence.
Results: Of 335 HIV-infected patients (95.8% male; mean age 52 years; hepatitis
coinfection 9.2%), 65 patients (19.6%) stated that it was difficult or very difficult to
meet pharmacy dispensing costs, 49 (14.6%) reported that they had delayed
purchasing medication because of pharmacy costs, and 30 (9.0%) reported that they
had ceased medication because of pharmacy costs. Of the 65 patients with
difficulties meeting pharmacy costs, 19 (29.2%) had ceased medication vs 11
(4.1%) of the remaining 270 patients (P less than 0.0001). In addition, 19 patients
(5.7%) also stated that it was difficult or very difficult to meet travel costs to the
clinic. Treatment cessation and interruption were both independently associated
with difficulty meeting both pharmacy and clinic travel costs. Only 4.9% had been
asked if they were having difficulty paying for medication.
Conclusions: These are the first data to show that pharmacy dispensing and clinic
travel costs may affect treatment adherence in a resource-rich setting. Patients
should be asked if financial stress is limiting their treatment adherence.
144. Structural equation modeling of the proximal-distal continuum of adherence
drivers
CA McHorney, NJ Zhang, T Stump, X Zhao
Patient Preference and Adherence Nov 2012;6:789-804
Objectives: Nonadherence to prescription medications has been shown to be
significantly influenced by three key medication-specific beliefs: patients' perceived
need for the prescribed medication, their concerns about the prescribed medication,
and perceived medication affordability. Structural equation modelling was used to
test the predictors of these three proximal determinants of medication adherence
using the proximal-distal continuum of adherence drivers as the organising
conceptual framework.
Methods: In Spring 2008, survey participants were selected from the Harris
Interactive Chronic Illness Panel, an internet-based panel of hundreds of thousands
of adults with chronic disease. Respondents were eligible for the survey if they were
aged 40 years and older, resided in the USA, and reported having at least one of six
chronic diseases: asthma, diabetes, hyperlipidaemia, hypertension, osteoporosis, or
other cardiovascular disease. A final sample size of 1072 was achieved. The
proximal medication beliefs were measured by three multi-item scales: perceived
need for medications, perceived medication concerns, and perceived medication
affordability. The intermediate sociomedical beliefs and skills included four multiitem scales: perceived disease severity, knowledge about the prescribed medication,
perceived immunity to side effects and perceived value of nutraceuticals. Generic
health beliefs and skills consisted of patient engagement in their care, health
information-seeking tendencies, internal health locus of control, a single-item
measure of self-rated health, and general mental health. Structural equation
modelling was used to model proximal-distal continuum of adherence drivers.
87
Results: The average age was 58 years (range = 40-90 years), and 65% were
female and 89% were white. 41% had at least a 4-year college education, and just
under half (45%) had an annual income of US$50,000 or more. Hypertension and
hyperlipidaemia were each reported by about a quarter of respondents (24% and
23%, respectively). A smaller percentage of respondents had osteoporosis (17%),
diabetes (15%), asthma (13%) or other cardiovascular disease (8%). Three
independent variables were significantly associated with the three proximal
adherence drivers: perceived disease severity, knowledge about the medication and
perceived value of nutraceuticals. Both perceived immunity to side effects and
patient engagement was significantly associated with perceived need for medications
and perceived medication concerns.
Conclusion: Testing the proximal-distal continuum of adherence drivers shed light on
specific areas where adherence dialogue and enhancement should focus. Our results
can help to inform the design of future adherence interventions as well as the
content of patient education materials and adherence reminder letters. For longterm medication adherence, patients need to autonomously and intrinsically commit
to therapy and that, in turn, is more likely to occur if they are both informed (disease
and medication knowledge and rationale, disease severity, consequences of
nonadherence and side effects) and motivated (engaged in their care, perceive a
need for medication and believe the benefits outweigh the risks).
145. Medication adherence among Latino and non-Latino white children with
asthma
EL McQuaid, RS Everhart, R Seifer, SJ Kopel, D Koinis Mitchell, RB Klein, CA Esteban, GK
Fritz, G Canino
Pediatrics Jun 2012;129(6):e1404-e1410
Objective: Latino children of Caribbean descent remain at high risk for poorly
controlled asthma. Controller medications improve asthma control; however,
medication adherence remains suboptimal, particularly among minorities. This study
assessed socioeconomic, family-based and parent factors in medication adherence
among children with asthma from Rhode Island (RI; Latino and non-Latino white
(NLW)) and Puerto Rico.
Methods: Data collection occurred as part of a multicentre study of asthma
disparities. Our sample included children (ages 7-16) prescribed objectively
monitored controller medications (n = 277; 80 island Puerto Rico, 114 RI Latino, 83
RI NLW). Parents completed questionnaires regarding family background and beliefs
about medications. Families participated in an interview regarding asthma
management. Multilevel analyses (maximum likelihood estimates) accounting for
children being nested within site and ethnic group assessed the contribution of social
context, family, and parent variables to medication adherence.
Results: Medication adherence differed by ethnic group (F2, 271 = 7.46, P less than
0.01), with NLW families demonstrating the highest levels of adherence. Multilevel
models indicated that parental beliefs about medication necessity and family
organisation regarding medication use were significant predictors of adherence, even
for families below the poverty threshold. With family factors in the model, a
substantial improvement in model fit occurred (Akaike Information Criterion change
of 103.45).
Conclusions: Adherence to controller medications was lower among Latino children in
our sample. Targeted interventions that capitalise on existing family resources,
emphasise structure, and address parental beliefs about the importance of
medications may be of benefit to families from different cultural backgrounds.
88
146. Patients' Beliefs about Medicines in a primary care setting in Germany
C Mahler, K Hermann, R Horne, S Jank, WE Haefeli, J Szecsenyi
Journal of Evaluation in Clinical Practice Apr 2012;18(2):409-413
Objectives: The aim of this study was to explore patients' beliefs about medicines by
administering the German version of the Beliefs about Medicines Questionnaire
(BMQ) in a primary care setting among chronically ill patients and to examine its
psychometric properties. The BMQ assesses patients' beliefs about their individual
prescribed medication as well as their beliefs about medicines in general.
Methods: A cross-sectional survey of 485 chronically ill patients was performed. The
German version of the BMQ was evaluated in terms of internal consistency, validity
and scale structure. To assess validity the German versions of the Medication
Adherence Report Scale (MARS-D) and the Satisfaction with Information about
Medicines Scale (SIMS-D) were applied.
Results: The BMQ showed good internal consistency (Cronbach's alpha 0.79 to 0.83).
Patients' belief about the specific necessity of their medicines correlated positively
with the MARS-D (ρ = 0.202; P less than 0.01). There were significant correlations in
the predicted direction between the MARS-D and all the BMQ subscales with the
exception of the General-Overuse subscale (rho = -0.06; P = 0.30). Relationship to
the SIMS-D was comparable to the original study. Factor analysis corroborated the
scale structure.
Conclusions: The BMQ is a suitable instrument to measure patients' beliefs in
medicines in German primary care settings. Most patients in our sample had positive
beliefs concerning the necessity of their medication. Their levels of concern were
associated with higher non-adherence.
147. Looking beyond polypharmacy: quantification of medication regimen
complexity in the elderly
N Mansur, A Weiss, Y Beloosesky
American Journal of Geriatric Pharmacotherapy Aug 2012;10(4):223-229
Background: Polypharmacy has been shown to influence outcomes in elderly
patients. However, the impact of medication regimen complexity, quantified by the
Medication Regimen Complexity Index (MRCI), on health outcomes after discharge of
elderly patients has not been studied.
Objective: Our aim was to test the convergent, discriminant and predictive validity of
the MRCI in older hospitalised patients with varying functional and cognitive levels.
Methods: We retrospectively applied the MRCI to the medication regimen of 212
hospitalised patients in Israel and assessed its validity.
Results: The mean (SD) MRCI scores for medication regimens and number of
medications at discharge were 30.27 (13.95) and 5.95 (2.40), respectively. The
MRCI scores were strongly correlated with the number of medications (r = 0.94, P
less than 0.001) and the number of daily doses (r = 0.87, P less than 0.001) and
increased as the number of medications taken ≥3 times daily increased (27.35,
34.45 and 43.00 for none, 1 and 2 drugs, respectively; P less than 0.001). Positive
correlations were observed between the Cumulative Illness Rating Scale-Geriatrics
score and both the number of medications and the MRCI score (r = 0.40, r = 0.46, P
less than 0.001, respectively). No relationship was found between MRCI scores and
the number of medications and age, sex, and post-discharge medication
modifications. Patients nonadherent to at least 1 drug were discharged with a higher
MRCI score and higher number of medications compared with medication-compliant
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patients (33.3 and 7.0 vs 27 and 5.8, respectively; P less than 0.01). An inverse
correlation was found between overall adherence 1 month after discharge and the
MRCI score (r = −0.188, P = 0.028); however, no such correlation was found
regarding the number of medications at discharge.
Conclusions: The MRCI showed satisfactory validity and good evidence of classifying
regimen complexity over a simple medication count. The MRCI demonstrated
application in clinical research and practice in the elderly. However, more studies
are needed to investigate its advantage over the number of medications for
identifying patients with complex medication regimens and directing interventions to
simplify their medication regimen complexity.
148. Lay perspectives on hypertension and drug adherence: systematic review of
qualitative research
IJ Marshall, CDA Wolfe, C McKevitt
British Medical Journal 2012;345:e3953 (published early online 9 Jul 2012)
Objective: To synthesise the findings from individual qualitative studies on patients'
understanding and experiences of hypertension and drug taking; to investigate
whether views differ internationally by culture or ethnic group and whether the
research could inform interventions to improve adherence.
Design: Systematic review and narrative synthesis of qualitative research using the
2006 UK Economic and Social Research Council research methods programme
guidance.
Data Sources: Medline, Embase, the British Nursing Index, Social Policy and Practice,
and PsycInfo from inception to Oct 2011.
Study Selection: Qualitative interviews or focus groups among people with
uncomplicated hypertension (studies principally in people with diabetes, established
cardiovascular disease or pregnancy-related hypertension were excluded).
Results: 59 papers reporting on 53 qualitative studies were included in the synthesis.
These studies came from 16 countries (United States, United Kingdom, Brazil,
Sweden, Canada, New Zealand, Denmark, Finland, Ghana, Iran, Israel, Netherlands,
South Korea, Spain, Tanzania and Thailand). A large proportion of participants
thought hypertension was principally caused by stress and produced symptoms,
particularly headache, dizziness and sweating. Participants widely intentionally
reduced or stopped treatment without consulting their doctor. Participants
commonly perceived that their blood pressure improved when symptoms abated or
when they were not stressed, and that treatment was not needed at these times.
Participants disliked treatment and its side effects and feared addiction. These
findings were consistent across countries and ethnic groups. Participants also
reported various external factors that prevented adherence, including being unable
to find time to take the drugs or to see the doctor; having insufficient money to pay
for treatment; the cost of appointments and healthy food; a lack of health insurance;
and forgetfulness.
Conclusions: Non-adherence to hypertension treatment often resulted from patients'
understanding of the causes and effects of hypertension; particularly relying on the
presence of stress or symptoms to determine if blood pressure was raised. These
beliefs were remarkably similar across ethnic and geographical groups; calls for
culturally specific education for individual ethnic groups may therefore not be
justified. To improve adherence, clinicians and educational interventions must better
understand and engage with patients' ideas about causality, experiences of
symptoms and concerns about drug side effects.
http://www.bmj.com/content/345/bmj.e3953.pdf+html
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149. Family support, medication adherence, and glycemic control among adults
with Type 2 diabetes
LS Mayberry, CY Osborn
Diabetes Care Jun 2012;35(6):1239-1245
Objective: We used a mixed-methods approach to explore the relationships between
participants' perceptions of family members' diabetes self-care knowledge, family
members' diabetes-specific supportive and nonsupportive behaviours, and
participants' medication adherence and glycaemic control (A1C).
Research Design and Methods: Adults with type 2 diabetes participated in focus
group sessions that discussed barriers and facilitators to diabetes management (n =
45) and/or completed surveys (n = 61) to collect demographic information,
measures of diabetes medication adherence, perceptions of family members'
diabetes self-care knowledge, and perceptions of family members' diabetes-specific
supportive and nonsupportive behaviours. Most recent A1C was extracted from the
medical record.
Results: Perceiving family members were more knowledgeable about diabetes was
associated with perceiving family members performed more diabetes-specific
supportive behaviours, but was not associated with perceiving family members
performed fewer nonsupportive behaviours. Perceiving family members performed
more nonsupportive behaviours was associated with being less adherent to one's
diabetes medication regimen, and being less adherent was associated with worse
glycaemic control. In focus groups, participants discussed family member support
and gave examples of family members who were informed about diabetes but
performed sabotaging or nonsupportive behaviours.
Conclusions: Participant reports of family members' nonsupportive behaviours were
associated with being less adherent to one's diabetes medication regimen.
Participants emphasised the importance of instrumental help for diabetes self-care
behaviours and reported that nonsupportive family behaviours sabotaged their
efforts to perform these behaviours. Interventions should inform family members
about diabetes and enhance their motivation and behavioural skills around not
interfering with one's diabetes self-care efforts.
150. Is customization in antidepressant prescribing associated with acute-phase
treatment adherence?
EL Merrick, D Hodgkin, L Panas, SB Soumerai, G Ritter
Journal of Pharmaceutical Health Services Research Mar 2012;3(1):11-16
Objectives: The objective of this study was to explore whether prescribing variation
is associated with duration of antidepressant use during the acute phase of
treatment. Improving quality of care and increasing the extent to which treatment is
patient-centred and customised are inter-related goals. Prescribing variation may be
considered a marker of customisation, and could be associated with better
antidepressant treatment adherence.
Methods: A cross-sectional secondary data analysis was carried out, examining the
association between providers' antidepressant prescribing variation and patient
continuity of antidepressant treatment. The data source was Medicaid claims for
dual-eligibility Medicaid/Medicare patients from two US states. The sample included
383 patients with new episodes of antidepressant treatment, representing 70
providers with at least four patients in the sample. We tested two alternative
measures of prescribing concentration: (1) share of prescriber's initial antidepressant
prescribing accounted for by the two most common regimens and (2) Herfindahl
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index. The HEDIS performance measure of effective acute-phase treatment (at least
84 out of 114 days with antidepressant) was the dependent variable.
Key Findings: In multivariate analyses, the concentration measure based on the top
two regimens was significant and inversely related to duration adequacy (P less than
0.05). The Herfindahl index measure showed a trend towards a similar inverse
relationship (P less than 0.10).
Conclusions: The findings provide some support for the hypothesised relationship
between prescribing variation and adequate antidepressant treatment duration
during the acute phase of treatment. Future work with more detailed, clinical
longitudinal data could extend this inquiry to understand the causal mechanisms
better using a more direct measure of customised care.
151. White coat adherence over the first year of therapy in pediatric epilepsy
AC Modi, LM Ingerski, JR Rausch, TA Glauser, D Drotar
Journal of Pediatrics Oct 2012;161(4):695-699.e1
Objective: To examine white coat adherence over time in children with epilepsy.
Study Design: This was a longitudinal prospective study in the USA to examine
medication adherence prior to and following consecutive clinic visits over a 13-month
period in 120 children with newly diagnosed epilepsy (mean age = 7.2 +/- 2.9 years;
38% female) and their caregivers. Electronic monitors were used to assess
adherence and ordinal logistic regression models were employed.
Results: Results demonstrated white coat adherence, with adherence increasing
during the 3 days preceding clinic visits. Data also revealed a significant interaction,
whereby adherence increased following initial clinic visits, but decreased following
the last clinic visit.
Conclusions: White coat adherence occurs for children with newly diagnosed
epilepsy. Increased awareness of white coat adherence has important implications
for clinical decision-making and should be examined in other paediatric populations.
Increased monitoring of medication patterns can help clinicians avoid unnecessary
changes to the treatment regimen. Interventions targeting improved communication
around adherence behaviours are necessary to maximise therapy benefits.
152. The roles of past behavior and health beliefs in predicting medication
adherence to a statin regimen
TD Molfenter, A Bhattacharya, DH Gustafson
Patient Preference and Adherence 5 Sep 2012;6:643-651
Purpose: Current medication-adherence predictive tools are based on patient
medication-taking beliefs, but studying past behaviour may now be a more
explanatory and accessible method. This study will evaluate whether past
medication-refill behaviour for a statin regimen is more predictive of medication
adherence than patient medication-taking health beliefs.
Patients and Methods: This prospective longitudinal study was implemented in a
national managed care plan in the United States. A group of 1433 statin patients
were identified and followed for 6 months. Medication-taking health beliefs, collected
from self-reported mail questionnaires, and past medication-refill behaviour, using
proportion of days covered (PDC), were collected prior to 6-month follow-up.
Outcomes were measured using categorical PDC variable (of adherence, PDC 85% or
above, versus nonadherence, PDC less than 85%), with model fit estimated using
receiver operator characteristic analysis.
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Results: The area under the receiver operator characteristic curve for past behaviour
(Az = 0.78) was significantly greater (P less than 0.05) than for patient health beliefs
(Az = 0.69), indicating that past prescription-refill behaviour is a better predictor of
medication adherence than prospective health beliefs. Among health beliefs, the
factor most related to medication adherence was behavioural intent (odds ratio,
5.12; 95% CI, 1.84 to 15.06). The factor most strongly related to behavioural intent
was impact of regimen on daily routine (odds ratio, 3.3; 95% CI, 1.41 to 7.74).
Conclusions: Electronic medical records and community health-information networks
may make past prescription-refill rates more accessible and assist physicians with
managing medication-regimen adherence. Health beliefs, however, may still play an
important role in influencing medication-taking behaviours.
153. Factors associated with dropout from tuberculosis treatment in the province
of Granada
(Factores asociados al abandono del tratamiento de la tuberculosis en la provincia de
Granada)
MJ Molina Rueda, A Fernandez Ajuria, MM Rodriguez Del Aguila, B Lopez Hernandez
Revista Clinica Espanola Sep 2012;212(8):383-388
Objectives: The factors associated with tuberculosis (TB) treatment drop-out can be
very specific to the population and the local health care organisation. We studied the
factors associated with TB treatment drop-out in the province of Granada (Spain).
Subjects and Methods: A retrospective cohort study of TB cases registered in the
province of Granada by the Epidemiological Surveillance System of Andalusia (SVEA)
between 2003 and 2010. Incidence was calculated in the native and foreign
population. An univariate analysis was performed to describe the characteristics of
both groups and a logistic regression model was used to identify factors associated
with abandoning therapy.
Results: A decreasing trend in the incidence of TB was observed, (20.47 in 2007 to
11 cases per 100,000 inhabitants in 2010, respectively). Mean age of foreign
patients was lower than that of the natives (30.8 years vs 46.0 years, P less than
0..001). The former predominately lived in the Granada district, while the natives
lived in the Metropolitan district. The percentage of patients who abandoned
antitubercular treatment was 12.2%, this being somewhat higher in the foreign
patients than the national ones (14% vs 10%; P = 0.062). Being male (OR: 1.65;
95% CI, 1.04 to 2.60; P = 0.033), foreign (OR: 1.72; 95% CI, 1.04 to 2.83; P =
0.032), resident in the North-East district (OR: 3.64; 95% CI, 1.76 to 7.52; P =
0.005) and/or having extrapulmonary TB (OR: 1.78; 95% CI, 1.06 to 3.00; P =
0.029) were associated significantly with abandoning therapy.
Conclusions: The incidence of TB in the province of Granada has decreased to about
10 cases per 100,000 inhabitants/year. The percentage of patients who abandon TB
treatment is significant, it being higher in foreign patients than in the natives. TB
treatment abandonment was associated with being male, living in the North-East
district of Granada and having extrapulmonary TB.
154. Adherence to the oral contraceptive pill: a cross-sectional survey of
modifiable behavioural determinants
GJ Molloy, H Graham, H McGuinness
BMC Public Health 2 Oct 2012;12:838
Background: Poor adherence to the oral contraceptive pill (OCP) is reported as one of
the main causes of unintended pregnancy in women who rely on this form of
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contraception. This study aims to estimate the associations between a range of wellestablished modifiable psychological factors and adherence to OCP.
Method: A cross-sectional survey of 130 female university students currently using
OCP (Mean age: 20.46, SD: 3.01, range 17--36) was conducted. An OCP specific
Medication Adherence Report Scale was used to assess non-adherence.
Psychological predictor measures included necessity and concern beliefs about OCP,
intentions, perceived behavioural control (pbc), anticipated regret and action and
coping planning. Multiple linear regression was used to analyse the data.
Results: 52% of participants reported missing their OCP once or more per month and
14% twice or more per month. In bivariate analysis intentions (r = -0.25),
perceived behavioural control (r = -0.66), anticipated regret (r = 0.20), concerns
about OCP (r = 0.31) and action (r = -0.25) and coping (r = -0.28) planning were all
significantly associated with adherence to OCP in the predicted direction. In a
multivariate model almost half (48%) of the variation in OCP adherence could be
explained. The strongest and only statistically significant predictors in this model
were perceived behavioural control (beta = -0.62, p less than 0.01) and coping
planning (beta = -0.23, p = 0.03). A significant interaction between intentions and
anticipated regret was also observed.
Conclusions: The present data point to a number of key modifiable psychological
determinants of OCP use. Future work will establish whether changing these
variables results in better adherence to the OCP.
155. Beyond the usual suspects: positive attitudes towards positive symptoms is
associated with medication noncompliance in psychosis
S Moritz, J Favrod, C Andreou, AP Morrison, F Bohn, R Veckenstedt, P Tonn, A Karow
Schizophrenia Bulletin 2012;doi:10.1093/schbul/sbs005 (published early online 15 Feb
2012)
Antipsychotic medication represents the treatment of choice in psychosis according
to clinical guidelines. Nevertheless, studies show that half to almost three-quarters
of all patients discontinue medication with antipsychotics after some time, a fact
which is traditionally ascribed to side-effects, mistrust against the clinician and poor
illness insight. The present study investigated whether positive attitudes toward
psychotic symptoms (i.e. gain from illness) represent a further factor for medication
noncompliance. An anonymous online survey was set up in order to prevent
conservative response biases that are likely to emerge in a clinical setting. Following
an iterative selection process, data from a total of 113 patients with a likely
diagnosis of schizophrenia and a history of antipsychotic treatment were retained for
the final analyses (80%). While side-effect profile and mistrust emerged as the most
frequent reasons for drug discontinuation, 28% of the sample reported gain from
illness (e.g. missing voices, feeling of power) as a motive for noncompliance. At
least every fourth patient reported the following reasons: stigma (31%), mistrust
against the physician/therapist (31%) and rejection of medication in general (28%).
Approximately every fifth patient had discontinued antipsychotic treatment because
of forgetfulness. On average, patients provided 4 different explanations for
noncompliance. Ambivalence toward symptoms and treatment should be considered
thoroughly when planning treatment in psychosis. While antipsychotic medication
represents the evidence-based cornerstone of the current treatment in
schizophrenia, further research is needed on nonpharmacological interventions for
noncompliant patients who are willing to undergo intervention but refuse
pharmacotherapy.
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http://schizophreniabulletin.oxfordjournals.org/content/early/2012/02/15/schbul.sbs005.ab
stract
156. Rates and clinical correlates of treatment non-adherence in schizoaffective
bipolar patients
A Murru, I Pacchiarotti, AMA Nivoli, CM Bonnin, B Patrizi, B Amann, E Vieta, F Colom
Acta Psychiatrica Scandinavica May 2012;125(5):412-418
Objective: To analyse demographic, clinical and therapeutic variables that may be
associated with pharmacological non-adherence in a sample of schizoaffective
patients, bipolar type.
Method: Adherence to treatment and its clinical correlates were assessed at the end
of a 10-year follow-up in 76 patients in Barcelona, Spain, meeting DSM-IV-TR
diagnosis of schizoaffective disorder, bipolar type. Adherent and poorly adherent
patients were compared regarding clinical and therapeutic variables.
Results: The rate of poorly adherent patients was 32/76 (41.2%) of the sample.
Adherent patients were more likely to have presented an affective episode at illness
onset and to have fewer purely - non-affective - psychotic episodes. Demographic or
other clinical variables were not found to be associated to treatment adherence.
Family history for psychiatric disorders or suicide did not correlate either, and neither
did any specific pharmacological agent.
Conclusions: Rates of non-adherence in schizoaffective disorder are high. Adherence
seems to be associated with a more affective course of illness (affective first episode
and fewer purely psychotic episodes). Patients with more prominent schizophrenialike characteristics could be at higher risk for poor adherence and need to be closely
followed and monitored. Even when properly treated, schizoaffective disorder is a
disabling and severe disorder with high risk for recurrences.
157. The effects of financial pressures on adherence and glucose control among
racial/ethnically diverse patients with diabetes
Q Ngo-Metzger, DH Sorkin, J Billimek, S Greenfield, SH Kaplan
Journal of General Internal Medicine Apr 2012;27(4):432-437
Background: The Affordable Care Act is designed to decrease the numbers of
uninsured patients in the USA. However, even with insurance, patients who have
financial hardships may have difficulty obtaining their medications because of cost
issues.
Objective: Among patients with type 2 diabetes, to examine the association between
patients' self-reported financial pressures on cost-related medication non-adherence
and glucose control. Additionally, to examine whether having insurance decreases
the financial pressures of diabetes care.
Design and Participants: Racially/ethnically diverse patients (N = 1361; 249 nonHispanic whites, 194 Vietnamese and 533 Mexican-American) with type 2 diabetes
were recruited from seven outpatient clinics for a cross-sectional, observational
study.
Results: Although both Vietnamese and Mexican-American patients reported having
low annual incomes, more Mexican-Americans reported the presence of financial
barriers to getting medical care and perceived financial burden due to their diabetes,
compared to whites and Vietnamese (p less than 0.001). Over half (53.2%) of
Mexican-Americans reported cost-related non-adherence compared to 27.2% of
white and 27.6% of Vietnamese patients (p less than 0.001). Perceived financial
burden was found to be associated with poor glucose control (HbA1c = 8% or
above), after adjusting for sociodemographic and health characteristics (aOR = 1.70;
95
95% CI, 1.09 to 2.63), but not when adjusting for non-adherence. Similarly, a
significant association between presence of financial barriers and HbA1c (aOR = 1.69;
95% CI, 1.23 to 2.32) was attenuated with the inclusion of insurance status in the
model. Being uninsured (aOR = 1.90; 95% CI, 1.13 to 3.21) and non-adherent
(aOR = 1.49; 95% CI, 1.06 to 2.08) were each independently associated with HbA1c.
Conclusions: While having health insurance coverage eliminated some of the
financial barriers associated with having diabetes, low-income patients still faced
significant financial burdens. Thus, providing health insurance to more individuals is
only the first step towards eliminating health disparities. It is important to address
medication cost in order to improve medication adherence and glucose control.
158. Effect of health literacy on drug adherence in patients with heart failure
M Noureldin, KS Plake, DG Morrow, W Tu, J Wu, MD Murray
Pharmacotherapy Sep 2012;32(9):819-826
Study Objective: To assess the effect of health literacy on drug adherence in the
context of a pharmacist-based intervention for patients with heart failure.
Design: Post hoc analysis of a randomised controlled trial.
Setting: Inner-city ambulatory care practice affiliated with an academic medical
centre in the USA.
Patients: The original trial enrolled 314 patients with heart failure who were aged 50
years or older and were taking at least one cardiovascular drug for heart failure; 122
patients received the pharmacist intervention (patient education, therapeutic
monitoring and communication with primary care providers) and 192 patients
received usual care (regular follow-up with primary care providers). We analysed
the results of 281 patients who had available health literacy and adherence data.
Measurements and Main Results: Drug adherence was assessed over 9 months using
electronic prescription container monitors on cardiovascular drugs. Health literacy
was assessed using the Short Test of Functional Health Literacy in Adults (scores
range from 0-36, with an adequate literacy score defined as 23 or higher). Taking
adherence, defined as the percentage of prescribed drug doses taken by the patient
compared with the number of doses prescribed by the physician, was assessed for
each group. Patients mean +/- SD age was 63 +/- 9 years, 51% had less than 12
years of education, 29% had inadequate health literacy and they received a mean of
11 +/- 4 drugs. In the usual care group, taking adherence was greater among
patients with adequate (69.4%) than those with inadequate (54.2%) health literacy
(p = 0.001). In the intervention group, the difference in taking adherence among
patients with adequate (77.3%) and inadequate (65.3%) health literacy was not
statistically significant (p = 0.06). Among patients with inadequate health literacy,
the intervention increased adherence (65%;, 95% CI, 54 to 77%) by an order of
magnitude similar to that of the baseline adherence of patients with adequate health
literacy (69%; 95% CI, 65 to 74%). Multivariable analysis supported the association
between health literacy and adherence.
Conclusions: In patients with heart failure, those with adequate health literacy have
better adherence to cardiovascular drugs than those with inadequate health literacy.
The pharmacist intervention improved adherence in patients with adequate and
inadequate health literacy. Health literacy may be an important consideration in
drug adherence interventions.
159. Reason for clozapine cessation
NB Pai, SC Vella
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Acta Psychiatrica Scandinavica Jan 2012;125(1):39-44
Objective: Approximately 30% of individuals diagnosed with schizophrenia suffer
from treatment-resistant or refractory schizophrenia. The gold standard for
treatment of refractory schizophrenia is clozapine. However, a significant number of
patients cease clozapine therapy; therefore this study explores patients' motives for
cessation.
Method: The motives for cessation and duration of clozapine treatment from a
retrospective database of 151 patients with schizophrenia or schizo-affective disorder
who had ceased clozapine once or more were reviewed, with the motives for
cessation coded. The general motives for cessation were non-compliance, own
decision, medical, poor response and other. In addition, the medical reasons for
cessation were further codified: cardiac complications, neutropenia, fevers, other
side effects and pregnancy.
Results: The majority of patients ceased clozapine owing to non-compliance with
medical protocols or citing their own decision. Approximately half ceased after a
period of 6 months or less. 17% of patients ceased owing to medical reasons, with
the largest proportions discontinuing treatment because of other side effects or
neutropenia.
Conclusion: Future research should seek to further investigate why patients decide
to be non-compliant and formulate their own decision to cease treatment, as this will
facilitate strategies to promote adherence amongst these two groups that are
potentially the most amenable to change.
160. Exploring the beliefs of heart failure patients towards their heart failure
medicines and self care activities
M Percival, WN Cottrell, R Jayasinghe
International Journal of Clinical Pharmacy Aug 2012;34(4):618-625
Aim: To identify heart failure patients' beliefs towards their medications and how
these beliefs relate to adherence.
Methods: Patients attending a multi-disciplinary, community-based heart failure clinic
on the Gold Coast, Australia were interviewed using a questionnaire composed of
four parts: repertory grid technique; Beliefs About Medicines Questionnaire (BMQ);
Medicines Adherence Reporting Scale (MARS); demographic details. Patients were
divided into those categorised as adherent (MARS score = 23 or above) and those
categorised as non-adherent (MARS score below 23). Necessity beliefs scores from
BMQ and the frequency of statements generated from the repertory grid portion of
the questionnaire were compared between these two groups.
Results: 43 patients were interviewed with a mean age (+/- SD) of 64 (+/- 17)
years, of whom 36 (83.7%) were male. 37 (86.0%) patients were categorised as
adherent; the remaining 6 (14.0%) as non-adherent. The 43 patients generated a
total of 262 statements about their medicines. The three most common themes
identified were 'Related to fluid' (36.6%), 'Helps the heart' (31.7%) and 'Related to
weight' (13.7%). There was a significantly higher median necessity score in the
adherent group compared to the non adherent group (22.0 vs 19.5, p = 0.0272).
Patients with a strong necessity score also had significantly higher self-reported
adherence compared to patients with a strong concerns score (21.5 vs 18.0, p =
0.006).
Conclusions: This study suggests that patients with heart failure possessing a strong
belief in the necessity of their treatment regimen are more likely to demonstrate
better adherence.
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161. An evaluation of the impact of patient cost sharing for antihypertensive
medications on adherence, medication and health care utilization, and
expenditures
JA Pesa, J Van Den Bos, T Gray, C Hartsig, RB McQueen, JJ Saseen, KV Nair
Objective: To assess the impact of patient cost-sharing for antihypertensive
medications on the proportion of days covered (PDC) by antihypertensive
medications, medical utilisation, and health care expenditures among commercially
insured individuals assigned to different risk categories.
Methods: Participants were identified from the Consolidated Health Cost Guidelines
(CHCG) database (1 Jan 2006 to 31 Dec 2008) based on a diagnosis (index) claim
for hypertension, continuous enrollment 12 months or longer pre- and post-index,
and no prior claims for antihypertensive medications. Participants were assigned to:
low-risk group (no comorbidities), high-risk group (1+ selected comorbidities), or
very high-risk group (prior hospitalisation for 1+ selected comorbidities). The
relationship between patient cost sharing and PDC by antihypertensive medications
was assessed using standard linear regression models, controlling for risk group
membership, and various demographic and clinical factors. The relationship between
PDC and health care service utilisation was subsequently examined using negative
binomial regression models.
Results: Of the 28,688 study patients, 66% were low-risk. The multivariate
regression model supported a relationship between patient cost sharing per 30-day
fill and PDC in the following year. For every US$1.00 increase in cost sharing, PDC
decreased by 1.1 days (P less than 0.0001). Significant predictors of PDC included
high risk, older age, gender, Charlson Comorbidity Index score, geography and total
post-index insurer- and patient-paid costs. An increase in PDC was associated with a
decrease in all-cause and hypertension-related inpatient, outpatient and emergency
room visits and medical, pharmacy and total costs.
Conclusions: The trend has been for managed care organisations and employers to
require patients to bear a greater out-of-pocket burden for health care resources
consumed. This study illustrates the potential adverse effects of higher patient cost
sharing among patients with hypertension stratified by different risk levels. A
decrease in PDC was predictive of higher resource utilisation and health care costs,
which should be of interest to payers and employers alike.
162. Co-occurring marijuana use is associated with medication nonadherence and
nonplanning impulsivity in young adult heavy drinkers
EN Peters, RF Leeman, LM Fucito, BA Toll, WR Corbin, SS O'Malley
Addictive Behaviors Apr 2012;37(4):420-426
Few studies have examined the co-occurrence of alcohol and marijuana use in
clinical samples of young adults. The present study investigated whether cooccurring marijuana use is associated with characteristics indicative of a high level of
risk in young adult heavy drinkers. Individuals between the ages of 18 and 25 years
(N = 122) participated in an ongoing 8-week randomised clinical trial that tested the
efficacy of placebo-controlled naltrexone plus brief individual counselling to reduce
heavy drinking. At intake participants completed self-report assessments on alcohol
consumption, alcohol-related negative consequences, motivation to reduce drinking,
trait impulsivity, expectancies for alcohol-induced disinhibition, use of cigarettes, and
history of medication nonadherence . In univariate tests heavy drinkers with and
without co-occurring marijuana use did not differ on alcohol consumption, most
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alcohol-related negative consequences, and motivation to reduce drinking. In
multivariate tests controlling for demographic characteristics, co-occurring heavy
alcohol and marijuana use was significantly associated with nonplanning impulsivity
(beta = 2.95) and a history of both unintentional (adjusted odds ratio (aOR) = 3.30)
and purposeful (aOR = 3.98) nonadherence to medication. Findings suggest that
young adult heavy drinkers with co-occurring marijuana use exhibit a high-risk
clinical profile and may benefit from interventions that increase adherence to
medications.
163. Insulin adherence behaviours and barriers in the multinational Global
Attitudes of Patients and Physicians in Insulin Therapy study
M Peyrot, AH Barnett, LF Meneghini, P-M Schumm-Draeger
Diabetic Medicine May 2012;29(5):682-689
Aims: To examine patient and physician beliefs regarding insulin therapy and the
degree to which patients adhere to their insulin regimens.
Methods: Internet survey of 1250 physicians (600 specialists, 650 primary care
physicians) who treat patients with diabetes and telephone survey of 1530 insulintreated patients (180 with Type 1 diabetes, 1350 with Type 2 diabetes) in China,
France, Japan, Germany, Spain, Turkey, the UK or the USA.
Results: One-third (33.2%) of patients reported insulin omission/non-adherence at
least 1 day in the last month, with an average of 3.3 days. Three-quarters (72.5%)
of physicians report that their typical patient does not take their insulin as
prescribed, with a mean of 4.3 days per month of basal insulin omission/nonadherence and 5.7 days per month of prandial insulin omission/non-adherence.
Patients and providers indicated the same 5 most common reasons for insulin
omission/non-adherence: too busy; travelling; skipped meals; stress/emotional
problems; public embarrassment. Physicians reported low patient success at
initiating insulin in a timely fashion and adjusting insulin doses. Most physicians
report that many insulin-treated patients do not have adequate glucose control
(87.6%) and that they would treat more aggressively if not for concern about
hypoglycaemia (75.5%). Although a majority of patients (and physicians) regard
insulin treatment as restrictive, more patients see insulin treatment as having
positive than negative impacts on their lives.
Conclusions: Glucose control is inadequate among insulin-treated patients, in part
attributable to insulin omission/non-adherence and lack of dose adjustment. There
is a need for insulin regimens that are less restrictive and burdensome with lower
risk of hypoglycaemia.
164. Trends in antidepressant prescribing for new episodes of depression and
implications for health system quality measures
PN Pfeiffer, BR Szymanski, M Valenstein, JF McCarthy, K Zivin
Medical Care Jan 2012;50(1):86-90
Background: The US nationally reported Healthcare Effectiveness Data and
Information Set (HEDIS) antidepressant medication management measure assesses
whether patients with new episodes of depression receive antidepressant coverage
for 84 of the first 114 days of treatment. Although initial prescriptions for a 90-day
supply satisfy measure requirements, they may circumvent its purpose of ensuring
adequate medication management.
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Objectives: To assess the extent to which 90-day initial prescriptions have
contributed to health system performance on the HEDIS antidepressant measure
from fiscal years 2001 to 2008.
Research Design: Retrospective cohort analysis of US Veterans Health Administration
administrative data.
Subjects: Patients with a new diagnosis of depression and a new antidepressant
prescription (N = 383,634).
Measures: HEDIS antidepressant measures, days supply of initial antidepressant
prescriptions, antidepressant refills and clinical encounters.
Results: Health system performance on the HEDIS acute phase antidepressant
measure increased from 63.1% in 2001 to 71.0% in 2008. Receipt of an initial 90day antidepressant supply increased from 10.5% to 29.1% during this same period;
when these are excluded, HEDIS performance was 58.8% in 2001 and 59.4% in
2008. Receiving an initial 90-day prescription was associated with prior
antidepressant treatment, fewer clinical encounters and similar rates of
antidepressant refills compared with patients prescribed less than 90-day supplies.
Conclusions: Although increases in initial 90-day supplies contribute to improved
performance on the HEDIS measure, actual adherence during the acute treatment
phase may not be changed by this practice. Quality measures based on pharmacy
fills may need modification in the setting of large initial prescriptions.
http://journals.lww.com/lwwmedicalcare/Abstract/2012/01000/Trends_in_Antidepressant_Prescribing_for_New.11.aspx
165. Complementary and alternative medicine use and adherence with pediatric
asthma treatment
JC Philp, J Maselli, LM Pachter, MD Cabana
Objectives: Complementary and alternative medicine (CAM) use for paediatric
asthma is increasing. The authors of previous studies linked CAM use with decreased
adherence to conventional asthma medicines; however, these studies were limited
by cross-sectional design. Our objective was to assess the effect of starting CAM on
paediatric adherence with daily asthma medications.
Methods: We used a retrospective cohort study design. Telephone surveys were
administered to caregivers of patients with asthma annually from 2004 to 2007 in
the USA. Dependent variables were percent missed doses per week and a previously
validated 'Medication Adherence Scale score'. Independent variables included
demographic factors, caregiver perception of asthma control, and initiation of CAM
for asthma. We used multivariate linear regression to assess the relationship
between medication adherence and previous initiation of CAM.
Results: From our longitudinal data set of 1322 patients, we focused on 187 children
prescribed daily medications for all 3 years of our study. Patients had high rates of
adherence. The mean percentage missed asthma daily controller medication doses
per week was 7.7% (SD = 14.2%). Medication Adherence Scale scores (range: 420, with lower scores reflecting higher adherence) had an overall mean of 7.5 (SD =
2.9). In multivariate analyses, controlling for demographic factors and asthma
severity, initiation of CAM use was not associated with subsequent adherence (P
greater than 0.05).
Conclusions: The data from this study suggest that CAM use is not necessarily
'competitive' with conventional asthma therapies; families may incorporate different
health belief systems simultaneously in their asthma management. As CAM use
becomes more prevalent, it is important for physicians to ask about CAM use in a
nonjudgmental fashion.
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166. Opportunity lost? Psychiatric medications and problems with sexual function:
a role for nurses in mental health
C Quinn, B Happell, G Browne
Journal of Clinical Nursing Feb 2012;21(3-4):415-423
Aim; To explore patients’ non-adherence to psychiatric medication with mental health
nurses.
Background: The ability of consumers to maintain normal sexual behaviours is
complicated by abnormally high incidence of sexual problems arising from the
medications they are prescribed. Sexual side effects of psychiatric medications are
identified as a major reason for non-adherence to psychiatric medication regimes yet
it remains an issue mental health nurses tend to avoid in their practice with
consumers.
Design: An exploratory, descriptive qualitative approach.
Methods: Individual interviews were conducted with 14 nurses currently working with
adult consumers of mental health services in Australia. Data analysis followed the
framework approach developed by Ritchie and Spencer as the process for
identification of the main themes.
Results: Problems with sexual function in relation to psychiatric medication issues
was one major theme to emerge from this research. More specifically the
participants referred to: assessment of sexual function, the side effects of psychiatric
medication, consumer embarrassment, and, the pros and cons of information.
Participants recognised that sexual side effects were likely to have an impact on
adherence to medication and that this was an important consideration but most did
not discuss this issue with consumers. Consumer embarrassment and the belief that
knowledge itself might cause non-adherence were the two main reasons for not
discussing this topic.
Conclusions: Problems with sexual function of consumers presents an important
practice consideration for nurses working in mental health settings. There is an
urgent need for strategies to enhance awareness and confidence among nurses in
exploring this topic with consumers.
Relevance to Clinical Practice: Mental health nurses can adopt a leadership role in
recognising the relevance of sexuality in care and treatment for consumers of mental
health services. Strategies to assist in developing skill and confidence in this domain
are required as a matter of priority.
167. Characteristics of patients with primary non-adherence to medications for
hypertension, diabetes, and lipid disorders
MA Raebel, JL Ellis, NM Carroll, EA Bayliss, B McGinnis, et al.
Journal of General Internal Medicine Jan 2012;27(1):57-64
Background: Information comparing characteristics of patients who do and do not
pick up their prescriptions is sparse, in part because adherence measured using
pharmacy claims databases does not include information on patients who never pick
up their first prescription, that is, patients with primary non-adherence. Electronic
health record medication order entry enhances the potential to identify patients with
primary non-adherence, and in organisations with medication order entry and
pharmacy information systems, orders can be linked to dispensings to identify
primarily non-adherent patients.
Objective: This study aims to use database information from an integrated system to
compare patient, prescriber and payment characteristics of patients with primary
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non-adherence and patients with ongoing dispensings of newly initiated medications
for hypertension, diabetes and/or hyperlipidaemia.
Design: This is a retrospective observational cohort study.
Participants: Participants of this study include patients with a newly initiated order
for an antihypertensive, antidiabetic and/or antihyperlipidaemic within an 18-month
period.
Main Measures: Proportion of patients with primary non-adherence overall and by
therapeutic class subgroup. Multivariable logistic regression modeling was used to
investigate characteristics associated with primary non-adherence relative to ongoing
dispensings.
Key Results: The proportion of primarily non-adherent patients varied by therapeutic
class, including 7% of patients ordered an antihypertensive, 11% ordered an
antidiabetic, 13% ordered an antihyperlipidaemic and 5% ordered medications from
more than one of these therapeutic classes within the study period. Characteristics
of patients with primary non-adherence varied across therapeutic classes, but these
characteristics had poor ability to explain or predict primary non-adherence (models
c-statistics = 0.61 to 0.63).
Conclusions: Primary non-adherence varies by therapeutic class. Healthcare delivery
systems should pursue linking medication orders with dispensings to identify
primarily non-adherent patients. We encourage conduct of research to determine
interventions successful at decreasing primary non-adherence, as characteristics
available from databases provide little assistance in predicting primary nonadherence.
http://link.springer.com/article/10.1007%2Fs11606-011-1829-z
168. Medication adherence among hypertensive patients of primary health clinics
in Malaysia
A Ramli, NS Ahmad, T Paraidathathu
Patient Preference and Adherence 31 Aug 2012;6:613-622
Purpose: Poor adherence to prescribed medications is a major cause for treatment
failure, particularly in chronic diseases such as hypertension. This study was
conducted to assess adherence to medications in patients undergoing hypertensive
treatment in the Primary Health Clinics of the Ministry of Health in Malaysia. Factors
affecting adherence to medications were studied, and the effect of nonadherence to
blood pressure control was assessed.
Patients and Methods: This was a cross-sectional study to assess adherence to
medications by adult patients undergoing hypertensive treatment in primary care.
Adherence was measured using a validated survey form for medication adherence
consisting of 7 questions. A retrospective medication record review was conducted
to collect and confirm data on patients' demographics, diagnosis, treatments and
outcomes.
Results: Good adherence was observed in 53.4% of the 653 patients sampled.
Female patients were found to be more likely to adhere to their medication regimen,
compared to their male counterparts (odds ratio 1.46; 95% CI, 1.05 to 2.04; P less
than 0.05). Patients in the ethnic Chinese group were twice as likely (95% CI, 1.14
to 3.6; P less than 0.05) to adhere, compared to those in the Indian ethnic group.
An increase in the score for medicine knowledge was also found to increase the odds
of adherence. On the other hand, increasing the number of drugs the patient was
taking and the daily dose frequencies of the medications prescribed were found to
negatively affect adherence. Blood pressure control was also found to be worse in
noncompliers.
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Conclusions: The rate of medication adherence was found to be low among primary
care hypertensive patients. A poor adherence rate was found to negatively affect
blood pressure control. Developing multidisciplinary intervention programmes to
address the factors identified is necessary to improve adherence and, in turn, to
improve blood pressure control.
169. The effect of dementia on medication use and adherence among Medicare
beneficiaries with chronic heart failure
GB Rattinger, SK Dutcher, PT Chhabra, CS Franey, L Simoni-Wastila, SS Gottlieb, B Stuart,
IH Zuckerman
American Journal of Geriatric Pharmacotherapy Feb 2012;10(1):69-80
Background: Alzheimer's disease and related disorders (ADRD) are prevalent in older
adults, increase the costs of chronic heart failure (CHF) management, and may be
associated with undertreatment of cardiovascular disease.
Objective: The purpose of this study was to determine the relationship between
comorbid ADRD and CHF medication use and adherence among US Medicare
beneficiaries with CHF.
Methods: This 2-year (1/1/2006 to 31/12/2007) cross-sectional study used data
from the Chronic Condition Data Warehouse of the US Centers for Medicare and
Medicaid Services. Medicare beneficiaries with evidence of CHF who had systolic
dysfunction and Medicare Parts A, B and D coverage during the entire study period
were included. ADRD was identified based on diagnostic codes using the Chronic
Condition Data Warehouse algorithm. CHF evidence-based medications (EBMs) were
selected based on published guidelines: ACE inhibitors, angiotensin receptor
blockers, selected beta-blockers, aldosterone antagonists and selected vasodilators.
Measures of EBMs included a binary indicator of EBM use and medication possession
ratio among users.
Results: Of 9827 beneficiaries with CHF and systolic dysfunction, 24.2% had a
diagnosis of ADRD. Beneficiaries with ADRD were older (80.8 vs 73.6 years; P less
than 0.0001) and more likely to be female (69.3% vs 58.1%; P less than 0.0001).
Overall EBM use was lower in patients with CHF and ADRD compared with patients
with CHF but no ADRD (85.3% vs 91.2%; P less than 0.0001). Lower use among
those with ADRD was consistent across all EBM classes except vasodilators. Among
beneficiaries receiving EBM, those with ADRD had a slightly higher mean medication
possession ratio for EBM compared with those without ADRD (0.86 vs 0.84; P =
0.0001).
Conclusions: EBM medication adherence was high in this population, regardless of
ADRD status. However, patients with ADRD had lower EBM use compared with those
without ADRD. Low use of specific EBM medications such as beta-blockers was
found in both groups. Therefore, interventions targeting increased treatment with
specific EBMs for CHF, even among patients with ADRD, may be of benefit and could
help reduce CHF-related hospitalisations.
170. Changes in treatment adherence and glycemic control during the transition to
adolescence in Type 1 diabetes
JR Rausch, KK Hood, A Delamater, J Shroff Pendley, JM Rohan, G Reeves, L Dolan, D Drotar
Objective: To test models of unidirectional and bidirectional change between
treatment adherence and glycaemic control in youth with type 1 diabetes.
103
Research Design and Methods: We conducted a 2-year longitudinal, multisite study
of 225 youth with type 1 diabetes recruited at the cusp of adolescence (aged 9-11
years) to describe the mutual influences of glycaemic control as measured by HbA1c
and treatment adherence as measured by blood glucose monitoring frequency
(BGMF) during the transition to adolescence.
Results: HbA1c increased from 8.2 to 8.6% (P less than 0.001) and BGMF decreased
from 4.9 to 4.5 checks per day (P less than 0.02) during the 2-year period. Changes
in the BGMF slope predicted changes in HbA1c. A change (increase) in HbA1c was
associated with a change (decrease) in BGMF of 1.26 (P less than 0.001) after
controlling for covariates.
Conclusions: The magnitude of the effect of declining treatment adherence (BGMF)
on glycaemic control in young adolescents may be even greater than declines
observed among older adolescents. BGMF offers a powerful tool for targeted
management of glycaemic control for type 1 diabetes during the critical transition to
adolescence.
171. Two character traits associated with adherence to long term therapies
G Reach
Diabetes Research and Clinical Practice Oct 2012;98(1):19-25
Adherence is defined as the adequacy between the behaviours of patients and their
medical prescriptions. Adherence is a general behaviour, which can explain why
patients in the placebo arm of randomised clinical trials have a lower mortality rate
when they are adherent. We propose that this behaviour is related to two character
traits: patience (capacity to give priority to the future) and, more provocatively,
obedience. To support this claim, we bring arguments from the literature and from
two published personal studies. We previously showed that type 2 diabetic patients
who respond as non-adherers to a questionnaire on adherence to medication and to
whom one proposes a fictitious monetary choice between receiving Euro 500 today
or waiting one year to receive Euro 1500 never make the remote choice. We also
showed that obese diabetic patients who declare that they do not fasten their seat
belt when they are seated in the back of a car are more often non-adherent
concerning medication than those patients who claim that they follow this road
safety recommendation. Thus, one of the roles of empowerment and patient
education could be to encourage the patients, if they wish it, to replace passive
adherence behaviours with conscious active choices.
172. Patient-specific factors relating to medication adherence in a postpercutaneous coronary intervention cohort
GF Rushworth, S Cunningham, A Mort, I Rudd, SJ Leslie
International Journal of Pharmacy Practice Aug 2012;20 (4): 226-237
Objective: To explore the association between medication adherence and
qualitatively characterised patient-specific themes relating to medication adherence
in patients following percutaneous coronary intervention (PCI).
Methods: Data-collection questionnaires and qualitative topic guides were piloted in
two patients. A validated questionnaire generated an adherence score for a
convenience sample of 20 patients within 7 days of PCI. Semi-structured qualitative
interviews were subsequently carried out with all patients to explore patient-specific
themes relating to measured medication adherence.
Key findings: 14 out of 20 patients (70%) had scores indicative of good adherence.
Key factors associated with good adherence included having a good relationship with
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the doctor, having an understanding of the condition, knowledge of the indications
and consequences of non-adherence, perceived health benefits and medications
eliciting tangible symptom control. There were misconceptions of concern regarding
adverse drug reactions and the importance of aspirin, both of which had a negative
effect on adherence. The role of the community pharmacist was sometimes,
although not always, misunderstood.
Conclusions: This study suggests there is an association between patients' beliefs,
knowledge, understanding and misconceptions about medication and their adherence
in a post-PCI cohort. To optimise medication adherence it is vital for prescribers to
remain patient-focused and cognisant of patient-specific themes relating to
medication adherence. (40 refs.)
173. Rurality and other factors associated with adherence to immunosuppressant
medications in community-dwelling solid-organ transplant recipients
J Sankaranarayanan, D Collier, A Furasek, T Reardon, LM Smith, M McCartan, AN Langnas
Research in Social and Administrative Pharmacy May-Jun 2012;8(3):228-239
Background: Data on immunosuppressant adherence of community-dwelling adult
solid-organ transplant recipients (SOTRs) from rural populations in the United States
are limited. Therefore, understanding the association of rurality and other factors of
immunosuppressant adherence will help providers design and deliver patientcentered adherence enhancing interventions.
Objectives: The objective was to examine factors associated with a previously
validated 4-item Immunosuppressant Therapy Adherence Scale (ITAS) score in
community-dwelling adult SOTRs who received a transplant from an academic centre
in the Midwestern United States.
Methods: For this observational study, cross-sectional survey data (patient
demographic, medical condition, immunosuppressant therapy and self-reported
ITAS) received from adult SOTRs aged 19 years or older with other data from an
academic transplant centre's database were merged. Using multivariate logistic
regression, significant SOTR characteristics associated with being adherent (ITAS
score = 12) versus nonadherent (ITAS score less than 12) were examined.
Results: The survey response rate was 30% (n = 556/1827). Those SOTRs
responding (n = 556) had a kidney (48%), liver (47%) or other (4.5%) transplant.
They were more likely to be 50- to 64-year olds (52%), men (55%), white (90%),
metroresident (59%), with an annual income less than US$55,000. The SOTRs were
living with a transplant for 6.3 years (median), reported excellent-to-good health
status (77%) and received different immunosuppressant regimens. More than half
of the SOTRs (58%) were adherent. In multivariate analyses, compared with
patients aged 65 years or older, younger patients, nonmetro rural- versus
metroresident, and those having more (6 or more) versus less (fewer than 6)
comorbidities were significantly less likely to report adherence. SOTRs receiving
tacrolimus-based combination immunosuppressant versus tacrolimus alone were
more likely to report adherence.
Conclusions: When designing and delivering patient care-centred interventions
including those that use technology to increase immunosuppressant adherence,
providers need to consider rural residence besides other well-established patient
factors (younger age, immunosuppressant drug and comorbidities) of nonadherence.
174. Association between different types of social support and medication
adherence
105
D Scheurer, N Choudhry, KA Swanton, O Matlin, W Shrank
American Journal of Managed Care Dec 2012;18(12):e461-e467
Study Design: A search of articles published before Nov 2010 in peer-reviewed,
healthcare-related journals was conducted using PubMed, EMBASE and Web of
Science, and search terms related to social support (social support OR friend OR
family OR agency) and adherence (patient compliance OR medication adherence),
yielding 5331 articles.
Methods: Articles were included if they directly measured the relationship between
medication adherence and some form of social support. Excluded were case studies,
studies with participants younger than 18 years of age, and non-English language
studies. Four social support categories were reported: structural, practical,
emotional and combination. Medication adherence was reported in the manner in
which it was described in each study.
Results: 50 studies were included in the final analysis. A greater degree of practical
support was most consistently associated with greater adherence to medication;
evidence for structural or emotional support was less compelling. However, most
studies were limited in size and design, and substantial variability in designs and
outcome measurement prohibited pooling of results, necessitating qualitative
evaluation of the studies.
Conclusions: This qualitative analysis found that practical social support was most
consistently associated with greater medication adherence. Interventions that use
existing contacts (friends or family) to engage patients in the mundane and practical
aspects of medication purchasing and administration may be an effective approach to
promoting better medication adherence. (58 refs.)
http://www.ajmc.com/articles/Association-Between-Different-Types-of-Social-Support-andMedication-Adherence
175. Pharmacy effect on adherence to antidiabetic medications
KP Sharma, TN Taylor
Medical Care Aug 2012;50(8):685-691
Background: There have been a number of studies relating medication adherence to
patient characteristics. There is less research on influence of health care providers
on patients' medication-taking behaviour.
Objectives: To evaluate the pharmacy-level effect on medication adherence for
patients receiving antidiabetic medications.
Research Design: This was a hypothesis-driven retrospective study using crosssectional design and US insurance claims data. The main analytical interest was the
pharmacy-level effect on proportion of days covered as the measure of medication
adherence. Multilevel random and mixed-effect models were used to tease out the
pharmacy-level effect on patient outcomes.
Subjects: The study population consisted individuals aged 18-64 years, insured
under employer-sponsored private health plans.
Results: We estimated models with and without covariates. In both models,
pharmacy cluster effect was statistically significant (P less than 0.001). In the model
without covariates, pharmacy cluster effect accounted for 12.8% (95% CI, 12.4% to
13.1%) of total variance in adherence, whereas in the model with covariates
pharmacies accounted for 12.1% (95% CI, 11.6% to 12.4%) of total variance.
Covariates associated significantly with adherence were age, sex, mail order
pharmacy and prescription drug copay.
Conclusions: The results suggest significant variation in medication adherence
attributable to pharmacy factor, independent of other effects. The underlying reason
could be varying level of influence from pharmacies' efforts to inform or influence
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patients to take medications in prescribed manners. More research is necessary to
better understand the effect of specific pharmacy characteristics and differences in
practice styles.
http://journals.lww.com/lwwmedicalcare/Abstract/2012/08000/Pharmacy_Effect_on_Adherence_to_Antidiabetic.10.aspx
176. Persistence with nebivolol in the treatment of hypertension: a retrospective
claims analysis
JE Signorovitch, TM Samuelson, K Ramakrishnan, M Marynchenko, EQ Wu, SI Blum, A
Ramasamy, S Chen
Current Medical Research and Opinion Apr 2012;28(4):591-599
Objective: Examine drug persistence by evaluating the hazard of discontinuation and
of switching to different antihypertensive drugs in patients initiating treatment with a
recently approved beta-blocker, nebivolol, versus other beta-blockers.
Methods: This retrospective analysis included all patients diagnosed with
hypertension in the US MarketScan Database (Jan 2007 to Dec 2008) with at least
two medical claims and no prior beta-blocker prescriptions within 6 months of the
initial prescription date. Multivariate Cox proportional hazard models (adjusted for
baseline differences in demographics, previous use of other antihypertensive
medications, initial doses and supply of medication, and number of distinct
prescriptions at baseline) were used to assess the hazard of discontinuation, defined
as the first prescription gap of 30 days or longer, and to assess the hazard of
switching to another antihypertensive drug, defined as a prescription fill for another
antihypertensive drug within 15 days before and 30 days after discontinuation of the
initial beta-blocker.
Results: Of the 173,200 patients included in the study population, the adjusted
hazard of discontinuation for nebivolol-initiated patients was 8-20% lower than that
of patients who initiated treatment with atenolol (hazard ratio (HR) 0.82, p less than
0.001), metoprolol (HR 0.91, p less than 0.001), carvedilol (HR 0.92, p less than
0.001) or other beta-blockers (HR 0.80, p less than 0.001). The adjusted hazard of
nebivolol-treated patients switching to a different antihypertensive medication was
12-22% lower than that of the other four beta-blocker cohorts (atenolol: HR 0.80, p
less than 0.001; metoprolol: HR 0.86, p less than 0.001; carvedilol: HR 0.88, p less
than 0.001; other beta-blockers: HR 0.78, p less than 0.001). Sensitivity analyses
defined discontinuation as prescription gaps of 45 days or longer and 60 days or
longer and showed a lower hazard of discontinuation among patients initiating
nebivolol than among patients initiating all other drug cohorts (p less than 0.001).
Limitations: Comparisons of non-randomised treatment groups may be confounded
by unobserved differences in patients' baseline characteristics.
Conclusions: Initiation with nebivolol was associated with greater persistence than
initiation with atenolol, carvedilol, metoprolol or other beta-blockers.
177. Primacy of effective communication and its influence on adherence to
artemether-lumefantrine treatment for children under five years of age: a
qualitative study
DO Simba, DC Kakoko
BMC Health Services Research 8 Jun 2012;12:146
Background: Prompt access to artemesinin-combination therapy (ACT) is not
adequate unless the drug is taken according to treatment guidelines. Adherence to
the treatment schedule is important to preserve efficacy of the drug. Although some
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community-based studies have reported fairly high levels of adherence, data on
factors influencing adherence to artemether-lumefantrine (AL) treatment schedule
remain inadequate. This study was carried-out to explore the provider's instructions
to care-takers, care-takers' understanding of the instructions and how that
understanding was likely to influence their practice with regard to adhering to AL
treatment schedule.
Methods: A qualitative study was conducted in five villages in Kilosa district,
Tanzania. In-depth interviews were held with providers who included prescribers
and dispensers; and care-takers whose children had just received AL treatment.
Information was collected on providers' instructions to caretakers regarding dose
timing and how to administer AL; and care-takers' understanding of providers'
instructions.
Results: Mismatch was found on providers' instructions as regards to dose timing.
Some providers' (dogmatists) instructions were based on strict hourly schedule
(conventional) which was likely to lead to administering some doses at awkward
hours and completing treatment several hours before the scheduled time. Other
providers (pragmatists) based their instruction on the existing circumstances
(contextual) which was likely to lead to delays in administering the initial dose with
serious treatment outcomes. Findings suggest that the national treatment guidelines
do not provide explicit information on how to address the various scenarios found in
the field. A communication gap was also noted in which some important instructions
on how to administer the doses were sometimes not provided or were given with
false reasons.
Conclusions: There is need for a review of the national malaria treatment guidelines
to address local context. In the review, emphasis should be put on on-the-job
training to address practical problems faced by providers in the course of their work.
Further research is needed to determine the implication of completing AL treatment
prior to scheduled time.
178. Communication during pediatric asthma visits and self-reported asthma
medication adherence
B Sleath, DM Carpenter, C Slota, D Williams, G Tudor, K Yeatts, S Davis, GX Ayala
Pediatrics Oct 2012;130(4):627-633
Objective: Our objectives were to examine how certain aspects of provider-patient
communication recommended by national asthma guidelines (i.e. provider asking for
child and caregiver input into the asthma treatment plan) were associated with child
asthma medication adherence 1 month after an audio-taped medical visit.
Methods: Children aged 8 to 16 years with mild, moderate or severe persistent
asthma and their caregivers were recruited at 5 paediatric practices in nonurban
areas of North Carolina, USA. All medical visits were audio-tape recorded. Children
were interviewed 1 month after their medical visits, and both children and caregivers
reported the child's control medication adherence. Generalised estimating equations
were used to determine whether communication during the medical visit was
associated with medication adherence 1 month later.
Results: Children (n = 259) completed a home visit interview approx 1 month after
their audio-taped visit, and 216 of these children were taking an asthma control
medication at the time of the home visit. Children reported an average control
medication adherence for the past week of 72%, whereas caregivers reported the
child's average control medication adherence for the past week was 85%. Child
asthma management self-efficacy was significantly associated with both child- and
caregiver-reported control medication adherence. When providers asked for
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caregiver input into the asthma treatment plan, caregivers reported significantly
higher child medication adherence 1 month later.
Conclusions: Providers should ask for caregiver input into their child's asthma
treatment plan because it may lead to better control medication adherence.
http://pediatrics.aappublications.org/content/130/4/627.abstract
179. Perceived information needs and non-adherence: evidence from Greek
patients with hypertension
C Stavropoulou
Health Expectations Jun 2012;15(2):187-196
Background: The role of information on patients' decision to non-adhere is
important, yet not well explored.
Objective: To identify differences between perceived information needs for
hypertension and medication to treat it, to explore the information channels used by
patients and to test what type of information is more important to adhere to
medication.
Design, Setting and Participants: A questionnaire study was designed and conducted
by telephone in the Centre for the Treatment of Hypertension in Athens, Greece,
among 743 individuals.
Main Variables Studied: The main variables included perceived information needs,
information channels, non-adherence to medication and socio-demographic
characteristics.
Main Outcome Measures: Non-adherence to medication was measured using the
Morisky scale.
Results: Patients reported feeling better informed about hypertension (90%) than
medication to treat it (80%). The doctor remains the dominant information source,
while the media and magazines on health issues were reported more frequently than
the family and the pharmacist. Feeling well informed about medication for
hypertension was a predictor of better adherence. Other determinants of adherence
were the use of the Internet and the media.
Discussion: The results confirm the importance of patients leaving the consultation
feeling well informed about their medication as this improves adherence. They also
show that the use of the Internet and the media can be beneficial for adherence.
Conclusions: Given the restricted time the doctor can usually spend with the patient,
it is important to know that more emphasis on the information regarding medication
is important.
180. Self-reported adherence supports patient preference for the single tablet
regimen (STR) in the current cART era
G Sterrantino, L Santoro, D Bartolozzi, M Trotta, M Zaccarelli
Patient Preference and Adherence 7 Jun 2012;6:427-433
Objective: To analyse self-reported adherence to antiretroviral regimens containing
ritonavir-boosted protease inhibitors, nonnucleoside reverse transcriptase inhibitors
(NNRTI), raltegravir and maraviroc.
Methods: Overall, 372 consecutive subjects attending a referral centre for HIV
treatment in Florence, Italy, were enrolled in the study, from Dec 2010 to Jan 2012
(mean age 48 years). A self-report questionnaire was filled in. Patients were
defined as 'nonadherent' if reporting one of the following criteria: less than 90% of
pills taken in the last month, one or more missed dose in the last week, spontaneous
treatment interruptions reported or refill problems in the last 3 months. Gender,
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age, CD4, HIV-RNA, years of therapy and type of antiretroviral regimen were
analysed with respect to adherence.
Results: At the time of the questionnaire, 89.8% of patients had below 50 copies/mL
HIV-RNA and 14.2% were on their first combined antiretroviral therapy. 57% of
patients were prescribed a regimen containing ritonavir boosted protease inhibitors
(boosted PI), 41.7% NNRTI, 17.2% raltegravir and 4.8% maraviroc; 49.5% of the
subjects were on twice daily regimens, while 50.5% were on once daily regimens,
with 23.1% of these on the single tablet regimen (STR):
tenofovir/emtricitabine/efavirenz. The proportion of nonadherence was lower in
NNRTI than in boosted-PI treatments (19.4% vs 30.2%), and even lower in STR
patients (17.4%). In multivariable logistic regression, patients with the NNRTI
regimen (OR: 0.56; 95% CI, 0.34 to 0.94) and the STR (OR: 0.45; 95% CI, 0.22 to
0.92) reported lower nonadherence. Efavirenz regimens were also associated with
lower nonadherence (OR: 0.42; 95% CI, 0.21 to 0.83), while atazanavir/ritonavir
regimens were associated with higher nonadherence. No other relation to specific
antiretroviral drugs was found. A higher CD4 count, lower HIV-RNA and older age
were also found to be associated with lower nonadherence, while a longer time on
combined antiretroviral therapy was related to higher nonadherence.
Conclusion: STR maintains an advantage in improving adherence with respect to
other combined antiretroviral therapies, even though new antiretroviral drugs and
drug classes have become available in recent years.
181. Medication adherence among geriatric outpatients prescribed multiple
medications
K-T Tsai, J-H Chen, C-J Wen, H-K Kuo, et al.
American Journal of Geriatric Pharmacotherapy Feb 2012;10(1):61-68
Background: Poor medication adherence (PMA) is associated with higher risks of
morbidity, hospitalisation, and mortality. Polypharmacy is not only a determinant of
PMA but is also associated with many adverse health outcomes.
Objective: We aimed to determine the prevalence and correlates of PMA in an older
population with polypharmacy.
Methods: Baseline data from 193 older adults from the Medication Safety Review
Clinic Taiwan Study were analysed. Patients were either prescribed 8 or more longterm medications or visited 3 or more different physicians between Aug and Oct
2007. PMA was defined as taking either less than 80% or more than 120% of
prescribed amounts of a medication. Patients were classified as no (0%), low level
(more than 0 but less than 25%) and high level (25% or more) PMA depending on
what percentage of entire medication regimen taken reached PMA.
Results: Mean (SD) age was 76 (6) years, and mean number of medications was 9
(3), with a mean medication class number of 4 (1). Of the 1713 medications
reviewed, 19% had PMA. However, at patient level, 34%, 32% and 34% of patients
were classified as no, low level and high level PMA, respectively. Correlates varied
by levels of PMA. Compared with patients without PMA, higher medication class
number and use of alimentary tract, psychotropic and haematological agents were
associated with both low and high level PMA. History of dizziness was associated
with low level PMA, and higher Mini Mental Status Examination score was associated
with high level PMA.
Conclusions: To enhance medication adherence in older adults prescribed multiple
medications, medication class numbers and certain high-risk medication classes
should be taken into account. Physicians should also routinely assess systemic (e.g.
cognition) or drug-specific characteristics (e.g. side effects).
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182. Second-year pharmacy students' perceptions of adhering to a complex
simulated medication regimen
T Ulbrich, D Hamer, K Lehotsky
American Journal of Pharmaceutical Education 2012;76(1):article 11
Objective: To conduct a simulated medication regimen with second-year pharmacy
students to determine their anticipated versus actual difficulty in adhering to it.
Methods: Second-year pharmacy students at Northeast Ohio Medical University were
given 6 fictitious medications (jellybeans) and a drug regimen to adhere to for 6
days. Pre- and post-intervention surveys were conducted to compare participants
anticipated vs actual difficulty with adherence and changes in empathy toward
patients.
Results: The 69 (96%) students who participated in the study missed on average
16% of all simulated medication doses and noted that adhering to the complex
medication regimen was more difficult than they had anticipated. 89% of students
agreed or strongly agreed the project was valuable in developing empathy towards
patients taking complex medication regimens.
Conclusions: Pharmacy students participating in a simulated medication regimen
missed a notable number of doses and reported a greater level of empathy for
patients taking complex medication regiments. Finding meaningful ways to integrate
adherence into the curriculum is essential.
http://www.ajpe.org/doi/pdf/10.5688/ajpe76111
183. Psychiatrists' perceptions of potential reasons for non- and partial adherence
to medication: results of a survey in bipolar disorder from eight European
countries
E Vieta, J-M Azorin, M Bauer, S Frangou, G Perugi, G Martinez, A Schreiner
Journal of Affective Disorders 20 Dec 2012;143(1-3):125-130
Background: Partial/non-adherence to medication by patients with bipolar disorder is
associated with exacerbation of symptoms, neurocognitive decline and increased risk
of suicide and has a major influence on patient outcomes. Understanding
psychiatrists' views on the causes and management of non-adherence are vital to
address adherence problems effectively.
Methods: A 15-question survey was conducted of 2448 psychiatrists treating patients
with bipolar disorder in eight European countries to ascertain their perceptions of the
level and causes of non-adherence, and their preferred methods by which to assess
it.
Results: A majority of patients (57%) were estimated to be partially/non-adherent.
Three in four psychiatrists responded that most patients who deteriorated after
stopping medication were unable to attribute this to non-adherence. An irregular
daily routine/living circumstance affecting adherence was considered the most
important reason for patients discontinuing medication. Only 4% of psychiatrists
deemed intolerable side effects had led to most patients stopping their medication;
11% responded that drug/alcohol consumption may have impacted on adherence to
medication for the majority of patients.
Limitations: The survey was not distributed to all psychiatrists in the countries and
the impact on the results, of any difference in the demographics of the respondents
with respect to the population of psychiatrists across the eight countries, is not
known.
Conclusions: Partial/non-adherence remains a considerable problem amongst
patients with bipolar disorder. There is a need for increased knowledge concerning
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partial/non-adherence at the level of the clinician–patient interaction, to reduce its
impact and bring about improved clinical outcomes.
184. Asthma controller adherence in mail order pharmacy compared to retail
pharmacy
J Visaria, S Glave Frazee, ST Devine
American Journal of Pharmacy Benefits May-Jun 2012;4(3):e73-e80
Objectives: To determine whether the use of mail order pharmacy is associated with
improved medication adherence to asthma controller medication (ACM) compared
with retail pharmacy and whether dispensing channel has an impact on patients' allcause medical costs.
Methods: Commercially insured US patients aged 12 to 63 years with access to mail
order and retail pharmacy, medically diagnosed for asthma and started on ACM,
were selected and followed for 1 year using a retrospective, claim-based design.
Medication possession ratio (MPR) for the index ACM agent was used as a proxy for
adherence. Medical costs were classifi ed as asthma-specific and all-cause costs.
The relationship between index ACM claim dispensing channel and outcomes was
evaluated using a generalised linear model.
Results: A total of 6014 patients were included in the final study cohort. The
adjusted MPR for ACM in the retail pharmacy cohort was 39.70% (95% CI, 37.08%
to 42.52%) compared with 62.43% (95% CI, 58.19% to 66.97%) in the mail order
cohort. Patients in the mail order cohort had a greater likelihood of having an MPR
of 80% or greater (odds ratio (OR) 2.28; 95% CI, 1.97 to 2.63) compared with
retail. After multivariate adjustment, there were no significant differences in
asthma-related and all-cause medical costs between mail order and retail pharmacy
cohorts.
Conclusions: Patients using mail order pharmacy had significantly better average
adherence to ACM compared with retail, though overall average ACM adherence was
poor and may explain the lack of association between adherence and medical cost.
Mail order pharmacy may help patients reach optimal adherence over the course of
ACM therapy.
http://www.ajpblive.com/media/pdf/AJPB_12mayjun_Visaria_e73to80.pdf
185. Factors influencing adherence to antiretroviral treatment in Asian
developing countries: a systematic review
SP Wasti, E van Teijlingen, P Simkhada, J Randall, S Baxter, P Kirkpatrick, VS Gc
Tropical Medicine and International Health Jan 2012;17(1):71-81
Objective: To review systematically the literature on factors affecting adherence to
antiretroviral treatment (ART) in Asian developing countries.
Methods: Database searches in Medline/Ovid, Cochrane library, CINAHL, Scopus and
PsychINFO for studies published between 1996 and Dec 2010. The reference lists of
included papers were also checked, with citation searching on key papers.
Results: A total of 437 studies were identified, and 18 articles met the inclusion
criteria and were extracted and critically appraised, representing 12 quantitative, 4
qualitative and two mixed-method studies. 22 individual themes, including financial
difficulties, side effects, access, stigma and discrimination, simply forgetting and
being too busy, impeded adherence to ART, and 11 themes, including family support,
self-efficacy and desire to live longer, facilitated adherence.
Conclusions: Adherence to ART varies between individuals and over time. We need
to redress impeding factors while promoting factors that reinforce adherence through
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financial support, better accessible points for medicine refills, consulting doctors for
help with side effects, social support and trusting relationships with care providers.
186. Associations between self-reported adherence to asthma anti-inflammatory
therapy and child/parent attitudes and behaviors regarding disease management
AG Weinstein, J Laurenceau, J Vok
Journal of Allergy and Clinical Immunology Feb 2012;129(2-Suppl.):AB143
Presented at the American Academy of Allergy, Asthma and Immunology annual meeting,
Orlando, Florida, USA, 2-6 Mar 2012.
Background: Assessment of patient adherence status and reasons for non-adherence
can assist physicians in helping patients to overcome these barriers, and ultimately
improve asthma outcomes.
Methods: 361 parents of children (59.6% male; 64.1% Caucasian; mean age 8.07
years) with intermittent and persistent asthma completed the AsthmaPACT (from
8/2009 to 6/2011). This survey, hosted by the Asthma and Allergy Foundation of
America website, serves to identify barriers to adherence to asthma treatment.
Results: 259 parents (72%) reported giving their child anti-inflammatory
medications (AI) prescribed by their physician. Of these, 69 (27%) were classified
as non-adherent. Non-adherence was operationalised as parental report of giving at
least one AI 'less than prescribed by their physician'. During the 4 weeks prior to
completing the survey, 43% of those receiving AI reported having daily symptoms.
In this cross-sectional data set, items intended to relate risk factors to nonadherence were examined using chi-squared analysis. Individuals classified as nonadherent were more likely to report: 1) Ineffective asthma management behaviours
by the child such as medication forgetfulness (p = 0.001); poor trigger avoidance, (p
= 0.013); lack of perception of worsening asthma, (p = 0.008); and delaying
treatment (p less than 0.001) and 2) Negative attitudes about medication by the
parent: medication does not work, (p = 0.002); child is taking too much medicine;
(p = 0.001); refusal to administer oral steroids (p = 0.002) as well as inhaled
corticosteroids, (p less than 0.001).
Conclusions: By providing both patient self-report of adherence and identifying risk
factors for non-adherence, the AsthmaPACT can help physicians to have meaningful
conversations with patients to overcome these barriers.
http://www.jacionline.org/article/S0091-6749(11)02443-2/fulltext
187. Characterisation of complementary and alternative medicine use and its
impact on medication adherence in inflammatory bowel disease
AV Weizman, E Ahn, R Thanabalan, W Leung, K Croitoru, MS Silverberg, AH Steinhart, GC
Nguyen
Alimentary Pharmacology and Therapeutics Feb 2012;35(3):342-349
Background: Complementary and alternative medicine (CAM) use among
inflammatory bowel disease (IBD) patients is common. We characterised CAM
utilisation and assessed its impact on medical adherence in the IBD population.
Aim: To characterise CAM utilisation and assess its impact on medical adherence in
the IBD population.
Methods: Inflammatory bowel disease patients recruited from an out-patient clinic at
a tertiary centre in Canada were asked to complete a questionnaire on CAM
utilisation, conventional IBD therapy, demographics and communication with their
gastroenterologist. Adherence was measured using the self-reported Morisky scale.
Demographics, clinical characteristics and self-reported adherence among CAM and
non-CAM users were compared.
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Results: We recruited prospectively 380 IBD subjects (57% Crohn’s disease; 35%
ulcerative colitis and 8% indeterminate colitis). The prevalence of CAM use was 56%
and did not significantly vary by type of IBD. The most common reason cited for
using CAM was ineffectiveness of conventional IBD therapy (40%). The most
popular form of CAM was probiotics (53%). CAM users were younger than non-CAM
users at diagnosis (21.2 vs 26.2, P less than 0.0001) and more likely than non-CAM
users to have a University-level education or higher (75% vs 62%, P = 0.006).
There was no overall difference in adherence between CAM and non-CAM users
(Morisky score: 1.0 vs 0.9, P = 0.26).
Conclusions: The use of complementary and alternative medicine is widely prevalent
among IBD patients, and is more frequent among those with experience of adverse
effects of conventional medications. From this cross-sectional analysis,
complementary and alternative medicine use does not appear to be associated with
reduced overall adherence to medical therapy.
188. Predictors of noncompliance in an oral contraceptive clinical trial
CL Westhoff, AT Torgal, ER Mayeda, N Shimoni, FZ Stanczyk, MC Pike
Contraception May 2012;85(5):465-469
Background: This analysis was conducted to identify the participant characteristics
associated with noncompliance in an oral contraceptive (OC) clinical trial.
Study Design: We studied ovarian suppression among normal-weight and obese
women during the use of levonorgestrel (LNG)-containing combination OCs.
Participants underwent twice weekly phlebotomy during the study cycle and received
up to US$360 for participation. Along with other study assays, we analysed 903
specimens from 181 women to measure LNG to assess OC compliance. Consistently
undetectable LNG levels indicated noncompliance. To evaluate predictors of OC
noncompliance during this study, we compared the characteristics of compliant and
noncompliant participants using multivariable logistic regression. We assigned each
participant to a relative poverty level based on US census data; all other individual
characteristics came directly from participant responses during the baseline
interview.
Results: 181 women completed the study; 31 were noncompliant (17%). In
multivariable analyses, poverty level was the strongest predictor of noncompliance.
Compared with those women in the quartile with the lowest level of residential
poverty, other women were far more likely to be noncompliant, especially women in
the quartile with the greatest prevalence of poverty (adjusted odds ratio, 8.4; 95%
CI, 1.5 to 46.1). Additional factors associated with noncompliance were education
level less than a bachelor's degree and Hispanic ethnicity. Other demographic and
psychometric measures were not associated with compliance.
Conclusions: We found that noncompliance was strongly associated with residential
poverty level, an indirect measure of individual income. In the United States,
poverty is associated with female obesity, Hispanic ethnicity and low education,
which were also associated here with noncompliance. Study compensation may
motivate poor individuals to participate in clinical trials for income. Noncompliance
in clinical trials, particularly differential noncompliance, jeopardises study validity.
http://www.contraceptionjournal.org/article/S0010-7824(11)00573-7/abstract
189. Factors of hyperlipidemia medication adherence in a nationwide health plan
P Wiegand, JS McCombs, JJ Wang
American Journal of Managed Care Apr 2012;18(4):193-199
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Objectives: To evaluate the factors associated with nonadherence in a US nationally
representative sample of patients receiving lipid-lowering therapy (LLT).
Study Design: Retrospective database analysis of treatment-naive (1 year without
LLT claim) hyperlipidaemia patients evidenced by a new pharmacy claim for lipidlowering therapy.
Methods: Pharmacy and medical claims data were analysed for currently enrolled
members receiving a new LLT from 2007 to 2008. Adherence was defined as
percentage of days covered (PDC) and values below 80% were used to categorise
nonadherent patients. Independent variables included patient demographics,
pharmacy utilisation and medical conditions. Stepwise logistic regression was used
to predict the odds of nonadherence. Laboratory data variables were incorporated in
an exploratory sub-analysis to test the robustness of the original model.
Results: Adherence to LLT was estimated in 88,635 patients. 65% of patients were
nonadherent (mean PDC = 0.33). Compared with statins, patients treated with bile
acid sequestrants were 6.75 times as likely to be nonadherent (P less than 0.001).
Significant (P less than 0.05) predictors of nonadherence included age 45 to 55 years
(ref: age over 75 years) (odds ratio (OR): 1.11); prior diabetes diagnosis (OR:
1.15); and unique pharmacies used (OR = 1.10). Significant factors reducing
nonadherence include male gender (OR: 0.77); previous heart attack (OR: 0.82);
prior adherent behaviour (OR: 0.89); and unique physicians seen (OR: 0.97).
Compared with no copayment, patients with US$5 to $30 copayments had a
significant reduction in the likelihood of nonadherence.
Conclusions: Medication adherence remains poor in patients receiving LLT.
Treatment outcomes and healthcare resource use may be improved by prioritising
adherence programmes in at-risk patient populations.
http://www.ajmc.com/publications/issue/2012/2012-4-vol18-n4/Factors-of-HyperlipidemiaMedication-Adherence-in-a-Nationwide-Health-Plan
190. Measures of adherence to oral hypoglycemic agents at the primary care clinic
level: the role of risk adjustment
ES Wong, JD Piette, C-F Liu, M Perkins, ML Maciejewski, GL Jackson, DK Blough, SD Fihn,
DH Au, CL Bryson
Medical Care Jul 2012;50(7):591-598
Background: Prior research found that in the US Veterans Affairs health care system
(VA), the proportion of patients adherent to oral hypoglycaemic agents varies from
50% to 80% across primary care clinics. This study examined whether variation in
patient and facility characteristics determined those differences.
Methods: Retrospective cohort study of 444,418 VA primary care patients with
diabetes treated in 559 clinics in fiscal year (FY) 2006-07. Patients' adherence to
each oral hypoglycaemic agent was computed for the first 3 months of FY2007 and
averaged across agents to produce an adherence score for the patient's overall
regimen. Patients with an adherence score over 0.8 were defined as adherent. Risk
adjustment used hierarchical logistic regression accounting for patient factors and
facility effects by clustering patients within clinics and clinics within parent VA
medical centres. We then assessed the influence of risk adjustment using observedto-expected (O/E) ratios computed for each clinic.
Results: The mean unadjusted proportion of adherent patients in clinics was 0.715
(interdecile range 0.559-0.826). The percentage variation in patients' likelihood of
being adherent explained at the patient, clinic and parent VA medical centre levels
was 2.94%, 0.27% and 0.76%, respectively. The mean clinic-level observed-toexpected ratio was 1.001 (interdecile range 0.975-1.027).
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Conclusions: The variation in the proportion of patients adherent across clinics
remained large after risk adjustment. As patient and facility effects explained only
4% of the variance in adherence, comparing clinics based on unadjusted scores is a
reasonable starting point unless more predictive patient, provider and facility factors
are identified.
http://journals.lww.com/lwwmedicalcare/Abstract/2012/07000/Measures_of_Adherence_to_Oral_Hypoglycemic_Agents.
6.aspx
191. Discontinuation of angiotensin-converting enzyme inhibitors: a cohort study
MCS Wong, RKC Lau, JY Jiang, SM Griffiths
Journal of Clinical Pharmacy and Therapeutics Jun 2012;37(3):335-341
Objective: Angiotensin-converting enzyme inhibitors (ACEI) are among the most
commonly used antihypertensive agents worldwide. Factors associated with their
discontinuation in clinical practice are not well defined as studies undertaken in
different ethnic populations have yielded conflicting results. We aimed to identify
predictors of ACEI discontinuation among Chinese patients.
Methods: We used a validated clinical database for this cohort study. We included all
adult patients aged 18 years or older who visited any primary care clinic in one
Territory of Hong Kong and who were prescribed an ACEI from Jan 2004 to Jun
2007. The cumulative incidence of discontinuation 180 days after prescription of an
ACEI was measured. Factors associated with discontinuation were evaluated by
multiple regression analyses.
Results: Among 9398 eligible patients, 14.0% discontinued their prescriptions. After
controlling for patient’s age, gender, socio-economic status, service type, district of
residence, visit type and number of comorbidities, patients aged 70 or above
(adjusted odds ratio (AOR) = 1.27; 95% CI, 1.04 to 1.56; P = 0.022), male subjects
(AOR = 1.21; 95% CI, 1.05 to 1.40; P = 0.008), new visitors (AOR = 0.64; 95% CI,
0.55 to 0.75; P less than 0.001), patients who obtained their prescriptions in a
Family Medicine Specialist Clinic (FMSC) (AOR = 1·43, 95% CI, 1.14 to 1.79; P =
0.002), patients who lived in the less urbanized district (AOR = 1.96; 95% CI, 1.55
to 2.48; P less than 0.001) and the most rural district (AOR = 1.24; 95% CI, 1.03 to
1.49; P = 0.027), and patients with no comorbidity, were more likely to discontinue
their medications.
Conclusions: Physicians should pay attention to adherence problems particularly
when prescribing ACEI to male patients, those who are older than 70 years, have no
comorbidity, live in less urbanised or more rural areas, qualify for fee-waiver, are
new attendees of consultations or obtain their ACEI prescriptions in FMSC. Future
research should evaluate the reasons for ACEI discontinuation among these higherrisk groups.
192. Visiting friends and relatives may be a risk for non-adherence for HIV-positive
travelers
I Woolley, C Bailey
International Journal of STD and AIDS Nov 2012;23(11):833-834
Report of three cases of immigrants to Australia, living with HIV/AIDS, who, while
travelling in countries of origin or migration, were unable to continue to take their
antiretrovirals appropriately. The authors discuss the possible reasons for this and
ways to reduce the possibility of it happening. Travel may be a significant risk factor
for non-adherence; pre-travel advice and planning might help to prevent it occurring.
http://ijsa.rsmjournals.com/content/23/11/833.abstract
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193. The association of race, comorbid anxiety, and antidepressant adherence
among Medicaid enrollees with major depressive disorder
C-H Wu, SR Erickson, JD Piette, R Balkrishnan
Research in Social and Administrative Pharmacy May-Jun 2012;8(3):193-205
Background: Depressed patients often have comorbid anxiety. African-Americans
with depression are less likely to adhere to antidepressant treatment. Knowledge of
the association between race, comorbid anxiety and adherence among Medicaid
enrollees with depression is limited.
Objective: The objective of this study was to evaluate the association of race,
comorbid anxiety, and antidepressant adherence and persistence among US Medicaid
enrollees with major depressive disorder (MDD).
Methods: The MarketScan Multi-State Medicaid Database (Thomson Reuters, Ann
Arbor, MI, USA) was used in this retrospective cross-sectional study. Medicaid
enrollees aged between 18 and 64 years, with MDD but without bipolar disorders,
and with a newly initiated antidepressant between 1 Jan 2004 and 31 Dec 2006 were
identified. An index date was assigned corresponding to the newly initiated
antidepressant. Patients having claims for any antidepressant refills during the 12
months before the index date were excluded. Eligible patients were then followed-up
for 12 months after the index date. Adherence was measured by a modified
medication possession ratio. Adherence was evaluated using multivariate logistic
regression. Persistence was assessed based on treatment discontinuation and
examined by Kaplan-Meier survival curves and Cox-propositional hazard regression
models.
Results: A total of 3083 Medicaid patients with MDD were included. Approximately
25% of patients had comorbid anxiety. The odds of adhering to antidepressants
were 40% lower among African-Americans than Caucasians, adjusting for covariates
(AOR (adjusted odds ratio) = 0.60; 95% CI, 0.51 to 0.72; P less than 0.001). MDD
patients with comorbid anxiety were more likely to adhere to antidepressants than
patients with MDD alone (AOR = 1.55; 95% CI, 1.27 to 1.90; P less than 0.001).
African-Americans had a higher hazard of not persistently taking antidepressants
(hazard ratio = 1.47; 95% CI, 1.30 to 1.65; P less than 0.001). The interaction
between race and comorbid anxiety was not associated with adherence or
persistence.
Conclusions: Among Medicaid enrollees with MDD, race and comorbid anxiety
disorders are significantly associated with antidepressant adherence and persistence.
Physicians need to recognise comorbid anxiety and race as two important
determinants of antidepressant use behaviours when they encounter Medicaid
patients with MDD.
http://www.rsap.org/article/S1551-7411(11)00047-7/abstract
194. A pilot study on cost-related medication nonadherence in Ontario
B Zheng, A Poulose, M Fulford, A Holbrook
Journal of Population Therapeutics and Clinical Pharmacology 2012;19(2):e239-e247
Background: Cost-related nonadherence (CRN) describes patients cutting back on
their prescribed medication due to an inability to pay. CRN is influenced by drug
insurance coverage plans, which vary widely among different healthcare systems.
Little is known about CRN in Canada and Ontario.
Objective: To develop and pilot a questionnaire about CRN.
Methods: An interviewer-administered questionnaire assessing demographics,
socioeconomic status, health status and health literacy, medication costs and CRN
was developed for this pilot study. Participants were recruited from a general
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internal medicine rapid assessment outpatient clinic of a large urban teaching
hospital.
Results: 60 patients were recruited (mean age 60.3 years; 48.3% female; mean of
5.3 prescription medications per patient). Nine patients (15%) reported some form
of CRN. Unfilled prescriptions, delayed prescriptions, less frequent and smaller doses
were the most common forms of CRN. Seven patients (11.7%) had no drug
insurance. Patients without drug insurance were more likely to experience CRN than
patients with private insurance (OR 20.70; 95% CI, 1.46 to 292.75); government
coverage also increased the likelihood of CRN compared to private coverage (OR
4.51; 95% CI, 0.376 to 54.11). Patients spending over Can$100 a month out-ofpocket were more likely to experience CRN than patients spending less than $20 (OR
42.52; 95% CI, 2.02 to 894.03). 33 patients (55%) said that their physicians had
not asked them about how they deal with the cost of prescriptions.
Conclusions: Based on our pilot survey, a significant minority of specialty clinic
outpatients experience CRN and prescribers frequently forget to inquire whether
patients can afford their medications.
http://www.cjcp.ca/jptcpe239_e247_holbrook-r185510
195. Does an increase in non-antihypertensive pill burden reduce adherence with
antihypertensive drug therapy?
IH Zuckerman, M Sato, GB Rattinger, C Zacker, B Stuart
Journal of Pharmaceutical Health Services Research Sep 2012;3(3):135-139
Objectives: Hypertensive patients often are prescribed multiple medications for their
hypertension as well as for other chronic conditions. Poor adherence has been both
positively and negatively associated with increasing numbers of medications or
required daily doses. We sought to determine whether adherence with
antihypertensive drugs changes in response to a change in non-antihypertensive pill
burden.
Methods: This retrospective cohort analysis used 2006-2007 US MarketScan
Medicare Supplemental and Coordination of Benefits administrative data. The study
sample comprised 471,359 beneficiaries diagnosed with hypertension. We measured
monthly proportion of days covered (PDC) with antihypertensive medications and
average number of daily doses with non-antihypertensive drugs (pill burden). We
assessed the effect of changes in pill burden on subsequent changes in
antihypertensive PDC using difference equations with sensitivity tests for the sign
and magnitude of monthly change in pill burden and the presence of physician visits.
Key Findings: Changes in monthly non-antihypertensive pill burden had essentially
no impact on antihypertensive adherence rates for Medicare beneficiaries in retiree
health plans. A monthly addition of one non-antihypertensive pill/day resulted in a
statistically significant reduction in the following month's antihypertensive medication
PDC of approximately one percentage point (-0.98). Similar results were obtained in
a 3-month lag model (-0.88). These findings were insensitive to changes in model
parameters.
Conclusions: While physicians should pay close attention to individual factors that
may affect their patients' adherence to antihypertensive medications, these findings
indicate that changes in medications used to treat concomitant diseases should have
little short-term impact on antihypertensive adherence.
196. Unfilled prescriptions in pediatric primary care
RT Zweigoron, HJ Binns, RR Tanz
Pediatrics Oct 2012;130(4):620-626
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Background and Objectives: Filling a prescription is the important first step in
medication adherence, but has not been studied in paediatric primary care. The
objective of this study was to use claims data to determine the rate of unfilled
prescriptions in paediatric primary care and examine factors associated with
prescription filling.
Methods: This retrospective observational study of paediatric primary care patients
in the USA compares prescription data from an electronic medical record with
insurance claims data. Illinois Medicaid provided claims data for 4833 patients who
received 16,953 prescriptions during visits at 2 primary care sites over 26 months.
Prescriptions were compared with claims to determine filling within 1 day and 60
days. Clinical and demographic variables significant in univariate analysis were
included in logistic regression models.
Results: Patients were 51% male; most (84%) spoke English and were AfricanAmerican (38.7%) or Hispanic (39.1%). 78% of all prescriptions were filled. Among
filled prescriptions, 69% were filled within 1 day. African-American, Hispanic and
male patients were significantly more likely to have filled prescriptions. Younger age
was associated with filling within 1 day but not with filling within 60 days.
Prescriptions for antibiotics, from one of the clinic sites, from sick/follow-up visits,
and electronic prescriptions were significantly more likely to be filled.
Conclusions: More than 20% of prescriptions in a paediatric primary care setting
were never filled. The significant associations with clinical site, visit type and
electronic prescribing suggest system-level factors that affect prescription filling.
Development of interventions to increase adherence should account for the factors
that affect primary adherence.
http://pediatrics.aappublications.org/content/130/4/620.abstract
119
Effect of Adherence on Outcomes and Costs
Non-adherence has been shown to be associated with markers of
poorer clinical outcomes198 such as inadequate control of blood
pressure236 or blood glucose251,252, and even with mortality203.
This is presumably the reason for observations of increased use of
healthcare services such as hospitalisation, emergency department visits
and primary care appointments.
This in turn results in increased health care costs210,211,224. In some cases,
interventions to improve adherence have been shown to be cost –
effective212,274 or even cost-saving.
One interesting result229 showed improved outcomes associated with
better adherence to placebo, which raises the possibility that to some
extent adherence to medications may be a marker for a number of
behaviours associated with improved health.
197. Nonadherence to oral mercaptopurine and risk of relapse in Hispanic and nonHispanic white children with acute lymphoblastic leukemia: a report from the
Children's Oncology Group
S Bhatia, W Landier, M Shangguan, L Hageman, et al.
Journal of Clinical Oncology 10 Jun 2012;30(17):2094-2101
Purpose: Systemic exposure to mercaptopurine (MP) is critical for durable remissions
in children with acute lymphoblastic leukaemia (ALL). Nonadherence to oral MP
could increase relapse risk and also contribute to inferior outcome in Hispanics. This
study identified determinants of adherence and described impact of adherence on
relapse, both overall and by ethnicity.
Patients and Methods: A total of 327 children with ALL (169 Hispanic; 158 nonHispanic white) participated. Medication Event-Monitoring System (MEMS) caps
recorded date and time of MP bottle openings. Adherence rate, calculated monthly,
was defined as ratio of days of MP bottle opening to days when MP was prescribed.
Results: After 53,394 person-days of monitoring, adherence declined from 94.7%
(month 1) to 90.2% (month 6; P less than 0.001). Mean adherence over 6 months
was significantly lower among Hispanics (88.4% vs 94.8%; P less than 0.001),
patients age 12 years or older (85.8% vs 93.1%; P less than 0.001) and patients
from single-mother households (80.6% vs 93.1%; P = 0.001). A progressive
increase in relapse was observed with decreasing adherence (reference: adherence
= 95% or higher; 94.9% to 90%: hazard ratio (HR), 4.1; 95% CI, 1.2 to 13.5; P =
0.02; 89.9% to 85%: HR, 4.0; 95% CI, 1.0 to 15.5; P = 0.04; less than 85%: HR.
5.7; 95% CI, 1.9 to 16.8; P = 0.002). Cumulative incidence of relapse (+/standard deviation) was higher among Hispanics (16.5% +/- 4.0% vs 6.3% +/2.2%; P = 0.02). Association between Hispanic ethnicity and relapse (HR, 2.6; 95%
CI, 1.1 to 6.1; P = 0.02) became nonsignificant (HR, 1.8; 95% CI, 0.6 to 5.2; P =
0.26) after adjusting for adherence and socioeconomic status. At adherence rates of
90% or higher, Hispanics continued to demonstrate higher relapse, whereas at rates
below 90%, relapse risk was comparable to that of non-Hispanic whites.
120
Conclusions: Lower adherence to oral MP increases relapse risk. Ethnic difference in
relapse risk differs by level of adherence - an observation currently under
investigation.
http://jco.ascopubs.org/content/30/17/2094.abstract
198. Associating medication adherence with improved outcomes: a systematic
literature review
KA Boswell, CL Cook, SP Burch, MT Eaddy, CR Cantrell
American Journal of Pharmacy Benefits Jul-Aug 2012;4(4):e97-e108
Objectives: To evaluate the strength of the evidence addressing the relationship
between medication adherence and outcomes across selected common chronic
diseases and to identify gaps in the literature.
Study Design: Systematic literature review.
Methods: Original research articles relating medication adherence to clinical,
economic and/or utilisation outcomes in North American study populations were
examined for 12 diseases: coronary artery disease (CAD)/hyperlipidaemia, heart
failure (HF), hypertension, post–myocardial infarction (post-MI), bipolar disorder,
depression, schizophrenia, diabetes, migraine, seizures, asthma and chronic
obstructive pulmonary disease (COPD). A 10-point rating system was developed to
further quantify the level of evidence: range, -5 (lowest) to 5 (highest).
Results: A total of 105 articles (none for migraines) were eligible. Most clinical
outcomes were positively related to adherence, ranging from 64.3% to 100%
positive across the diseases (81.0% positive overall); neutral relationships accounted
for all remaining clinical outcomes. Although most economic and utilisation
outcomes were positively related to adherence (56.6% and 73.6%, respectively),
results were based on fewer studies and demonstrated greater variability (including
some negative relationships) relative to clinical outcomes. The level-of-evidence
rating system demonstrated overall positive scores for most clinical, economic and
utilisation outcomes, with exceptions being HF- and asthma-related economic
outcomes, and COPD-related clinical and economic outcomes.
Conclusions: The highest levels of evidence were achieved for studies pertaining to
post-MI, CAD/hyperlipidaemia, schizophrenia and diabetes, all disease states for
which more than 10 studies assessed the adherence-outcomes association. Few
studies were identified for seizures, migraines and COPD, illustrating gaps in the
literature where future investigation is needed.
http://www.ajpblive.com/media/pdf/AJPB_12julaug_Boswell_e97to108apdx.pdf
199. Association between second-generation antipsychotic medication half-life and
hospitalization in the community treatment of adult schizophrenia
MS Broder, JA Bates, Y Jing, T Hebden, RA Forbes, E Chang
Journal of Medical Economics Feb 2012;15(1):105-111
Objective: To examine the effect of antipsychotic medication half-life on the risk of
psychiatric hospital admission and emergency department (ED) visits among adults
with schizophrenia.
Methods: Retrospective claims-based cohort study of adult US Medicaid patients with
schizophrenia who were prescribed second-generation antipsychotic monotherapy
following hospital discharge between 1 Jan 2004 and 31 Dec 2006. Cox proportional
hazards models were applied to compare adjusted hazards of mental disorder
admission among patients treated with oral antipsychotics that have either a long
(risperidone (t1/2 = 20 h), olanzapine (t1/2 = 30 h), aripiprazole (t1/2 = 75 h))
(n = 1479) or short (quetiapine (t1/2 = 6 h), ziprasidone (t1/2 = 7 h)) (n = 837) halflife. Day-level models controlled for baseline background characteristics and
121
antipsychotic adherence over time as measured by gaps in the prescription record.
Similar analyses examined either hospitalisation or ED visits as separate endpoints.
Results: A significantly lower rate of hospitalisation/ED visits was evident for long
(0.74/patient-year) vs short (1.06/patient-year) half-life antipsychotics (p less than
0.001). The unadjusted rate of hospitalisation alone was significantly lower for long
(0.38/patient-year) vs short (0.52/patient-year) half-life antipsychotics (p = 0.005).
Compared with short half-life antipsychotic drugs, the adjusted hazard ratio
associated with long half-life medications was 0.77 (95% CI, 0.67 to 0.88) for
combined hospitalisation/ED visits and 0.80 (95% CI, 0.67 to 0.96) for
hospitalisation. The corresponding number needed to treat with long, rather than
short, half-life medications to avoid one hospitalisation was 16 patients for 1 year
and to avoid one hospitalisation or ED visit was 11 patients for 1 year.
Limitations: This study demonstrated an association between antipsychotic
medication half-life and hospitalisation, not a causal link. Patients using long half-life
medications had fewer comorbid mental health conditions and took fewer psychiatric
medications at baseline. Other unmeasured differences may have existed between
groups and may partially account for the findings.
Conclusions: In schizophrenia management, longer-acting second-generation
antipsychotics were associated with a lower risk of hospital admission/ED visits for
mental disorders. Authors suggest that patients using long half-life antipsychotics
would be less affected by imperfect adherence to treatment.
The study was funded by Bristol-Myers Squibb Co. and Otsuka Pharmaceuticals.
200. Adequate adherence to intranasal corticosteroids is associated with
significantly reduced number and costs of outpatient visits among patients newly
diagnosed with allergic rhinitis
PO Buck, CS Hankin, L Cox, A Bronstone, Z Wang, MS Lepore
Value in Health Nov 2012;15(7):A282
Paper MA4 presented at the ISPOR 15th Annual European Congress, Berlin, 3-7 Nov 2012.
Two of the authors are with Teva Pharmaceuticals.
201. Effect of a continuous measure of adherence with infliximab maintenance
treatment on inpatient outcomes in Crohn's disease
CT Carter, HC Waters, DB Smith
Background: To assess the impact of a continuous measure of adherence with
infliximab maintenance treatment in Crohn's disease (CD) during the first year of
treatment on CD-related health care utilisation, CD-related hospitalisations, inpatient
costs and length of hospital stay.
Patients and Methods: A retrospective claims analysis using the IMS LifeLink Health
Plan Claims Database (1 Sep 2004 to 30 Jun 2009) was conducted. Continuous
enrollment for 12 months before and 12 months after the index date was required.
Patients were required to have at least two claims with an International Classification
of Diseases, 9th Revision, Clinical Modification diagnosis code for CD (555.xx) preindex and be aged 18 years or older at index. Patients with three infusions during
the first 56 days post-index and at least one infusion following day 56 post-index
were considered to have maintenance therapy. Adherence and nonadherence were
defined as a medication possession ratio of 80% or higher and less than 80%,
respectively.
122
Results: 448 patients were included in the analysis (mean age, 42.6 years; 56%
female; mean +/- standard deviation (SD) and median number of infliximab
infusions, 7.35 +/- 1.60 and 8). The number of patients who met the definition of
adherence was 344 (77%). CD-related health care utilisation was not significantly
impacted by adherence except for ancillary services and radiology. Fewer adherent
patients were hospitalised compared with nonadherent patients (9% vs 16%; P =
0.03). Adherent patients had fewer mean +/- SD and median days in the hospital
(5.5 +/- 3.4 and 5 days) compared with nonadherent patients (13.1 +/- 14.2 and 8
days; P = 0.01). Mean +/- SD and median hospital costs were significantly greater
for nonadherent patients (US$40,822 +/- $49,238 and $28,864) compared with
adherent patients ($13,704 +/- $10,816 and $9938; P = 0.002).
Conclusions: Adherence with maintenance infliximab over 12 months was associated
with lower rates of CD-related hospitalisations and inpatient costs and a shorter
length of hospital stay.
202. Assessment of the relationship between adherence with antiemetic drug
therapy and control of nausea and vomiting in breast cancer patients receiving
anthracycline-based chemotherapy
A Chan, XH Low, KY-L Yap
Journal of Managed Care Pharmacy Jun 2012;18(5):385-394
Background: There are few prevalence data in the literature on nonadherence to
outpatient antiemetic regimens for prophylaxis of chemotherapy-induced nausea and
vomiting (CINV). It is unclear whether adherence with outpatient antiemetic
regimens is associated with better CINV control. Our previous survey research
supports the work of clinical pharmacists in collaborative practice with medical
oncologists in improving adherence with antiemetic therapy in women undergoing
highly emetic chemotherapy for breast cancer.
Objectives: To (a) evaluate the impact of adherence to delayed antiemetics (days 24 following anthracycline-based chemotherapy) on CINV control in breast cancer
patients after anthracycline-based chemotherapy and (b) identify patient-related
factors associated with nonadherence to delayed antiemetics.
Methods: A single-centre, prospective, observational study was conducted from Dec
2006 to Jan 2011 in breast cancer patients receiving anthracycline-based
chemotherapy (doxorubicin or epirubicin) and antiemetics at the National Cancer
Centre Singapore (NCCS), the largest ambulatory cancer centre in Singapore.
Patients included were aged 21 years or older with confirmed diagnoses of breast
cancer and receiving anthracycline-containing chemotherapy with antiemetics.
Patients were excluded if they (a) were diagnosed with intestinal obstruction or
received concurrent radiotherapy that predisposed them to nausea and vomiting, (b)
had vomited in the 24 hours preceding chemotherapy, or (c) had brain metastases
that would impair their judgment. Patients documented in a standardised diary their
emesis events, severity of nausea, use of rescue therapy with metoclopramide and
compliance with dose instructions for antiemetic drug therapy for 5 days: day 1 was
the day of chemotherapy and first day of antiemetic therapy, and day 5 was the day
after completion of delayed antiemetic therapy (days 2-4). Three definitions were
used to describe the CINV outcomes: (a) complete response (no emetic episodes and
no rescue therapy); (b) complete protection (no emetic episodes, no rescue therapy,
and no significant nausea (Likert score 2 or less)); and (c) complete control (no
emetic episodes, no rescue therapy and no nausea). The delayed (days 2-5 postchemotherapy) phase of these endpoints was analysed. Nonadherence was defined
as missing at least 1 dose of the delayed antiemetics from the prescribed regimen.
123
Pearson chi-squared or Fisher’s exact tests and multiple logistic regression analysis
were used to assess the relationship between adherence and CINV outcomes.
Results: Of 519 eligible patients, 88 (17.0%) patients declined participation; 35
(6.7%) were lost to follow-up; and another 35 (6.7%) were excluded due to the
absence of therapy with delayed antiemetics according to guideline protocol. Of the
361 (69.6%) patients included in the final analysis, the mean (SD) age was 50.0
(8.9); the majority was Chinese (80.1%) and diagnosed with stage 2 or higher
breast cancer (88.1%). A total of 152 patients (42.1%) self-reported nonadherent
use of delayed antiemetics. Among all the nonadherent patients (n = 152), 16.4%
(n = 25) achieved complete control; 34.2% (n = 52) achieved complete protection;
and 58.6% (n = 89) achieved complete response, compared with rates of 26.8%
(n = 56), 39.7% (n = 83) and 62.7% (n = 131), respectively, for adherent patients
(n = 209). The rate of adherence to dexamethasone, which was prescribed for all
study patients, was low (62.6%). After adjusting for potential confounders
(ethnicity, educational level and disease stage), adherent patients were more likely
to achieve complete control of CINV (adjusted odds ratio = 1.74; 95% CI, 1.01 to
3.01; P = 0.048). Among the demographic and CINV risk-factor variables, higher
education, alcohol consumption and prior exposure to other (nonanthracyclinebased) chemotherapy regimens were associated with nonadherence (P less than
0.05).
Conclusions: Although 42% of breast cancer patients receiving anthracycline-based
chemotherapy were nonadherent with the dose administration protocol for postchemotherapy antiemetic therapy, there was no significant difference in control of
CINV compared with adherent patients except for the category of complete CINV
control, defined as no nausea, no emesis and no use of the rescue medication
metoclopramide.
203. The impact of treatment noncompliance on mortality in people with Type 2
diabetes
CJ Currie, M Peyrot, CL Morgan, CD Poole, S Jenkins-Jones, RR Rubin, CM Burton, M Evans
Objective: To assess the association of compliance with treatment (medication and
clinic appointments) and all-cause mortality in people with insulin-treated type 2
diabetes.
Research Design and Methods: Data were extracted from UK general practice records
and included patients (N = 15,984) who had diagnostic codes indicative of type 2
diabetes or who had received a prescription for an oral antidiabetic agent and were
treated with insulin. Records in the 30 months before the index date were inspected
for clinical codes (recorded at consultation) indicating medication noncompliance or
medical appointment nonattendance. Noncompliance was defined as missing more
than one scheduled visit or having at least one provider code for not taking
medications as prescribed. Relative survival postindex date was compared by
determining progression to all-cause mortality using Cox proportional hazards
models.
Results: Those identified as clinic nonattenders were more likely to be smokers,
younger, have higher HbA1c, and have more prior primary care contacts and greater
morbidity (P less than 0.001). Those identified as medication noncompliers were
more likely to be women (P = 0.001), smokers (P = 0.014), and have higher HbA1c,
more prior primary care contacts and greater morbidity (all P less than 0.001). After
adjustment for confounding factors, medication noncompliance (hazard ratio 1.579;
95% CI, 1.167 to 2.135), clinic nonattendance of one or two missed appointments
124
(1.163; 1.042 to 1.299) and clinic nonattendance of greater than two missed
appointments (1.605; 1.356 to 1.900) were independent risk factors for all-cause
mortality.
Conclusions: Medication noncompliance and clinic nonattendance, assessed during
routine care by primary care physicians or their staff, were independently associated
with increased all-cause mortality in patients with type 2 diabetes receiving insulin.
204. The association between medication adherence and treatment intensification
with blood pressure control in resistant hypertension
SL Daugherty, JD Powers, DJ Magid, FA Masoudi, KL Margolis, PJ O'Connor, JA Schmittdiel,
PM Ho
Hypertension Aug 2012;60(2):303-309
Patients with resistant hypertension are at risk for poor outcomes. Medication
adherence and intensification improve blood pressure (BP) control; however, little is
known about these processes or their association with outcomes in resistant
hypertension.
This retrospective study included patients from 2002 to 2006 with incident
hypertension from two health systems in the USA who developed resistant
hypertension or uncontrolled BP despite adherence to 3 or more antihypertensive
medications. Patterns of hypertension treatment, medication adherence (percentage
of days covered) and treatment intensification (increase in medication class or dose)
were described in the year after resistant hypertension identification. Then, the
association between medication adherence and intensification with 1-year BP control
was assessed controlling for patient characteristics.
Of the 3550 patients with resistant hypertension, 49% were male, and mean age
was 60 years. One year after resistance hypertension determination, fewer patients
were taking diuretics (77.7% vs 92.2%; P less than 0.01), beta-blockers (71.2% vs
79.4%; P less than 0.01), and ACE inhibitor/angiotensin receptor blocker (64.8% vs
70.1%; P less than 0.01) compared with baseline. Rates of BP control improved
over 1 year (22% vs 55%; P less than 0.01). During this year, adherence was not
associated with 1-year BP control (adjusted odds ratio, 1.18; 95% CI: 0.94 to 1.47).
Treatment was intensified in 21.6% of visits with elevated BP. Increasing treatment
intensity was associated with 1-year BP control (adjusted odds ratio, 1.64; 95% CI,
1.58 to 1.71).
In this cohort of patients with resistant hypertension, treatment intensification but
not medication adherence was significantly associated with 1-year BP control. These
findings highlight the need to investigate why patients with uncontrolled BP do not
receive treatment intensification.
http://hyper.ahajournals.org/content/60/2/303.abstract
205. Adherence to statin treatment and health outcomes in an Italian cohort of
newly treated patients: results from an administrative database analysis
L Degli Esposti, S Saragoni, P Batacchi, S Benemei, P Geppetti, A Sturani, S Buda, E Degli
Esposti
Clinical Therapeutics Jan 2012;34(1):190-199
Background: Adherence to statin treatment is expected to be associated with health
outcomes. Much of the available evidence is derived from studies conducted on
selected populations (e.g. Medicaid population), on specific cohorts of patients (e.g.
patients with diabetes mellitus or those who have experienced acute myocardial
infarction (AMI)), or with respect to a single outcome (e.g. only death or only AMI).
125
Objective: The aim of this study was to evaluate the association between adherence
to statin therapy and all-cause mortality and cardiovascular morbidity (AMI and
stroke) in an unselected cohort of newly treated patients.
Methods: We performed a population-based retrospective cohort study that included
adult patients with a first prescription of a statin from 1 Jan 2004 to 31 Dec 2006,
using data from the administrative databases of the Local Health Unit of Florence,
Italy. Adherence to statin treatment was estimated as the proportion of days
covered (PDC) by filled prescriptions and classified as low (PDC, 21%-40%),
intermediate-low (PDC, 41%-60%), intermediate-high (PDC, 61%-80%), and high
(PDC, over 80%). Cases with PDC of 20% or lower were excluded. A Cox regression
model was used to investigate the association between adherence to treatment and
all-cause mortality and hospitalisation for AMI or stroke.
Results: The cohort consisted of 19,232 patients (9823 men and 9409 women) aged
18 to 102 years (mean (SD), 66.5 (11.4) years): 20.1% had been previously
hospitalised for cardiovascular events and 17.6% had been treated with
hypoglycaemic drugs. Adherence to statins was low in 4427 patients (23.0%),
intermediate-low in 3117 (16.2%), intermediate-high in 3784 (19.7%) and high in
7904 (41.1%). Lower-adherent patients were younger and had fewer comorbidities
compared with higher-adherent patients. In our multivariable analyses, high
adherence was significantly associated with decreased risk of all-cause death, AMI,
or stroke. Compared with low adherence (hazard ratio (HR) = 1), the risk was lower
in intermediate-low adherence (HR = 0.83; 95% CI, 0.71 to 0.98; P less than 0.05)
and much lower in intermediate-high (HR = 0.60; 95% CI, 0.51 to 0.70; P less than
0.001) and high adherence (HR = 0.61; 95% CI, 0.54 to 0.71; P less than 0.001).
Conclusions: In this Italian cohort of newly treated patients, suboptimal adherence to
statins occurred in a substantial proportion of patients and was associated with
increased risk of adverse health outcomes.
206. The threshold rate of oral atypical anti-psychotic adherence at which
paliperidone palmitate is cost saving
NC Edwards, E Muser, D Doshi, J Fastenau
Journal of Medical Economics Aug 2012;15(4):623-634
Objective: To identify, estimate and compare 'real world' costs and outcomes
associated with paliperidone palmitate compared with branded oral atypical
antipsychotics, and to estimate the threshold rate of oral atypical adherence at which
paliperidone palmitate is cost saving.
Methods: Decision analytical modelling techniques developed by Glazer and
Ereshefsky have previously been used to estimate the cost-effectiveness of depot
haloperidol, LAI risperidone and, more recently, LAI olanzapine. This study used
those same techniques, along with updated comparative published clinical data, to
evaluate paliperidone palmitate. Adherence rates were based on strict Medication
Event Monitoring System (MEMS) criteria. The evaluation was conducted from the
perspective of US healthcare payers.
Results: Paliperidone palmitate patients had fewer mean annual days of relapse (8.7
days; 6.0 requiring hospitalisation, 2.7 not requiring hospitalisation vs 17.8 days;
12.4 requiring hospitalisation, 5.4 not requiring hospitalisation) and lower annual
total cost (US$ 20,995) compared to oral atypicals (mean $22,481). Because
paliperidone palmitate was both more effective and less costly, it is considered
economically dominant. Paliperidone palmitate saved costs when the rate of
adherence of oral atypical anti-psychotics was below 44.9% using strict MEMS
criteria. Sensitivity analyses showed results were robust to changes in parameter
126
values. For patients receiving 156 mg paliperidone palmitate, the annual incremental
cost was $1216 per patient (ICER = $191 per day of relapse averted). Inclusion of
generic risperidone (market share 18.6%) also resulted in net incremental cost for
paliperidone palmitate ($120; ICER = $13). Limitations of this evaluation include
use of simplifying assumptions, data from multiple sources and generalisability of
results.
Conclusions: Although uptake of LAIs in the USA has not been as rapid as elsewhere,
many thought leaders emphasise their importance in optimising outcomes in patients
with adherence problems. The findings of this analysis support the costeffectiveness of paliperidone palmitate in these patients.
Three of the authors are with Janssen Scientific Affairs.
207. Medication nonadherence in diabetes: longitudinal effects on costs and
potential cost savings from improvement
LE Egede, M Gebregziabher, CE Dismuke, CP Lynch, RN Axon, Y Zhao, PD Mauldin
Diabetes Care Dec 2012;35(12):2533-2539
Objective: To examine the longitudinal effects of medication nonadherence (MNA) on
key costs and estimate potential savings from increased adherence using a novel
methodology that accounts for shared correlation among cost categories.
Research Design and Methods: US Veterans with type 2 diabetes (740,195) were
followed from Jan 2002 until death, loss to follow-up, or Dec 2006. A novel
multivariate, generalised, linear, mixed modelling approach was used to assess the
differential effect of MNA, defined as medication possession ratio (MPR) = 0.8 or
higher, on healthcare costs. A sensitivity analysis was performed to assess potential
cost savings at different MNA levels using the Consumer Price Index to adjust
estimates to 2012 dollar value.
Results: Mean MPR for the full sample over 5 years was 0.78, with a mean of 0.93
for the adherent group and 0.58 for the MNA group. In fully adjusted models, all
annual cost categories increased approx 3% per year (P = 0.001) during the 5-year
study time period. MNA was associated with a 37% lower pharmacy cost, 7% lower
outpatient cost and 41% higher inpatient cost. Based on sensitivity analyses,
improving adherence in the MNA group would result in annual estimated cost savings
ranging from approx US$661 million (MPR below 0.6 vs 0.6 or higher) to approx
$1.16 billion (MPR less than 1 vs 1). Maximal incremental annual savings would
occur by raising MPR from less than 0.8 to 0.8 or higher ($204,530,778) among MNA
subjects.
Conclusions: Aggressive strategies and policies are needed to achieve optimal
medication adherence in diabetes. Such approaches may further the so-called 'triple
aim' of achieving better health, better quality care and lower cost.
208. Antibiotics for acute cough: an international observational study of patient
adherence in primary care
NA Francis, D Gillespie, J Nuttall, K Hood, P Little, T Verheij, SS Coenen, JW Cals, H
Goossens, CC Butler
British Journal of General Practice Jun 2012;62(599):e429-e437
Background: Non-adherence to acute antibiotic prescriptions is poorly described and
may impact on clinical outcomes, healthcare costs and interpretation of research. It
also results in leftover antibiotics that could be used inappropriately.
127
Aim: To describe adherence to antibiotics prescribed for adults presenting with acute
cough in primary care, factors associated with non-adherence and associated
recovery.
Design and Setting: Prospective observational cohort study in general practices in 14
European primary care networks.
Method: GPs recorded patient characteristics and prescribing decisions for adults
with acute cough or clinical presentation suggestive of lower respiratory tract
infection. Patients recorded antibiotic consumption and daily symptoms over 28
days. Rates of adherence to prescribed antibiotics were assessed, and factors
associated with non-adherence were identified using logistic regression. Recovery
was compared using a Cox proportional hazards model.
Results: Of 2520 patients prescribed immediate or no antibiotics at the index
consultation, 282 (11.2%) took an antibiotic during the follow-up period that was not
prescribed for them at the index consultation. Of these, 38.1% had no
reconsultations during this period. Prior duration of symptoms, antibiotic treatment
duration, antibiotic choice and primary care network were all associated with
adherence. There was no difference in time to recovery between those who were
prescribed antibiotics at the index consultation and were fully adherent, partially
adherent and non-adherent.
Conclusions: Non-adherence to antibiotics for acute cough or lower respiratory tract
infection is common. Duration of treatment, choice of antibiotic and setting were
associated with adherence, but adherence to treatment was not associated with
differences in recovery.
http://www.ingentaconnect.com/content/rcgp/bjgp/2012/00000062/00000599/art00036
209. Assessing adherence-based quality measures in epilepsy
MJ Goodman, M Durkin, J Forlenza, X Ye, DI Brixner
International Journal for Quality in Health Care Jun 2012;24(3):293-300
Objective: To examine the relationship of three alternative measures of adherence
with 7 negative outcomes associated with epilepsy for development of a quality
measure in epilepsy.
Design: Retrospective cohort analysis.
Setting: PharMetrics US national claims database.
Participants: Patients in the PharMetrics database for the years 2004-08 taking
antiepileptic drugs.
Intervention: None.
Main Outcome Measures: For each definition of adherence, the odds ratios (ORs)
comparing non-adherent with adherent groups were assessed for consistency and
direction for the number of hospital admissions, emergency room (ER) visits, head
injuries including traumatic brain injuries, falls, motor vehicle accidents (MVAs),
fractures and a 'seizure' outcome defined as hospital admissions or ER visits with a
primary diagnosis of epilepsy or convulsions.
Results: The inclusion criteria were met by 31,635 individuals. In the multivariate
analysis, the adherent group had lower odds of hospital admissions with ORs for the
8 specifications ranging from 0.729 to 0.872 and ER visits where ORs for the 8
specifications ranged from 0.750 to 0.893. The 8 ORs for head injuries ranged from
0.647 to 0.888. For fractures, the ORs ranged from 0.407 to 0.841. Our proxy for
seizure was inconsistently associated with adherence status.
Conclusions: All the adherence measures defined non-adherent groups that were
associated with negative outcomes in epilepsy.
Two of the authors are with Ortho-McNeil Janssen Pharmaceuticals.
http://intqhc.oxfordjournals.org/content/24/3/293.abstract
128
210. Adherence to antipsychotics and cardiometabolic medication: association with
health care utilization and costs
RA Hansen, M Maciejewski, K Yu-Isenberg,JF Farley
Psychiatric Services Sep 2012;63(9):920-928
Objective: This study examined the association between adherence to antipsychotic
and cardiometabolic medication and annual use of health care services and
expenditures.
Methods: MarketScan US Medicaid files from 2004 to 2008 were used to evaluate
annual cross-sections of patients with both schizophrenia and diabetes, hypertension
or hyperlipidaemia. Annual adherence to antipsychotic and cardiometabolic
medication was defined as a score of at least 80% on proportion of days covered.
Logistic regression was used to examine the association between antipsychotic
adherence and adherence to cardiometabolic medications. Count data models and
generalised linear models estimated health care utilisation and health care
expenditures, respectively, for outpatient, emergency, inpatient and overall health
services.
Results: A total of 87,015 unique patients with schizophrenia received at least one
antipsychotic medication. The overall prevalence of any comorbid cardiometabolic
condition was 42.9% in 2004 and increased to 52.5% in 2008. Adherence to
cardiometabolic medications was significantly greater among patients who were
adherent to antipsychotic medications (adjusted odds ratio = 6.9). Adjusted annual
expenditures for emergency and inpatient care were higher for patients who were
nonadherent to either antipsychotics or cardiometabolic medications than for
patients who were adherent to antipsychotic and cardiometabolic medications. They
were highest for patients who were nonadherent to both groups of medications.
Outpatient, medication and overall expenditures were lower for patients who were
nonadherent to antipsychotic medications, regardless of cardiometabolic medication
adherence.
Conclusions: Among Medicaid patients with schizophrenia, cardiometabolic conditions
are common, and adherence to antipsychotics and adherence to cardiometabolic
medications are strongly related. Interventions that can improve medication
adherence to treatment of both schizophrenia and comorbid cardiometabolic
conditions may reduce emergency visits and hospitalisations.
211. Anti-inflammatory medication adherence, healthcare utilization and
expenditures among Medicaid and Children's Health Insurance Program enrollees
with asthma
JB Herndon, S Mattke, A Evans Cuellar, SY Hong, EA Shenkman
PharmacoEconomics May 2012;30(5):397-412
Background: Underuse of controller therapy among Medicaid-enrolled children is
common and leads to more emergency department (ED) visits and hospitalisations.
However, there is little evidence about the relationship between medication
adherence, outcomes and costs once controller therapy is initiated.
Objective: This study examined the relationship between adherence to two
commonly prescribed anti-inflammatory medications, inhaled corticosteroids (ICS)
and leukotriene inhibitors (LI), and healthcare utilisation and expenditures among
children enrolled in Medicaid and the Children's Health Insurance Program in Florida
and Texas in the USA.
Methods: The sample for this retrospective observational study consisted of 18,456
children aged 2-18 years diagnosed with asthma, who had been continuously
129
enrolled for 24 months during 2004-07 and were on monotherapy with ICS or LI.
State administrative enrolment files were linked to medical claims data. Children
were grouped into three adherence categories based on the percentage of days per
year they had prescriptions filled (medication possession ratio). Bivariate and
multivariable regression analyses that adjusted for the children's demographic and
health characteristics were used to examine the relationship between adherence and
ED visits, hospitalisations and expenditures.
Results: Average adherence was 20% for ICS-treated children and 28% for LItreated children. Children in the highest adherence category had lower odds of an
ED visit than those in the lowest adherence category (p less than 0.001). We did not
detect a statistically significant relationship between adherence and hospitalisations;
however, only 3.7% of children had an asthma-related hospitalisation. Overall
asthma care expenditures increased with greater medication adherence.
Conclusions: Although greater adherence was associated with lower rates of ED
visits, higher medication expenditures outweighed the savings. The overall low
adherence rates suggest that quality improvement initiatives should continue to
target adherence regardless of the class of medication used. However, low baseline
hospitalisation rates may leave little opportunity to significantly decrease costs
through better disease management, without also decreasing medication costs.
http://adisonline.com/pharmacoeconomics/Abstract/2012/30050/Anti_Inflammatory_Medic
ation_Adherence,_Healthcare.4.aspx
212. The clinical and economic burden of poor adherence and persistence with
osteoporosis medications in Ireland
M Hiligsmann, B McGowan, K Bennett, M Barry, J-Y Reginster
Value in Health Jul-Aug 2012;15(5):604-612
Objectives: Medication nonadherence is common for osteoporosis, but its
consequences have not been well described. This study aimed to quantify the clinical
and economic impacts of poor adherence and to evaluate the potential costeffectiveness of improving patient adherence by using hypothetical behavioural
interventions.
Methods: A previously validated Markov microsimulation model was adapted to the
Irish setting to estimate lifetime costs and outcomes (fractures and quality-adjusted
life-year [QALY]) for three adherence scenarios: no treatment, real-world adherence,
and full adherence over 3 years. The real-world scenario employed adherence and
persistence data from the Irish Health Services Executive-Primary Care
Reimbursement Services pharmacy claims database. We also investigated the costeffectiveness of hypothetical behavioural interventions to improve medication
adherence (according to their cost and effect on adherence).
Results: The number of fractures prevented and the QALY gain obtained at realworld adherence levels represented only 57% and 56% of those expected with full
adherence, respectively. The costs per QALY gained of real-world adherence and of
full adherence compared with no treatment were estimated at Euro 11,834 and Euro
6341, respectively. An intervention to improve adherence by 25% would result in an
incremental cost-effectiveness ratio of Euro 11,511 per QALY and Euro 54,182 per
QALY, compared with real-world adherence, if the intervention cost an additional
Euro 50 and Euro 100 per year, respectively.
Discussion: Poor adherence with osteoporosis medications results in around a 50%
reduction in the potential benefits observed in clinical trials and a doubling of the
cost per QALY gained from these medications. Depending on their costs and
outcomes, programmes to improve adherence have the potential to be an efficient
use of resources.
130
213. Impact of medication adherence to disease-modifying drugs on severe
relapse, and direct and indirect costs among employees with multiple sclerosis in
the US
JI Ivanova, RE Bergman, HG Birnbaum, AL Phillips, M Stewart, DM Meletiche
Journal of Medical Economics Jun 2012;15(3):601-609
Objective: To compare rates of severe relapse and total direct and indirect costs over
a 2-year period between US-based employees with multiple sclerosis (MS) who were
adherent and non-adherent to disease-modifying drugs (DMDs).
Methods: Employees with one or more MS diagnosis (ICD-9-CM: 340.x) and one or
more DMD pharmacy claim between 1 Jan 2002 and 31 Dec 2007 were identified
from a large US administrative claims database. Patients had continuous coverage
for 6 months or longer before (baseline) and 24 months or more after (study period)
their index date (first DMD claim). Adherence was measured using medication
possession ratio (MPR) over the study period. Patients with MPR = 80% or higher
were considered adherent (n = 448) and those with MPR below 80% as nonadherent (n = 200). Multivariate analyses were used to compare rates of severe
relapse (inpatient or emergency department visit with MS diagnosis) and costs in
2007 US$ between DMD adherent and non-adherent patients. Direct costs were
calculated as reimbursements to providers for medical services and prescription
drugs excluding DMDs. Indirect costs included disability and medically-related
absenteeism costs.
Results: DMD adherent patients were on average older (43.5 vs 41.8 years, p =
0.015) and more likely to be male (38.6% vs 26.0%, p = 0.002) compared with
non-adherent patients. Adherent patients had lower rates of depression, higher
rates of previous DMD use, and higher baseline MS-related costs. After adjusting for
differences in baseline characteristics, DMD adherent patients had a lower rate of
severe relapse (12.4% vs 19.9%, p = 0.013) and lower total (direct and indirect)
costs ($14,095 vs $16,638, p = 0.048) over the 2-year study period.
Conclusions: In this study, DMD adherence was associated with a significantly lower
rate of severe relapse and lower total costs over 2 years. Causality cannot be
inferred because adherence and outcomes were measured over the same period.
The study was subject to limitations associated with use of claims data and the
absence of clinical measures.
214. Adherence styles of schizophrenia patients identified by a latent class
analysis of the Medication Adherence Rating Scale (MARS): a six-month follow-up
study
S Jaeger, C Pfiffner, P Weiser, R Kilian, T Becker, G Langle, GW Eschweiler, D Croissant, W
Schepp, T Steinert
Psychiatry Research 30 Dec 2012;200(2-3):83-88
The purpose of this study was to examine patients' response profiles to the
Medication Adherence Rating Scale (MARS) and to evaluate the potential of response
styles as predictors of the future course of psychotic disorders in terms of
rehospitalisation and maintenance of medication.
A total of 371 psychiatric inpatients with schizophrenia or schizoaffective disorder
who were taking part in a naturalistic long-term study completed a German version
of the MARS. A Latent Class Analysis (LCA) was performed.
Five latent classes of response styles could be identified: 'moderately adherent',
'critical discontinuers', 'good compliers', 'careless and forgetful' and 'compliant
131
sceptics'. Class membership was found to be related to the severity of symptoms,
level of functioning, insight into illness, insight into necessity of treatment, treatment
satisfaction and medication side effects. At a 6-month follow-up appointment,
significant differences between the classes persisted. Participants showing a 'good
compliers' response pattern had a significantly better prognosis in terms of
rehospitalisation rate and maintenance of the original medication than 'critical
discontinuers'.
Evaluation of the MARS by studying response profiles provides informative results
that reach beyond the results obtained by an evaluation by scores. Patients can be
classified into adherence groups that are of predictive value for long-term patient
outcome.
215. Long-run health effects of cost-related non-adherence to prescribed
medications among adults in late midlife
GA Jensen, Y Li
Journal of Pharmaceutical Health Services Research Jun 2012;3(2):85-93
Objectives: Sub-optimal adherence to prescribed medications due to cost is known to
have adverse health effects over 2-4 years, but little is known about its longer run
effects. Here we quantify whether and how cost-related non-adherence (CRN)
influences the risk of adverse health events over a 10-year period.
Methods: Nationally representative 1994-2004 data from the Health and Retirement
Study, conducted by the US University of Michigan, are analysed for 2460 adults
aged 50-59 years in 1994 who were regularly taking medication(s) and had one or
more chronic health conditions at baseline (hypertension, heart disease, diabetes,
cancer, lung problems, arthritis or had experienced a heart attack or stroke).
Regression models are estimated to quantify CRN's effects on the risk of four
different adverse health events, paying careful attention to the potential endogeneity
of CRN.
Key Findings: Patients who underused medication(s) due to cost are significantly
more likely to see new chronic conditions emerge, to be hospitalised, to experience a
heart attack or stroke and to see problems develop limiting their ability to work. We
also find the more frequent the CRN, the more probable each of these outcomes.
Conclusions: Adults in late midlife with chronic conditions who underuse medications
for cost reasons place themselves at much higher risk for serious adverse events
over the long run.
216. Adherence rate to beclomethasone dipropionate and the level of asthma
control
NS Jentzsch, P Camargos, ESC Sarinho, J Bousquet
Respiratory Medicine Mar 2012;196(3):338-343
There are only a few studies assessing the relationship between adherence rate to
inhaled corticosteroids (ICS), as assessed by electronic monitoring, and the level of
asthma control in childhood.
The present study was carried out to examine the relationship between adherence to
beclomethasone diproprionate (BDP) as well as other factors related to poor asthma
control. In this prospective cohort study, 102 steroid naive randomly selected
subjects with persistent asthma, aged 5-14 years were prescribed 500-750 microg
daily of BDP-CFC and followed up for 1 year. Adherence to BDP was measured
electronically in the 4th, 8th and 12th months of study. The level of asthma control
132
was classified as either controlled or uncontrolled instead of the current three
categories recommended by the Global Initiative for Asthma (GINA).
Mean adherence rate was higher in patients with controlled asthma during follow-up,
but went down from 60.4% in the 4th month to 49.8% in the 12th month (p =
0.038). Conversely, among patients with uncontrolled asthma, the mean adherence
rate decreased from 43.8% to 31.2% (p = 0.001). Multivariate analysis showed that
the level of asthma control was independently associated with the adherence rate in
all follow-up visits (p-values equal or lower than 0.005). The level of asthma control
was directly proportional to adherence rate. Our results suggest that a BDP daily
dose by 300 microg seems to be enough to attain control over mild and moderate
persistent asthma, including exercise-induced asthma.
http://www.resmedjournal.com/article/S0954-6111(11)00440-9/abstract
217. Greater adherence to diabetes drugs is linked to less hospital use and could
save nearly $5 billion annually
AK Jha, RE Aubert, J Yao, JR Teagarden, RS Epstein
Health Affairs Aug 2012;31(8):1836-1846
Improving adherence to medication offers the possibility of both reducing costs and
improving care for patients with chronic illness. We examined a US national sample
of diabetes patients from 2005 to 2008 and found that improved adherence to
diabetes medications was associated with 13% lower odds of subsequent
hospitalisations or emergency department visits. Similarly, losing adherence was
associated with 15% higher odds of these outcomes. Based on these and other
effects, we project that improved adherence to diabetes medication could avert
699,000 emergency department visits and 341,000 hospitalisations annually, for a
saving of US$4.7 billion. Eliminating the loss of adherence (which occurred in one
out of every four patients in our sample) would lead to another $3.6 billion in
savings, for a combined potential savings of $8.3 billion. These benefits were
particularly pronounced among poor and minority patients. Our analysis suggests
that improved adherence among patients with diabetes should be a key goal for the
health care system and policy makers. Strategies might include reducing
copayments for certain medications or providing feedback about adherence to
patients and providers through electronic health records.
http://content.healthaffairs.org/content/31/8/1836.abstract
218. Valuing lost work time: connecting medication adherence and short-term
disability
K Jinnett, T Parry
American Journal of Pharmacy Benefits May-Jun 2012;4(3):e56-e64
Objectives: To examine the effects of medication adherence on the incidence of
short-term disability (STD) for a sample of employees with rheumatoid arthritis (RA).
Study Design: The study population included 10 employers, 39 health plans and
3007 employees with RA (including 695 with STD episodes) taken from a master
database provided by Ingenix that contained eligibility, medical, pharmacy and
disability claims data for different regions of the USA.
Methods: To be included in this study, employees with RA had to have at least 1
medical claim associated with an International Classification of Diseases, Ninth
Revision, Clinical Modification code indicating RA during the 3-year study period
(2001-03) and had to have received at least 1 disease-modifying antirheumatic drug
(DMARD) in 2001 or 2002. Multilevel logistic regression was used to model the
effect of medication adherence in 2001 or 2002 on STD claims incidence in 2002 or
2003, respectively, while accounting for clustering of employees in health plans and
133
4 individual characteristics (sex, age, comorbidity, medication adherence in year of
STD claim).
Results: At the highest medication adherence level in 2001 (over 75%), the odds of
filing an STD claim in 2002 declined. This effect was not significant in the second
time-lagged model (effect of 2002 adherence on 2003 STD incidence). Comorbidity
was significantly associated with higher odds of filing an STD claim in both timelagged models.
Conclusions: Adequate levels of adherence to a DMARD early on in treatment for RA
may reduce the costs associated with missed work and lost productivity resulting
from an STD episode.
http://www.ajpblive.com/media/pdf/AJPB_12mayjun_Jinnett_e56to64.pdf
219. Inclusion of compliance and persistence in economic models: past, present
and future
A Kadambi, RJ Leipold, AR Kansal, S Sorensen, D Getsios
Applied Health Economics and Health Policy Nov 2012;10(6):365-379
Economic models are developed to provide decision makers with information related
to the real-world effectiveness of therapeutics, screening and diagnostic regimens.
Although compliance with these regimens often has a significant impact on realworld clinical outcomes and costs, compliance and persistence have historically been
addressed in a relatively superficial fashion in economic models.
In this review, we present a discussion of the current state of economic modelling as
it relates to the consideration of compliance and persistence. We discuss the
challenges associated with the inclusion of compliance and persistence in economic
models and provide an in-depth review of recent modelling literature that considers
compliance or persistence, including a brief summary of previous reviews on this
topic and a survey of published models from 2005 to 2012. We review the recent
literature in detail, providing a therapeutic-area-specific discussion of the approaches
and conclusions drawn from the inclusion of compliance or persistence in economic
models.
In virtually all publications, variation of model parameters related to compliance and
persistence was shown to have a significant impact on predictions of economic
outcomes. Growing recognition of the importance of compliance and persistence in
the context of economic evaluations has led to an increasing number of economic
models that consider these factors, as well as the use of more sophisticated
modelling techniques such as individual simulations that provide an avenue for more
rigorous consideration of compliance and persistence than is possible with more
traditional methods. However, we note areas of continuing concern cited by previous
reviews, including inconsistent definitions, documentation and tenuous assumptions
required to estimate the effect of compliance and persistence. Finally, we discuss
potential means to surmount these challenges via more focused efforts to collect
compliance and persistence data.
http://adisonline.com/healtheconomics/Abstract/2012/10060/Inclusion_of_Compliance_and
_Persistence_in.3.aspx
220. Long-term oral mesalazine adherence and the risk of disease flare in
ulcerative colitis: nationwide 10-year retrospective cohort from the Veterans
Affairs healthcare system
N Khan, AM Abbas, LA Bazzano, YN Koleva, M Krousel-Wood
Alimentary Pharmacology and Therapeutics Oct 2012;36(8):755-764
134
Background: Adherence is a major factor in determining disease activity in ulcerative
colitis (UC). There are limited data on long-term nationwide adherence levels among
patients with UC.
Aim: To evaluate the long-term adherence levels to oral mesalazine (mesalamine) in
the US Veterans Affairs (VA) healthcare system, to determine the impact of nonadherence on the risk of flares, and to evaluate the different pharmacy data-based
adherence indicators.
Methods: Nationwide data were obtained from the VA for the period 2001 to 2011.
UC patients who started mesalazine maintenance during the inclusion period were
included. Level of adherence was assessed using three different indicators:
medication possession ratio (MPR), continuous single-interval medication availability
(CSA) and continuous multiple-interval medication gaps (CMG). Cox regression
modelling was used to predict disease flares and assess the predictive value of each
adherence indicator.
Results: We included 13,062 patients into the analysis with median follow-up time of
6.1 years. Percentage of patients with high adherence was 47%, 43%, 31% as
identified by CSA, MPR and CMG respectively. Low adherers had a significant
increase in the risk of flares compared with high adherers (Hazard ratio: 2.8, 1.7 and
1.8; P less than 0.001 for CSA, MPR and CMG, respectively). Compared with other
adherence indicators, CSA offered the best trend in predicting disease flares.
Conclusions: Long-term high-adherence level was lower than previously reported.
Adherence was a significant factor in predicting disease flares. Pharmacy adherence
indicators may be useful to healthcare providers in identifying patients at high risk of
exacerbations.
http://onlinelibrary.wiley.com/doi/10.1111/apt.12013/abstract
221. The impact of first year adherence to antiretroviral therapy on long-term
clinical and immunological outcomes in the DART trial in Uganda and Zimbabwe
S Kiwuwa-Muyingo, AS Walker, H Oja, J Levin, G Miiro, E Katabira, C Kityo, J Hakim, J Todd
(DART Trial Team)
Tropical Medicine and International Health May 2012;17(5):584-594
Objectives: To describe associations between different summaries of adherence in
the first year on antiretroviral therapy (ART) and the subsequent risk of mortality, to
identify patients at high risk because of early adherence behaviour.
Methods: We previously described an approach where adherence behaviour at
successive clinic visits during the first year on ART was seen as a Markov chain (MC),
and the individually estimated transition probabilities between 'good', 'poor' and
'non-response' adherence states were used to classify HIV-infected adults in the
DART trial into subgroups with similar behaviour. The impact of this classification
and classifications based on traditional 'averaged' measures (mean drug possession
ratio (DPR) and self-reported adherence) were compared in terms of their impact on
longer-term mortality over the 2 to 5 years on ART using Cox proportional hazards
models.
Results: Of 2960 participants in follow-up after 1 year on ART, 29% had never
missed pills in the last month and 11% had 100% DPR throughout the first year.
The poorest adherers by self-reported measures were more likely to have only
none/primary education (P less than 0.01). Being in the poorest adherence
subgroup by MC and DPR was independently associated with increased mortality (HR
= 1.57; 95% CI, 1.02 to 2.42, and 1.82; 95% CI, 1.32 to 2.51, respectively).
Conclusions: Classification based on dynamic adherence behaviour is associated with
mortality independently of DPR. The classifications could be useful in understanding
135
adherence, targeting focused interventions and improving longer-term adherence to
therapy.
222. Association of long-term adherence to evidence-based combination drug
therapy after acute myocardial infarction with all-cause mortality. A prospective
cohort study based on claims data
J Kuepper-Nybelen, M Hellmich, S Abbas, P Ihle, R Griebenow, I Schubert
European Journal of Clinical Pharmacology Oct 2012;68(10):1451-1460
Purpose: To determine long-term adherence to evidence-based secondary preventive
combination pharmacotherapy in survivors of acute myocardial infarction (AMI) and
to investigate the association between adherence to recommended therapy and allcause mortality in claims data.
Methods: Prospective cohort study based on claims data of an 18.75% random
sample of all persons insured with the local statutory health insurance fund AOK
Hesse (Germany). Study population included patients with hospital discharge
diagnoses of AMI between 2001 and 2005 excluding those who died within the first
30 days after AMI or who had been hospitalised with an AMI in the previous 2 years.
A total of 3008 patients were followed up until death, cancellation of insurance, or
the end of the study period on 31 Dec 2007, whichever came first (median follow-up:
4.2 years).
Results: Drug adherence to single drug groups as determined by proportion of days
covered 80% or above was 21.8% for antiplatelet drugs, 9.4% for beta-blockers,
45.6% for ACE inhibitors or angiotensin II receptor blockers and 45.1% for lipidlowering drugs. A total of 924 (39.7%) patients met our definition of guideline
adherence: Drugs available from three of four relevant drug groups on the same day
for at least 50% of the observation time. Of the patients adhering to the guidelines,
17.3% died and of the non-adherents, 32.4% died. All-cause mortality was 28%
lower for guideline-adherent patients than for the non-adherent group (adjusted HR
0.72; 95% CI, 0.60 to 0.86).
Conclusions: In everyday practice, post AMI patients benefit from guideline-oriented
treatment, but the percentage of adherent patients should be improved.
223. Adherence to and effectiveness of highly active antiretroviral treatment for
HIV infection: assessing the bidirectional relationship
K Lamiraud, J-P Moatti, F Raffi, M-P Carrieri, C Protopopescu, C Michelet, L Schneider, F
Collin, C Leport, B Spire
Medical Care May 2012;50(5):410-418
Background: It is well established that high adherence to HIV-infected patients on
highly active antiretroviral treatment (HAART) is a major determinant of virological
and immunological success. Furthermore, psychosocial research has identified a
wide range of adherence factors including patients' subjective beliefs about the
effectiveness of HAART. Current statistical approaches, mainly based on the
separate identification either of factors associated with treatment effectiveness or of
those associated with adherence, fail to properly explore the true relationship
between adherence and treatment effectiveness. Adherence behaviour may be
influenced not only by perceived benefits - which are usually the focus of related
studies - but also by objective treatment benefits reflected in biological outcomes.
Methods: Our objective was to assess the bidirectional relationship between
adherence and response to treatment among patients enrolled in the ANRS CO8
APROCO-COPILOTE study. We compared a conventional statistical approach based
136
on the separate estimations of an adherence and an effectiveness equation to an
econometric approach using a 2-equation simultaneous system based on the same 2
equations.
Results: Our results highlight a reciprocal relationship between adherence and
treatment effectiveness. After controlling for endogeneity, adherence was positively
associated with treatment effectiveness. Furthermore, CD4 count gain after baseline
was found to have a positive significant effect on adherence at each observation
period. This immunological parameter was not significant when the adherence
equation was estimated separately. In the 2-equation model, the covariances
between disturbances of both equations were found to be significant, thus confirming
the statistical appropriateness of studying adherence and treatment effectiveness
jointly.
Conclusions: Our results, which suggest that positive biological results arising as a
result of high adherence levels, in turn reinforce continued adherence and strengthen
the argument that patients who do not experience rapid improvement in their
immunological and clinical status after HAART initiation should be prioritised when
developing adherence support interventions. Furthermore, they invalidate the
hypothesis that HAART leads to 'false reassurance' among HIV-infected patients.
http://journals.lww.com/lwwmedicalcare/Abstract/2012/05000/Adherence_to_and_Effectiveness_of_Highly_Active.9.asp
x
224. Medication adherence and Medicare expenditure among beneficiaries with
heart failure
R Lopert, JS Shoemaker, A Davidoff, T Shaffer, AM Abdulhalim, J Lloyd, B Stuart
American Journal of Managed Care Sep 2012;18(9):556-563
Objectives: To (1) measure utilisation of and adherence to heart failure medications
and (2) assess whether better adherence is associated with lower Medicare spending.
Study Design: Pooled cross-sectional design using six 3-year cohorts of US Medicare
beneficiaries with congestive heart failure (CHF) from 1997 to 2005 (N = 2204).
Methods: Adherence to treatment was measured using average daily pill counts.
Bivariate and multivariate methods were used to examine the relationship between
medication adherence and Medicare spending. Multivariate analyses included
extensive variables to control for confounding, including healthy adherer bias.
Results: Approximately 58% of the cohort were taking an angiotensin-converting
enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB), 72% a diuretic, 37% a
beta-blocker and 34% a cardiac glycoside. Unadjusted results showed that a 10%
increase in average daily pill count for ACE inhibitors or ARBs, beta-blockers,
diuretics or cardiac glycosides was associated with reductions in Medicare spending
of US$508 (not significant (NS)), $608 (NS), $250 (NS) and $1244 (P less than
0.05), respectively. Estimated adjusted marginal effects of a 10% increase in daily
pill counts for beta-blockers and cardiac glycosides were reductions in cumulative 3year Medicare spending of $510 to $561 and $750 to $923, respectively (P less than
0.05).
Conclusions: Higher levels of medication adherence among Medicare beneficiaries
with CHF were associated with lower cumulative Medicare spending over 3 years,
with savings generally exceeding the costs of the drugs in question.
http://www.ajmc.com/publications/issue/2012/2012-9-vol18-n9/Medication-Adherenceand-Medicare-Expenditure-Among-Beneficiaries-With-Heart-Failure
225. Inertia and treatment compliance in patients with type 2 diabetes in primary
care
137
(Inercia y cumplimiento terapéutico en pacientes con diabetes mellitus tipo 2 en atención
primaria)
F Lopez-Simarro, C Brotons, I Moral, C Cols-Sagarra, A Selva, A Aguado-Jodar, S MiravetJimenez
Medicina Clinica 14 Apr 2012;138(9):377-384
Background and Objectives: Therapeutic inertia (TI) and therapeutic compliance (TC)
are two important barriers in achieving the therapeutic objectives recommended for
patients with diabetes mellitus type 2 (DM2). This study analyses therapeutic inertia
in patients with DM2 who do not achieve their glycaemic, blood pressure (BP) and
LDL-cholesterol (c-LDL) control goals, the patients' TC and the relationship between
TI and TC.
Patients and Methods: This is a descriptive study conducted in a primary health care
centre in Spain. We included 320 diabetic patients. Objectives of control were
HbA1c = 7% or below, blood pressure (BP) = 130/80 mmHg or lower, c-LDL = 100
mg/dL or below, TI (when the objectives of control were not reached and the
professional did not change the treatment) and TC (by counting withdrawals of
pharmacy prescriptions).
Results: The objectives of control for HbA1c, BP and c-LDL were reached by 66.4,
43.2 and 40.5% of patients, respectively. There was TI in 86.4% of patients for cLDL, in 76.7% for BP and in 40.6% for HbA1c. The percentage of therapeutic noncompliance was 36.1, 37.5 and 32.0% for antidiabetic, antihypertensive and lipid
lowering drugs, respectively. Elderly patients had better compliance. TI and TC
were not associated. We did not find any difference in the level of control, TI, use of
drugs or TC by sex.
Conclusions: TI and TC play an important role in the non-achievement of control
objectives in diabetic patients, especially regarding BP and lipids. TC is not related
to TI.
http://www.elsevier.es/en/revistas/medicina-clinica-2/inertia-and-treatment-compliance-inpatients-with-90119502-originales-2012
226. Adherence to antiretroviral therapy and treatment outcomes among
conflict-affected and forcibly displaced populations: a systematic review
JB Mendelsohn, M Schilperoord, P Spiegel, DA Ross
Conflict and Health 31 Oct 2012;6:9
Background: Optimal adherence to highly active antiretroviral therapy (HAART) is
required to promote viral suppression and to prevent disease progression and
mortality. Forcibly displaced and conflict-affected populations may face challenges
succeeding on HAART. We performed a systematic review of the literature on
adherence to HAART and treatment outcomes in these groups, including refugees
and internally-displaced persons (IDPs), assessed the quality of the evidence and
suggest a future research programme.
Methods: The Medline, Embase and Global Health databases for 1995 to 2011 were
searched using the Ovid platform. A backward citation review of subsequent work
that had cited the Ovid results was performed using the Web of Science database.
The ReliefWeb and Medecins Sans Frontieres (MSF) websites were searched for
additional grey literature.
Results and Conclusions: We screened 297 records and identified 17 reports covering
15 quantitative and two qualitative studies from 13 countries. Three-quarters
(11/15) of the quantitative studies were retrospective studies based on chart review;
5 studies included fewer than 100 clients. Adherence or treatment outcomes were
reported in resettled refugees, conflict-affected persons, internally-displaced persons
(IDPs) and combinations of refugees, IDPs and other foreign-born persons. The
138
reports reviewed showed promise for conflict-affected and forcibly-displaced
populations; the range of optimal adherence prevalence reported was 87 to 99.5%.
Treatment outcomes, measured using virological, immunological and mortality
estimates, were good in relation to non-affected groups. Given the diversity of
settings where forcibly-displaced and conflict-affected persons access ART, further
studies on adherence and treatment outcomes are needed to support scale-up and
provide evidence-based justifications for inclusion of these vulnerable groups in
national treatment plans. Future studies and programme evaluations should focus
on systematic monitoring of adherence and treatment interruptions by using facilitybased pharmacy records, understanding threats to optimal adherence and timely
linkage to care throughout the displacement cycle, and testing interventions
designed to support adherence and treatment outcomes in these settings.
http://www.conflictandhealth.com/content/pdf/1752-1505-6-9.pdf
227. Uninformed clinical decisions resulting from lack of adherence assessment in
children with new-onset epilepsy
AC Modi, YP Wu, SM Guilfoyle, TA Glauser
Epilepsy and Behavior Dec 2012;25(4):481-484
This study examined the relationship between nonadherence to antiepileptic drug
(AED) therapy and clinical decision making in a cohort of 112 children with newly
diagnosed epilepsy. Antiepileptic drug adherence was monitored using electronic
monitoring over the first 6 months of therapy. The primary outcome measure was
rate of uninformed clinical decisions as defined by the number of participants with
AED dosage or drug changes to address continued seizures who demonstrated
nonadherence prior to the seizure.
Among the 52 (47%) participants who had an AED change for continued seizures, 30
(27% of the overall cohort) had imperfect medication adherence prior to their
seizures. A quarter of the children with new-onset epilepsy had uninformed
medication changes because adherence was not rigorously assessed in clinical
practice.
The results highlight the importance of routinely assessing medication adherence in
this population.
228. The relationship between clinical outcomes and medication adherence in
difficult-to-control asthma
AC Murphy, A Proeschal, ME Linnett, CE Brightling, AJ Wardlaw, I Pavord, P Bradding, RH
Green
Thorax Aug 2012;67(8):751-753
Medication non-adherence and the clinical implications in difficult-to-control asthma
were audited. Prescription issue data from 115 patients identified sub-optimal
adherence (less than 80%) in 65% of patients on inhaled corticosteroids (ICS) or
combined ICS/long-acting beta2 agonist (LABA). In those using separate ICS and
LABA, adherence to LABA (50%) was significantly better than to ICS (14.3%).
Patients with sub-optimal ICS adherence had reduced FEV1 and higher sputum
eosinophil counts. Adherence ratio was an independent predictor of previous
ventilation for acute severe asthma (p = 0.008). The majority of patients with
difficult-to-control asthma are non-adherent with their asthma medication. Nonadherence is correlated with poor clinical outcomes.
Also presented at the United Kingdom Clinical Pharmacy Association (UKCPA) autumn
symposium, Hinckley, 18-20 Nov 2011 (Clinical Pharmacist Apr 2012;4(Suppl.2):S2).
http://thorax.bmj.com/content/67/8/751.abstract
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229. Placebo adherence and mortality in the Heart and Estrogen/Progestin
Replacement Study
AM Padula, AR Pressman, E Vittinghoff, D Grady, J Neuhaus, L Ackerson, P Rudd, AL Avins
American Journal of Medicine Aug 2012;125(8):804-810
Background: Analyses from double-blind randomised trials have reported lower
mortality among participants who were more adherent to placebo compared with
those who were less adherent. We explored this phenomenon by analysing data
from the placebo arm of the Heart and Estrogen/Progestin Replacement Study
(HERS), a randomized, double-blind, placebo-controlled trial of oestrogen plus
progestin for secondary prevention of coronary heart disease in postmenopausal
women. Our primary aim was to measure and explain the association between
adherence to placebo and total mortality among the placebo-allocated participants in
the HERS. Secondary aims included assessment of the association between placebo
adherence and cause-specific morbidity and mortality.
Methods: Participants with 'higher placebo adherence' were defined as having taken
at least 75% of their placebo study medication during each individual's participation
in the study, whereas those with 'lower placebo adherence' took less than 75%. The
primary outcome was in-study all-cause mortality.
Results: More adherent participants had significantly lower total mortality compared
with less adherent participants (hazard ratio, 0.52; 95% CI, 0.29 to 0.93). Adjusting
for available confounders did not change the magnitude or significance of the
estimates. Analyses revealed that the association of higher adherence and mortality
might be explained, in part, by time-dependent confounding.
Conclusions: Analyses of the HERS data support a strong association between
adherence to placebo study medication and mortality. Although probably not due to
simple confounding by healthy lifestyle factors, the underlying mechanism for the
association remains unclear. Further analyses of this association are necessary to
explain this observation.
230. Relation of statin nonadherence and treatment intensification
DG Pittman, C Fenton, W Chen, S Haffner, M Pendergrass
American Journal of Cardiology 15 Nov 2012;110(10):1459-1463
Failure to intensify medication and failure to adhere to medication have been shown
to contribute to suboptimal low-density lipoprotein cholesterol goal attainment.
To examine whether nonadherence to statins in 126,903 patients on stable statin
therapy is associated with subsequent treatment intensification, we conducted a
retrospective analysis using an integrated pharmacy and medical claims database
(Express Scripts, St Louis, Mo, USA). Pharmacy claims were analysed to determine
whether nonadherence, as measured by proportion of days covered on statins below
80%, was associated with intensification of statin treatment over a 360-day followup.
Of 11,361 patients who had treatment intensification, 44% were previously
nonadherent to statins. Patients whose treatment was intensified had slightly lower
adherence to statin therapy than those without intensification (76% vs 78%, p less
than 0.0001) and were more likely to be nonadherent as defined by proportion of
days covered below 80% (44% vs 37%, p less than 0.0001). After controlling for
confounding factors, patients nonadherent to statins were 30% more likely to have
treatment intensification compared to adherent patients (odds ratio 1.30; 95% CI,
1.25 to 1.36). In addition, patients with statin intensification were more likely to be
younger, women, and have coronary artery disease, diabetes, hypertension,
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dyslipidemia, stroke, peripheral arterial disease, heart failure or depression. Primary
care physicians were more likely to escalate therapy than cardiologists.
In conclusion, nearly 1/2 of patients with therapy escalation were nonadherent to
statins. Clinicians should inquire about adherence and consider adherence before
escalating statin therapy.
231. Adherence to statins is associated with reduced incidence of idiopathic
venous thromboembolism: real-life data from a large healthcare maintenance
organization
L Rabinowich, A Steinvil, E Leshem-Rubinow, S Berliner, D Zeltser, O Rogowski, V Shalev, R
Raz, G Chodick
Heart Dec 2012;98(24):1817-1821
Objective: Previous reports on the association between statin use and venous
thromboembolism (VTE) did not examine patient adherence to medications, thus
their applicability in a real life setting is questionable. Our objective was to
investigate the association between the use of statins and incidence of first ever
idiopathic VTE.
Design: A retrospective cohort study.
Settings: A large healthcare maintenance organisation in Israel.
Patients: Included were statin initiators aged 30 years or older since 2003 who did
not have a statin prescription for at least 4 years before that and had at least 18
months follow-up. Excluded were patients with known risk factors for VTE. End of
follow-up was defined as the first of the following: leaving Maccabi Healthcare
Services, death, VTE or 27 Oct 2010.
Interventions: Prescription drug purchase data were analysed in order to evaluate
the association between statin use and adherence and between VTE prevention.
Main Outcome Measures: VTE diagnosis during follow-up.
Results: The study population included 127,822 subjects (53,618 females). The
follow-up period was 594,190 patient-years, and included 1375 VTE cases and a 5year cumulative incidence rate of 1.15%. Cox regression analysis demonstrated a
significantly lower VTE risk of 19% and 22% in the more adherent patient groups,
compared to the risk for the lowest adherence group. The dose of simvastatin, the
most frequently prescribed statin, was negatively associated with the risk of VTE.
Conclusions: In a real-life healthcare maintenance organisation setting, better
adherence to statins is associated with a reduced risk of first ever idiopathic VTE
events.
http://heart.bmj.com/content/98/24/1817.abstract
232. Does treatment adherence correlates with health related quality of life?
Findings from a cross sectional study
F Saleem, MA Hassali, AA Shafie, GA Awad, M Atif, N ul Haq, H Aljadhey, M Farooqui
BMC Public Health 30 Apr 2012;12:318
Background: Although medication adherence and health-related quality of life
(HRQoL) are two different outcome measures, it is believed that adherence to
medication leads to an improvement in overall HRQoL. The study aimed to evaluate
the association between medication adherence and HRQoL.
Methods: A questionnaire-based cross-sectional study design was undertaken with
hypertension patients (who had been using antihypertensives for at least 6 months)
attending public teaching hospitals in Quetta, Pakistan. HRQoL was measured by
Euroqol EQ-5D. Medication adherence was assessed by the Drug Attitude Inventory.
Descriptive statistics was used to tabulate demographic and disease-related
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information. Spearman's correlation was used to assess the association between the
study variables. All analysis was performed using SPSS 17.0.
Results: Among 385 study patients, the mean age (SD) was 39.02 (6.59), with
68.8% of males dominating the entire cohort. The mean (SD) duration of
hypertension was 3.01+/-0.939 years. 40% (n = 154) had a bachelor's degree level
of education with 34.8% (n = 134) working in the private sector. A negative and
weak correlation (-0.77) between medication adherence and EQ-5D was reported.
In addition, a negatively weak correlation (-0.120) was observed among medication
adherence and EQ-VAS.
Conclusions: Correlations among the study variables were negligible and negative.
Hence, there is no 'apparent' relationship between the variables.
233. Effect of adherence as measured by MEMS, ritonavir boosting, and CYP3A5
genotype on atazanavir pharmacokinetics in treatment-naive HIV-infected
patients
RM Savic, A Barrail-Tran, X Duval, G Nembot, X Panhard, D Descamps, C Verstuyft, B
Vrijens, A-M Taburet, C Goujard, F Mentre (ANRS 134–COPHAR 3 Study Group)
Clinical Pharmacology and Therapeutics Nov 2012;92(5):575-583
Population pharmacokinetics and pharmacogenetics of ritonavir-boosted atazanavir
(ATV) were investigated using drug intake times exactly recorded by the Medication
Event Monitoring System (MEMS). The ANRS 134-COPHAR 3 trial was conducted in
35 HIV-infected treatment-naive patients. ATV (300mg), ritonavir (100mg), and
tenofovir (300mg) + emtricitabine (200mg), in bottles with MEMS caps, were taken
once daily for 6 months. Six blood samples were collected at week 4 to measure
drug concentrations, and trough levels were measured bimonthly. A model
integrating ATV and ritonavir pharmacokinetics and pharmacogenetics used nonlinear
mixed effects. Use of exact dosing data halved unexplained variability in ATV
clearance. The ritonavir-ATV interaction model suggested that optimal boosting
effect is achievable at lower ritonavir exposures. Patients with at least one copy of
the CYP3A5*1 allele exhibited 28% higher oral clearance. The study provides
evidence that variability in ATV pharmacokinetics is defined by adherence, CYP3A5
genotype, and ritonavir exposure.
http://www.nature.com/clpt/journal/v92/n5/abs/clpt2012137a.html
234. The prognostic role of perceived criticism, medication adherence and family
knowledge in bipolar disorders
J Scott, F Colom, M Pope, M Reinares, E Vieta
Journal of Affective Disorders 15 Dec 2012;142(1-3):72-76
Background: In schizophrenia, high levels of critical comments by significant others
are associated with early relapse, especially if medication adherence is sub-optimal.
Levels of criticism may be influenced by family knowledge about both the disorder
and its treatment. No study has explored whether this combination factors influence
outcome in adults with bipolar disorders.
Methods: Medication adherence was assessed in 81 individuals with bipolar disorder
of whom 75 rated perceived criticism by an identified 'significant other' as well as
their own perceived sensitivity. 33 (of the 75) had a close family member who
agreed to complete an assessment of their knowledge and understanding of bipolar
disorders. Psychiatric admissions were then recorded prospectively over 12 months.
Results: Perceived criticism and medication adherence were significant predictors of
admission. In the patient-family member dyads (n = 33), the odds ratio (OR) for
admission was 3.3 (95% CI, 1.3 to 8.6) in individuals with low levels of medication
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adherence, high perceived criticism, and a family member with poor knowledge and
understanding.
Limitations: The small sub-sample of patient-family member dyads means those
findings require replication. Sensitivity to criticism by professional caregivers may
not equate to that by relatives.
Conclusions: Perceived criticism may be a simple but robust clinical predictor of
relapse in mood disorders. High levels of perceived criticism, poor understanding of
bipolar disorder by a significant other, and sub-optimal treatment adherence are risk
factors for hospitalisation in adults with bipolar disorders that are potentially
modifiable through the use of strategic psychosocial interventions.
235. Continuation of statin therapy and primary prevention of nonfatal
cardiovascular events
V Shalev, I Goldshtein, A Porath, D Weitzman, J Shemer, G Chodick
American Journal of Cardiology 15 Dec 2012;110(12):1779-1786
Although the beneficial effect of statins in secondary prevention of cardiac events is
well established, their effectiveness in primary prevention is questionable when most
evidence derives from randomised controlled trials and not 'real-life' data.
To evaluate the association between persistent use of statins and risk of acute
nonfatal cardiovascular events in primary prevention patients in community settings,
we retrospectively analysed a cohort of 171,535 adults 45 to 75 years old with no
indication of cardiovascular disease who began statin therapy from 1998 to 2009 in a
large health maintenance organisation in Israel. Persistence with statins was
measured by the proportion of days covered with dispensed prescriptions of statins
during the follow-up period. Main outcome measurements were occurrence of
myocardial infarction or performance of a cardiac revascularisation procedure.
Incidence of acute cardiovascular events during the follow-up period (993,519
person-years) was 10.22 per 1000 person-years. Persistence with statins was
associated with a lower risk of incident cardiac events (p for trend less than 0.01).
The most persistent users (covered with statins for 80% or more of their follow-up
time) had a hazard ratio of 0.58 (95% CI, 0.55 to 0.62) compared with
nonpersistent users (proportion of days covered less than 20%). Similar results
were found when analyses were limited to patients with more than 5 years of followup. Treatment with high efficacy statins was associated with a lower risk of cardiac
events.
In conclusion, the authors' large and unselected community-based study supports
the results of randomised controlled trials regarding the beneficial effect of statins in
the primary prevention of acute cardiac events.
236. Baseline medication adherence and blood pressure in a 24-month longitudinal
hypertension study
R Shaw, HB Bosworth
Journal of Clinical Nursing May 2012;21(9-10):1401-1406
Objectives: We sought to identify the feasibility and predictive validity of an easy and
quick self-reported measure of medication adherence and to identify characteristics
of people with hypertension that may warrant increase attentiveness by nurses to
address hypertensive self-management needs.
Background: Current control rates of hypertension are approximately 50%. Effective
blood pressure control can be achieved in most people with hypertension through
antihypertensive medication. However, hypertension control can only be achieved if
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the patient is adherent with their medication regimen. Patients who are nonadherent may be in need of additional intervention.
Design: This secondary analysis evaluated the systolic blood pressure of patients
who received usual hypertension management across 24 months at 6-month
intervals.
Methods: A longitudinal study of 159 hypertensive patients in two primary care
clinics in the USA.
Results: In a sample of 159 patients receiving care in a primary care facility, baseline
medication non-adherence was associated with a 6.3mm Hg increase in systolic
blood pressure (p less than 0.05) at baseline, a 8.4mm Hg increase in systolic blood
pressure (p less than 0.05) at 12 months and a 7.5 increase in systolic blood
pressure at 24 months (p less than 0.05) compared with adherent patients,
respectively. Results also indicate a significant increase in systolic blood pressure
across 24 months among people who identified as minority and of low financial
status.
Conclusions: Non-adherence with antihypertensive medication at baseline was
predictive of increased systolic blood pressure up to 24 months post-baseline.
Relevance to Clinical Practice: This study demonstrates the use of an easy-to-use
questionnaire to identify patients who are non-adherent. The authors recommend
assessing medication adherence to identify patients who are non-adherent with their
antihypertensive medication and to be especially vigilant with patients who are
minority or are considered low income.
237. Association of chronic obstructive pulmonary disease maintenance medication
adherence with all-cause hospitalization and spending in a Medicare population
L Simoni-Wastila, Y-J Wei, J Qian, IH Zuckerman, B Stuart, T Shaffer, AA Dalal, L BryantComstock
American Journal of Geriatric Pharmacotherapy Jun 2012;10(3):201-210
Background: Although maintenance medications are a cornerstone of chronic
obstructive pulmonary disease (COPD) management, adherence remains suboptimal.
Poor medication adherence is implicated in poor outcomes with other chronic
conditions; however, little is understood regarding links between adherence and
outcomes in COPD patients.
Objective: This study investigates the association of COPD maintenance medication
adherence with hospitalisation and health care spending.
Methods: Using the 2006 to 2007 Chronic Condition Warehouse administrative data,
this retrospective cross-sectional study included 33,816 Medicare beneficiaries
diagnosed with COPD who received at least 2 prescriptions for ≥1 COPD maintenance
medications. After a 6-month baseline period (1 Jan 2006 to 30 Jun 2006),
beneficiaries were followed through to 31 Dec 2007 or death. Two medication
adherence measures were assessed: medication continuity and proportion of days
covered (PDC). PDC values ranged from 0 to 1 and were calculated as the number
of days with any COPD maintenance medication divided by duration of therapy with
these agents. The association of adherence with all-cause hospital events and
Medicare spending were estimated using negative binomial and gamma generalised
linear models, respectively, adjusting for sociodemographics, Social Security
disability insurance status, low-income subsidy status, comorbidities and proxy
measures of disease severity.
Results: Improved adherence using both measures was significantly associated with
reduced rate of all-cause hospitalisation and lower Medicare spending. Patients who
continued with their medications had lower hospitalisation rates (relative rate (RR) =
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0.88) and lower Medicare spending (-$3764), compared with patients who
discontinued medications. Similarly, patients with PDC of 0.80 or above exhibited
lower hospitalisation rates (RR = 0.90) and decreased spending (-$2185), compared
with patients with PDC below 0.80.
Conclusions: COPD patients with higher adherence to prescribed regimens
experienced fewer hospitalisations and lower Medicare costs than those who
exhibited lower adherence behaviours. Findings suggested the clinical and economic
importance of medication adherence in the management of COPD patients in the
Medicare population.
Two of the authors are with GlaxoSmithKline.
238. Patient nonadherence in clinical trials: could there be a link to postmarketing
patient safety?
DL Smith
Drug Information Journal Jan 2012;46(1):27-34
Patient nonadherence is one of the most complex problems facing clinical
investigators. It not only affects clinical trial results but also could affect the clinical
efficacy and safety of a medication after it has been approved for usage in the
general population. Research shows that up to 30% of clinical trial participants may
be discarding their study medications prior to study visits. Undetected poor
adherence can result in overestimation of the dosage and underestimation of the
adverse event profile. Patients in the general population will be at risk if they take
the study dose but have a higher rate of patient adherence than the study
participants in the clinical trial. This becomes an issue if patients after the launch
receive more effective patient education than study participants in clinical trials and
are more adherent. Several interventions to increase study participant adherence
are recommended. The goal of study investigators should be to reach a high clinical
trial participant adherence level that will not require an increase in sample size to
maintain power of the study. This will give health professionals assurance that
patient safety is not in danger because the dose and adverse event profile would be
based on a higher level of patient adherence than would be expected in the general
population after the launch.
http://dij.sagepub.com/content/46/1/27.abstract
239. Adherence to gastroprotection during cyclooxygenase 2 inhibitor treatment
and the risk of upper gastrointestinal tract events: a population-based study
VE Valkhoff, EM van Soest, G Mazzaglia, M Molokhia, R Schade, G Trifiro, JL Goldstein, S
Hernandez-Diaz, EJ Kuipers, MCJM Sturkenboom
Arthritis and Rheumatism Aug 2012;64(8):2792–2802
Objective: Guidelines recommend coprescription of gastroprotective agents (GPAs) in
patients receiving cyclooxygenase 2 inhibitors (coxibs) who are at high risk of upper
gastrointestinal (UGI) tract complications (i.e. patients with a previous complicated
ulcer or with multiple risk factors). Suboptimal GPA adherence has been shown to
diminish the gastroprotective effect during use of nonselective nonsteroidal
antiinflammatory drugs, but little is known about the effect of GPA adherence during
coxib treatment. We undertook this study to determine the association between GPA
adherence and UGI tract events among patients receiving coxibs.
Methods: Using primary care data from 3 databases, we conducted a case-control
study in a cohort of patients aged 50 years or older who were newly starting
treatment with coxibs and concomitantly taking GPAs. Patients who had a UGI tract
event (bleeding or symptomatic ulcer) were matched to event-free controls for age,
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sex, database, and calendar date. Coxib treatment intervals were defined as
consecutive coxib prescriptions with intervening gaps not exceeding the duration of
the previous coxib prescription. Adherence to GPAs was calculated as the proportion
of days of coxib treatment covered by a GPA prescription. Odds ratios (ORs) with
95% CIs were calculated using conditional logistic regression analysis.
Results: The coxib plus GPA-treated cohort consisted of 14,416 coxib-treated
patients who received GPAs for at least 1 day, yielding 16,442 coxib treatment
intervals in which a GPA was coprescribed. Most patients were treated with coxibs
for less than 30 days. 74 patients had a UGI tract event during or shortly after a
coxib treatment interval in which a GPA was coprescribed, with an incidence rate of
11.9 (95% CI, 9.4 to 14.8) per 1000 years of coxib treatment. The risk of UGI tract
events was 1.97 (95% CI, 0.84 to 4.60) for patients with less than 20% adherence
to GPAs compared to patients with over 80% adherence to GPAs. For every 10%
decrease in GPA adherence, the risk of UGI tract events increased by 9% (OR 1.09;
95% CI, 1.00 to 1.18).
Conclusions: Decreasing GPA adherence among coxib-treated patients is associated
with an increased risk of UGI tract events.
http://onlinelibrary.wiley.com/doi/10.1002/art.34433/abstract
240. A comparison between antihypertensive medication adherence and treatment
intensification as potential clinical performance measures
R Vigen, S Shetterly, DJ Magid, PJ O'Connor, KL Margolis, J Schmittdiel, PM Ho
Circulation: Cardiovascular Quality and Outcomes May 2012;5(3):276-282
Background: Medication adherence and treatment intensification have been
advocated as performance measures to assess the quality of care provided.
Whereas previous studies have shown that adherence and treatment intensification
(TI) of antihypertensive medications is associated with blood pressure (BP) control at
the patient level, less is known about whether adherence and TI is associated with
BP control at the clinic level.
Methods and Results: We included 162,879 patients among 89 clinics in the (US)
Cardiovascular Research Network Hypertension Registry with incident hypertension
who were started on antihypertensive medications. Adherence was measured by the
proportion of days covered (PDC). TI was defined by the standard based method
with scores ranging between -1 and 1 and categorised as: -1 indicated no TI
occurred when BP was elevated; 0 indicated TI occurred when BP was elevated; and
1 indicated that TI was made at all visits, even when BP was not elevated. Logistic
regression models assessed the association between adherence and TI with blood
pressure control (BP = 140/90 or below at the clinic visit closest to 12 months after
study entry) at the patient and clinic levels. Mean adherence was 0.77 +/- 0.28
(PDC +/- SD) at the patient level and 0.78 +/- 0.05 at the clinic level. Mean TI was
0.026 +/- 0.23 at the patient level and 0.01 +/- 0.04 at the clinic level. At the
patient level, for each 0.25 increase in adherence and TI, the odds (OR) of achieving
blood pressure control increased by 28% and 55%, respectively (OR for adherence,
1.28; 95% CI, 1.26 to 1.29, and for TI, 1.55; 95% CI, 1.53 to 1.57). At the clinic
level, each 0.04 increment increase in treatment intensification was associated with
a 25% increased odds of achieving blood pressure control (OR, 1.24; 95% CI, 1.21
to 1.27). In contrast, there was an inverse association between increasing
adherence and BP control (OR, 0.93; 95% CI, 0.90 to 0.95).
Conclusions: Patient adherence to antihypertensive medications is not associated
with BP control at the clinic level and may not be suitable as a performance measure.
TI is associated with BP control, but its use as a performance measure may be
146
constrained by challenges in measuring it and by concerns about unintended
consequences of aggressive hypertension treatment in some subgroups of patients.
http://circoutcomes.ahajournals.org/content/5/3/276.full.pdf%20html
241. Impact of medication adherence on work productivity in hypertension
S Wagner, H Lau, F Frech-Tamas, S Gupta
Objectives: To evaluate the impact of antihypertensive medication adherence on
work productivity.
Study Design: Cross-sectional study.
Methods: Antihypertensive medication–treated respondents from the US 2007
National Health and Wellness Survey (NHWS; n = 16,474) were included. Blood
pressure measurements, medication adherence and work productivity measures
were obtained using subject self-reported data collected by the NHWS. Productivity
and adherence were evaluated using the Work Productivity and Activity Impairment
questionnaire and Morisky Medication Adherence Scale. Subjects were classified as
normotensive (systolic blood pressure (SBP) below 120 mm Hg and diastolic blood
pressure (DBP) below 80 mm Hg), prehypertensive (SBP 120-139 mm Hg or DBP 8089 mm Hg), stage 1 hypertensive (SBP 140-159 mm Hg or DBP 90-99 mm Hg) or
stage 2 hypertensive (SBP above 160 mm Hg or DBP above 100 mm Hg).
Multivariate linear regression was used to determine the relationship between
antihypertensive medication adherence and work productivity loss, while controlling
for important covariates.
Results: Among treated hypertensive subjects (n = 16,474), the mean age was 59.6
years and 49% were female. Respondents employed full time (n = 3041) were
younger (mean age = 51 years); 14%, 54%, 24% and 8% were normotensive,
prehypertensive, and stage 1 and 2 hypertensive, respectively. High adherence was
reported by 55% of employed respondents. Low adherence was associated with
more work productivity impairment (beta = 2.12; P less than 0.05). Stage 2
hypertension was associated with greater productivity impairment compared with
other stages (beta = -6.30 vs normotensives; beta = -6.79 vs prehypertensives;
beta = -5.18 vs stage 1; all P less than 0.05).
Conclusions: Low adherence to prescribed antihypertensive medication regimens was
associated with a reduction in work productivity. Programmes to support
antihypertensive medication adherence may present economic opportunities for
employers by reducing work productivity impairment.
http://www.ajpblive.com/media/pdf/AJPB_12julaug_Wagner_e88to96.pdf
242. Adherence to treatment with selective serotonin reuptake inhibitors and the
risk for fractures and bone loss: a population-based cohort study
I Zucker, G Chodick, L Grunhaus, R Raz, V Shalev
CNS Drugs Jun 2012;26(6):537-547
Background: Selective serotonin reuptake inhibitors (SSRIs) are suspected of
increasing the risk of bone loss and osteoporotic fractures.
Objective: The aim of this study was to investigate the association between
adherence to SSRI treatment and the risk of bone loss-related events.
Methods: The data used in this retrospective cohort study are part of the ongoing
medical documentation routinely collected in a large health maintenance organization
in Israel. Specifically, we used the information collected between Jan 2004 and Apr
2010. The study cohort included 10,621 women who were new users of SSRIs.
Bone loss-related events were defined as fractures or initiation of bisphosphonate
treatment. Adherence level was assessed by calculating the proportion of days
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covered (PDC) with an SSRI from the date of first dispensed SSRI (index date) to the
end of follow-up and was categorised as low (PDC 20% or lower), intermediate (PDC
21-79%) and high (PDC 80% or above). To validate the study model, we conducted
a similar analysis on patients using antiepileptic drugs, which are known to be
positively associated with an increased risk of osteoporotic fractures.
Results: Higher adherence to SSRI treatment was significantly associated with an
increased risk of bone loss-related events in a dose-response manner. The adjusted
hazard ratio for bone loss-related events adjusted for age, physician visits and body
mass index in patients who were covered with an SSRI for 21-79% of the time and
80% or more of the time was 1.15 (95% CI, 0.97 to 1.37) and 1.40 (95% CI, 1.14
to 1.73) compared with patients who were covered for less than 21% of the followup period.
Conclusions: Exposure to SSRI treatment is associated with an increased risk of bone
loss-related events. Further studies are required to determine the causality of the
association and its relevance to the clinical use of SSRIs.
http://adisonline.com/cnsdrugs/Abstract/2012/26060/Adherence_to_Treatment_with_Selec
tive_Serotonin.5.aspx
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Interventions to Improve Adherence
Interventions focus on (i) changing patients’ attitudes and behaviour, for
example by education, motivational interviewing312,331, financial
incentives300,303, etc., (ii) simplifying the process of taking medicines, for
example by removing un-needed medicines, reducing dose frequency or
using combination medicines247 or even the “Polypill”250,274, and (iii)
reminding patients when to take medication, for example by using
special packaging261,330, providing charts282 showing when medicines
have to be taken or sending text (SMS)324 or telephone253,313 messages.
Interventions may be targeted at high-risk groups or patients shown to
be non-adherent259.
243. Increasing medication adherence with the PatientConnect adherence
pharmacy program
R Ackerman, K Almquist, T Rawn, K Tam, D Kim, P Kostoff
Canadian Pharmacists Journal Jul-Aug 2012;145(Suppl.1):S4
Presented at the Canadian Pharmacists Association conference, Whistler, BC, Canada, 1-4
Jun 2012.
Objective: To assess the impact of pharmacy-level behaviour change intervention on
6-month medication adherence after patients start chronic pharmacotherapy.
Methods: Two pharmacy chains implemented 1-year programmes where pharmacies
had novel software integrated into their management systems, prompting therapytargeted adherence message printouts at each prescription fill. Sequential messages
for each subsequent refill followed a specific behaviour change and patient
engagement model. New pharmacotherapy initiator adherence rates were compared
in 8 chronic medication classes for the intervention year and the year prior (no
intervention) in the same stores. Medication classes included statins,
antidepressants, oral hypoglycaemic agents, beta-blockers, bisphosphonates,
calcium channel blockers, ACE inhibitors and angiotensin-receptor blockers.
Additionally, 1 pharmacy chain included control stores over the same time frame.
The adherence metric used was proportion of days covered (PDC). Comparison of
intervention and control groups employed nonparametric statistical analyses (Rank
Sum Test) for new initiators with 6 months or more of observation.
Results: Both pharmacy chains showed significant 6-month absolute increases in
medication adherence for new pharmacotherapy initiators receiving the new
intervention model, 9.4% and 10.4%, respectively (relative increases of 15.6% and
17.7%):
Chain 1: 69.5% (NIntervention = 2115); 60.1% (NControl = 1148), p less than
0.01.
Chain 2: 69.2% (NIntervention = 1689); 58.8% (NControl = 598), p less than 0.01.
In contrast, pharmacotherapy initiators in Chain 2 control stores receiving no
intervention had a 1% decrease in medication adherence over the same time frame:
Control: 57.0% (NControlYear2 = 1840); 58.0% (NControlYear1 = 1664), p greater
than 0.05.
Discussion: The programme's success in increasing medication adherence in new
chronic pharmacotherapy initiators from two community pharmacy chains
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demonstrates the programme transferability of this model. Potential benefits for
improving patient outcomes and increasing pharmacy profitability are discussed.
http://www.cpjournal.ca/doi/pdf/10.3821/145.4.cpjS1
244. Impact of pharmacist interventions on patients' adherence to
antidepressants and patient-reported outcomes: a systematic review
KA Al-Jumah, NA Qureshi
Background: Pharmacist intervention in improving patient adherence to
antidepressants is coupled with better outcomes.
Aims: The aim of this investigation was to examine the published literature
systematically to explore different types of pharmacist interventions used for
enhancing patient adherence to antidepressant medications. Three specific
questions guided the review: what is the impact of pharmacist interventions on
adherence to antidepressant medication? What is the impact of pharmacist
interventions on patient-reported outcomes and patient satisfaction? What are the
types of interventions used by pharmacists to enhance patients' adherence to
antidepressants?
Search strategies: A systematic review of the literature was conducted during AugNov 2010 using PubMed, BIOSIS Previews Web of Science, ScienceDirect, the
Cochrane Library, PsycINFO, IngentaConnect, Cambridge Journals Online and
Medscape databases. Key text words and medical subject headings included
pharmacist intervention, medication intervention, depression, medication adherence,
health-related quality of life, patient-reported outcomes and antidepressants.
Results: A total of 119 peer-reviewed papers were retrieved; 94 were excluded on
the basis of abstract review and 13 after full-text analysis, resulting in 12 studies
suitable for inclusion and intensive review. The most common intervention strategy
that pharmacists utilised was a combination of patient education and drug
monitoring. A cumulative patient adherence improvement in this review ranged from
15% to 27% attributed to utilisation of different interventions and different
combinations of interventions together with patient satisfaction with the treatment
when depression improved.
Conclusions: This review suggests that pharmacist intervention is effective in the
improvement of patient adherence to antidepressants. This may be a basis for more
studies examining the effectiveness of innovative interventions by pharmacists to
enhance patient adherence to antidepressant medications.
245. DOTx. MED: Pharmacist-delivered interventions to improve care for patients
with diabetes
JB Skelton (American Pharmacists Association)
Journal of the American Pharmacists Association Jan-Feb 2012;52(1):25-33
Objectives: To describe the development and implementation of the Discussions on
Taking Medications (DOTx.MED) Diabetes Pilot Program and to report the impact on
adherence to diabetes therapy, improvement in communication of pharmacists, and
satisfaction of patients, pharmacists and health care providers.
Participants: 10 community pharmacy residency sites across the United States
enrolled 216 patients with diabetes to participate in the pilot project.
Intervention: Pharmacists delivered behavioural interventions using motivational
interviewing techniques and increased personal communication with patients during
routine visits to the pharmacy during a 6-month period.
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Results: During the initial 6-month pilot programme, modest improvements in
medication adherence were documented. Patients in the intervention group showed
a 6.55% increase in proportion of days covered (PDC) compared with the previous
180 days pre-intervention and a 2.8% increase in PDC compared with the control
group. Based on survey results, overall reports of satisfaction from patients,
pharmacists and health care providers were favourable.
Conclusions: Access to educational programmes, tools and resources provided
through the DOTx.MED Diabetes Pilot Program improved pharmacist knowledge of
diabetes care and increased the amount of time spent communicating with patients.
The programme demonstrated that small, focused interactions addressing issues of
concern to patients can improve patient adherence to medication therapy.
246. Developing your consultation skills to support medicines adherence
N Barnett, A McDowell
Clinical Pharmacist Oct 2012;4(9):266-268
The authors explain how, by developing skills in health coaching, pharmacists can
help patients to take ownership of treatment decisions and thus encourage them to
adhere to their medicines. A number of key questions are listed for use in patient
consultations, such as discharge counselling in hospitals and medicines use reviews
in the community.
http://www.pjonline.com/clinical-pharmacist
247. Optimizing adherence in hypertension: a comparison of outcomes and costs
using single tablet regimens vs individual component regimens
JD Belsey
Journal of Medical Economics Oct 2012;15(5):897-905
Background: Several studies have demonstrated that the use of single tablet
regimens (STRs) in hypertension is associated with improved outcomes and reduced
healthcare costs compared with individual component regimens. The objective was
to carry out a retrospective analysis of a UK general practice population to test these
conclusions in a UK context.
Method: A retrospective cohort study was carried out using a primary care database
(The Health Improvement Network; THIN), comparing 9929 hypertensive patients on
STRs with 18,665 patients on individual component therapy. Data were collected for
prescriptions, significant cardiovascular events and outpatient referrals over a
minimum follow-up period of 5 years after initiation of therapy. Current NHS
costings were applied to the data, to arrive at an estimate of comparative resource
use.
Results: There were significantly more cardiovascular events in the individual
component group than those treated with a single tablet regimen. 5-year event
rates: 8.3% vs 13.6%; Absolute Risk Reduction (ARR) = 5.3%; Number needed to
treat (NNT) = 18.9. After correction for potential confounders, the hazard ratio was
0.74 (95% CI, 0.70 to 0.77; p less than 0.0001). Hospital admission costs were
lower in the STR group, but drug costs were higher. Overall, the mean annual
management cost per patient was similar in the two groups (GBP 191.49 vs GBP
189.35).
Limitations: The study was based on a retrospective cohort and the result may
therefore be influenced by unidentified confounders. It was not possible to identify
the reasons for individual prescriptions, some of which may have been issued for
reasons other than hypertension. Costings for some components of the outcome
could not be assessed from the dataset and are therefore omitted from the analysis.
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Finally, no attempt was made to distinguish outcomes associated with individual
classes of antihypertensives.
Conclusions: This study confirms the association observed by other authors that
patients treated with STRs are less likely to experience serious cardiovascular events
than those on individual component therapy. In a UK context this analysis has
shown that potential hospital savings broadly offset the additional drug acquisition
costs associated with STRs. These agents can therefore be considered cost neutral.
248. A randomized controlled study of two educational interventions on
adherence with oral contraceptives and condoms
AB Berenson, M Rahman
Contraception Dec 2012;86(6):716-724
Background: The study was conducted in the USA to examine the effectiveness of
two different interventions on oral contraception (OC) adherence and condom use.
Study Design: A total of 1155 women 16-24 years of age requesting OC were
randomised to receive either face-to-face behavioural counselling and education at
their baseline clinic visit (C group; n = 383) or this same intervention followed by
monthly phone calls for 6 months (C+P group; n = 384) or standard care (S group;
n = 388). Phone interviews at 3, 6 and 12 months after the initial visit as well as a
medical record review assessed OC continuation, condom use and several other
secondary and clinically meaningful outcomes such as pregnancy and sexually
transmitted infection (STI) rates and correct use of pills.
Results: The interventions did not have a significant effect on OC continuation after 3
(C+P: 58%; C: 50%; S: 55%), 6 (39%; 32%; 37%) or 12 months (20%; 18%;
20%) (p greater than 0.05). Condom use at last sexual intercourse did not differ by
intervention methods (p greater than 0.05). Moreover, no effect was observed on
pregnancy (S = 48 (12.4%), C = 63 (16.5%), C+P = 52 (13.5%); p = 0.22) and STI
[S = 18 (4.6%), C = 12 (3.1%), C+P = 13 (3.4%); p = 0.50) rates, and mean
number of correctly used pill packs (p = 0.06). However, those randomised to C+P
were more likely than C and S patients to identify a cue and report that the cue
worked as a reminder to take their OC on time based on 3 and 6 months follow-up
information (p less than 0.01 for all relationships).
Conclusions: Neither intervention in this study improved OC adherence among young
women.
249. An integrated pharmacy-based program improved medication prescription
and adherence rates in diabetes patients
TA Brennan, TJ Dollear, M Hu, OS Matlin, WH Shrank, NK Choudhry, W Grambley
Health Affairs Jan 2012;31(1):120-129
A substantial threat to the overall health of the American public is nonadherence to
medications used to treat diabetes, as well as physicians' failure to initiate patients'
use of those medications. To address this problem, we evaluated an integrated,
pharmacy-based programme to improve patients' adherence and physicians'
initiation rates. The study included 5123 patients with diabetes in the intervention
group and 24,124 matched patients with diabetes in the control group. The
intervention consisted of outreach from both mail-order and retail pharmacists who
had specific information from the pharmacy benefit management company on
patients' adherence to medications and use of concomitant therapies. The
interventions improved patients' medication adherence rates by 2.1% and increased
physicians' initiation rates by 38%, compared with the control group. The benefits
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were greater in patients who received counselling in the retail setting than in those
who received phone calls from pharmacists based in mail-order pharmacies. This
suggests that the in-person interaction between the retail pharmacist and patient
contributed to improved behaviour. The interventions were cost-effective, with a
return on investment of approximately US$3 for every $1 spent. These findings
highlight the central role that pharmacists can play in promoting the appropriate
initiation of and adherence to therapy for chronic diseases.
http://content.healthaffairs.org/content/31/1/120.abstract
250. Opinions of community pharmacists on the value of a cardiovascular polypill
as a means of improving medication compliance
K Burns, F Turnbull, A Patel, D Peiris
International Journal of Pharmacy Practice Jun 2012;20(3):155-163
Objective: Cardiovascular disease is a major public health problem despite
established treatment guidelines and significant healthcare expenditure worldwide.
Poor medication compliance accounts in part for some of the observed
evidence/practice gaps. Trials of fixed-dose combination pills are currently underway,
but the attitudes of relevant health professionals to the routine use of a
cardiovascular polypill are generally unknown. Pharmacists are a group of providers
who play an important role in patient compliance with long-term medications. The
objective was to identify the main perceived barriers to compliance and to
investigate pharmacists' opinions regarding the routine use of a cardiovascular
polypill.
Methods: The setting was community pharmacies in the metropolitan and greater
areas of New South Wales, Australia. Structured questionnaires were administered to
a random sample of community pharmacists and peer-to-peer, semi-structured
interviews were conducted with a sub-sample. Quantitative data were analysed using
SPSS V16.0 and interviews were analysed thematically.
Key findings: Questionnaires were completed by 72 of the 250 pharmacists invited to
participate. The major barrier to cardiovascular medication compliance identified by
respondents was polypharmacy. Other barriers included patient disinterest, time
constraints and costs. Most pharmacists agreed that a cardiovascular polypill could
be one potential solution to poor compliance by simplifying the treatment regimen
(73.6% agreed) and reducing patient costs (79.2% agreed). Inability to tailor
treatment and to ascribe side effects was among some of the identified concerns.
Conclusion: The use of a cardiovascular polypill as a means of increasing patient
compliance with long-term cardiovascular preventive therapies is seen as potentially
valuable by community pharmacists.
251. Medication adherence of patients attending a pharmacist-CDE led diabetes
intense medical management and education clinic
CL Cadiz, JD Hirsch, CM Morello
Type 2 diabetes patients with poor glycaemic control and multiple comorbidities may
have complex medication regimens that result in poor adherence, a factor
contributing to suboptimal therapeutic outcomes. Previous studies have shown that
better medication adherence is associated with superior clinical outcomes in diabetes
patients, with good adherence correlating with lower haemoglobin A1c scores. A
collaborative pharmacist-endocrinologist clinic (held 1/2 day per week) was
developed in California, USA, to help patients from a veteran population address
153
barriers to adherence and achieve metabolic goals. The model of the Diabetes
Intense Medical Management (DIMM) Clinic combines clinical care with patientspecific diabetes education emphasising medication and lifestyle modifications and
patient empowerment. The primary objective was to evaluate levels of medication
adherence between initial, 3 and 6 month clinic visits. Data were collected between
May 2009 and Sep 2011. At each visit, a validated Morisky 4-item self-reported
adherence assessment was administered. Good adherence was defined as a score of
3 or 4, while poor adherence was delineated by a score of less than 3. At baseline,
30% (n = 54) of patients were poor adherers, which improved to only 14% (n = 37)
at 3 months and 22% for those with 6-month follow-up visits (n = 27). Patients with
at least a 1-point improvement in Morisky adherence score had a greater degree of
A1c reduction at both 3 months (1.7 vs 1.2) and 6 months (2.7 vs 2.2). Although
not statistically significant with the small sample size this level of difference realised
clinical significance. Results demonstrate that despite intense mediation
management that often involved additional oral agents or starting insulin therapy,
patients were able to improve their medication adherence while attending a
pharmacist-led DIMM clinic.
252. The impact of educational interventions on patients with Type 2 diabetes
attending a tertiary care center
C Cani, L Lopes, M Queiroz, M Nery
The management of diabetes mellitus (DM) requires long-term continuous medical
care and a great deal of effort on the part of the patient regarding self-management
activities. According to the American Association of Diabetes Educators (AADE)
behaviour change can be most effectively achieved using the AADE 7 self-care
behaviours framework. The expansion of the diabetes educator role to professionals
such as pharmacists has been recognised and they are uniquely positioned to
educate patients on the adequate utilisation of medicines.
The aim of this study was to evaluate the impact of an educational programme
performed by a clinical pharmacist attending a tertiary care centre in Brazil on
patients with DM mainly based on taking medication, one of the AADE 7 self-care
behaviours. A total of 70 patients (aged 45 years or older) with type 2 DM (T2DM)
on prescribed insulin and presenting with HbA1c of 8% or above were recruited into
a randomized controlled clinical trial with a 6-month follow-up period. Patients in the
intervention group (IG) (n = 34) received instructions for diabetes education,
whereas patients in the control group (CG) (n = 36) received usual care.
Questionnaires were used to evaluate the secondary outcomes and the HPLC method
was used to measure HbA1c levels, adopted as the primary outcome.
Significant differences (p less than 0,001) in mean values (baseline vs 6 months) in
knowledge about diabetes (9.91 +/- 2.69 vs 15.74 +/- 3.03) and medicines (4.47
+/- 0.84 vs. 6.58 +/- 1.29), in adherence to medication (17.6% vs 70.6%), in
insulin injection (66.61 +/- 15.41 vs 87.81 +/- 10.89) and home blood glucose
monitoring technique (6.85 +/- 0.93 vs 8.88 +/- 1.04) as well as in health-related
quality of life (157.21 +/- 13.28 vs 152.06 +/- 14.98) were observed in the IG.
Significant reductions (p less than 0,001) in mean values of HbA1c (9.78% +/- 1.55
vs 9.21% +/- 1.41) were observed in the IG but not in the CG.
Concludes that the educational programme carried out by a clinical pharmacist
improved health outcomes and resulted in better glycaemic control in patients with
T2DM.
154
http://www.abstractsonline.com/Plan/ViewAbstract.aspx?sKey=465c09cc-e66a-403c-a6190f648526bd73&cKey=dc2768c4-703b-4a0c-8b2f-81cbfdaf230f&mKey={0F70410F-8DF349F5-A63D-3165359F5371}
253. Antidepressant medication adherence via interactive voice response
telephone calls
T Castle, MA Cunningham, GM Marsh
American Journal of Managed Care Sep 2012;18(9):e346-e355
Objectives: Outpatients given antidepressants discontinue treatment at a high rate
during the first few months. We evaluated the effectiveness of the use of interactive
voice response (IVR) to improve antidepressant medication adherence by Highmark,
a health plan in Pennsylvania, USA.
Study Design: Quasi-experimental cohort intervention study.
Methods: We placed 39,020 members newly given antidepressant medication into 3
intervention groups based on results of interactive voice response (IVR) call 1 month
post-prescription: (1) not reached; (2) reached but not transferred to depression
management consultant (DMC); and (3) reached and transferred to DMC. We
evaluated medication adherence based on the Healthcare Effectiveness Data and
Information Set (HEDIS) effective acute phase (3 months) and continuation phase (6
months) treatment outcomes using member claims data. We used generalised
estimating equations to model intervention effectiveness on medication adherence.
Results: Adherence increased markedly with age group, with members older than 65
years having a 5.11-fold higher odds (P less than 0.0001) of compliance than the
baseline group aged 18 to 24 years. In models adjusted for time, month of
intervention and drug, the odds of compliance for groups (3) and (2) relative to
group (1) were 1.34 (P = 0.009) and 1.19 (P less than 0.001), respectively. In
models also adjusted for age group, the group (3) and (2) odds decreased to 1.00
and 1.03 and were not statistically significant.
Conclusions: We found that IVR calls had little impact on antidepressant medication
adherence rates. Adherence rates increased markedly with increasing age in each
intervention group, suggesting that other intervention strategies to improve
adherence should focus on the younger segment of the patient population.
http://www.ajmc.com/articles/Antidepressant-Medication-Adherence-via-Interactive-VoiceResponse-Telephone-Calls
254. Effect of pharmaceutical follow-up in patients with secondary
hyperparathyroidism treated with cinacalcet
(Efecto del seguimiento farmacoterapéutico en pacientes con hiperparatiroidismo secundario
tratados con cinacalcet)
C Chemello, M Aguilera, MA Calleja-Hernandez, MJ Faus
Farmacia Hospitalaria Sep-Oct 2012;36(5):321-327
Objectives: To assess the effect of pharmaceutical intervention in the identification of
drug-related problems, to improve desired clinical outcomes, and to evaluate the
effectiveness of cinacalcet in achieving clinical outcomes recommended by the
KDOQI Clinical Guidelines.
Method: Quasi-experimental, pre-post intervention study. Patients with secondary
hyperparathyroidism due to chronic kidney disease, aged 18 years or older and
under treatment with cinacalcet were recruited at the outpatient pharmacy of a
hospital in Granada, Spain, between 2007 and 2009. The Dader follow-up method
and SMAQ and Morisky questionnaires were used to verify adherence at the first
interview. The pharmacist then analysed each case and designed an adequate
155
intervention. Clinical parameters were obtained from the hospital laboratory
database.
Results: 34 patients were included. 29 drug-related problems were found before
pharmacist intervention, and among these, non-adherence was the most common
(15). After the intervention, 9 drug-related problems remained, which means that
68.9% of them were resolved (P less than 0.001), reaching an adherence of 80%.
Parathyroid hormone, calcium and calcium-phosphorus product serum levels
decreased significantly after 3 months of treatment (P less than 0.001, less than
0.001 and 0.045, respectively), achieving the KDOQI Clinical Guideline
recommendations.
Conclusions: These results suggest that this simple and easy-to-apply intervention
was effective in preventing and resolving drug-related problems in these patients.
Moreover, it improved patient adherence and confirmed that cinacalcet treatment is
effective for achieving the clinical outcomes recommended by KDOQI clinical
guidelines.
255. Intervention toolbox to promote immunosuppressant therapy adherence in
adult renal transplant recipients
MA Chisholm-Burns, CA Spivey, E Sredzinski, SL Butler
Objectives: To provide a brief overview of published immunosuppressant therapy
(IST) adherence interventions in adult renal transplant recipients (RTRs) and to
describe the utility and aspects of an adherence toolbox for adult RTRs.
Setting: National independent specialty pharmacy.
Practice Description: IST adherence is critical to graft survival after a renal
transplant. However, IST nonadherence occurs in a large proportion of adult RTRs.
Although effective intervention strategies are needed to improve IST adherence, few
intervention studies have been conducted in the adult RTR population. To address
this gap in the literature, a randomised controlled trial of a patient-specific
behavioural contracts intervention to improve IST adherence among adult RTRs has
been implemented.
Practice Innovation: During the behavioural contracts intervention, researchers have
developed a toolbox of practical and replicable items and strategies to address
forgetfulness and confusion as barriers to IST adherence.
Conclusions: An adherence toolbox that includes simple, practical, accessible
mechanisms and strategies to improve IST adherence may benefit adult RTRs.
http://www.japha.org/data/Journals/JAPhA/25506/JAPhA_52_6_816.pdf
256. Developing consensus-based policy solutions for medicines adherence for
Europe: a Delphi study
W Clyne, S White, S McLachlan
BMC Health Services Research 23 Nov 2012;12:425
Background: Non-adherence to prescribed medication is a pervasive problem that
can incur serious effects on patients' health outcomes and well-being, and the
availability of resources in healthcare systems. This study aimed to develop practical
consensus-based policy solutions to address medicines non-adherence for Europe.
Methods: A four-round Delphi study was conducted. The Delphi Expert Panel
comprised 50 participants from 14 countries and was representative of:
patient/carers’ organisations; healthcare providers and professionals; commissioners
and policy makers; academics; and industry representatives. Participants engaged
in the study remotely, anonymously and electronically. Participants were invited to
156
respond to open questions about the causes, consequences and solutions to
medicines non-adherence. Subsequent rounds refined responses, and sought ratings
of the relative importance, and operational and political feasibility of each potential
solution to medicines non-adherence. Feedback of individual and group responses
was provided to participants after each round. Members of the Delphi Expert Panel
and members of the research group participated in a consensus meeting upon
completion of the Delphi study to discuss and further refine the proposed policy
solutions.
Results: 43 separate policy solutions to medication non-adherence were agreed by
the Panel. 25 policy solutions were prioritised based on composite scores for
importance, and operational and political feasibility. Prioritised policy solutions
focused on interventions for patients, training for healthcare professionals, and
actions to support partnership between patients and healthcare professionals. Few
solutions concerned actions by governments, healthcare commissioners, or
interventions at the system level.
Conclusions: Consensus about practical actions necessary to address non-adherence
to medicines has been developed for Europe. These actions are also applicable to
other regions. Prioritised policy solutions for medicines non-adherence offer a
benefit to policymakers and healthcare providers seeking to address this
multifaceted, complex problem.
257. Pharmacist counseling in a cohort of women with HIV and women at risk for
HIV
JM Cocohoba, KN Althoff, M Cohen, H Hu, CO Cunningham, A Sharma, RM Greenblatt
Background and Methods: Achieving high adherence to antiretroviral therapy for
human immunodeficiency virus (HIV) is challenging due to various system-related,
medication-related, and patient-related factors. Community pharmacists can help
patients resolve many medication-related issues that lead to poor adherence. The
purpose of this cross-sectional survey nested within the Women’s Interagency HIV
Study was to describe characteristics of women who had received pharmacist
medication counselling within the previous 6 months. The secondary objective was
to determine whether HIV-positive women who received pharmacist counseling had
better treatment outcomes, including self-reported adherence, CD4+ cell counts and
HIV-1 viral loads.
Results: Of the 783 eligible participants in the Women's Interagency HIV Study who
completed the survey, only 30% of participants reported receiving pharmacist
counselling within the last 6 months. Factors independently associated with
counselling included increased age (odds ratio (OR) 1.28; 95% CI, 1.07 to 1.55),
depression (OR 1.75; 95% CI, 1.25 to 2.45) and use of multiple pharmacies (OR
1.65; 95% CI, 1.15 to 2.37). Patients with higher educational attainment were less
likely to report pharmacist counselling (OR 0.68; 95% CI, 0.48 to 0.98), while HIV
status did not play a statistically significant role. HIV-positive participants who
received pharmacist counselling were more likely to have optimal adherence (OR
1.23; 95% CI, 0.70 to 2.18) and increased CD4+ cell counts (+43 cells/mm3; 95%
CI, 17.7 to 104.3) compared with those who had not received counselling, though
these estimates did not achieve statistical significance.
Conclusions: Pharmacist medication counselling rates are suboptimal in HIV-positive
and at-risk women. Pharmacist counselling is an underutilised resource which may
contribute to improved adherence and CD4+ counts, though prospective studies
should be conducted to explore this effect further.
157
258. Medication adherence of patient assistance program recipients: a pilot study
CS Conley, PJ Hughes
Innovations in Pharmacy 2012;3(3):article 85
Purpose: To evaluate medication adherence of prescription assistance program
recipients at an inner-city clinic in Alabama, USA.
Methods: Surveys were administered at enrollment and 6 months following
enrollment to patients who were either recipients of at least one patient assistance
program (PAP) or had prescription benefits through Alabama Medicaid. Data on
patient demographics, Morisky Medication Adherence Survey (MMAS) scores, mean
possession ratio (MPR), and drug classes were collected for 6 months.
Results: The baseline MMAS score concluded that both the PAP group and Alabama
Medicaid group were highly motivated and highly knowledgeable regarding
adherence to prescribed medications. After 6 months, administration of the same
MMAS instrument resulted in a category change in the PAP group from highly
motivated and knowledgeable to low motivation and high knowledge. The Medicaid
MMAS adherence category did not change from baseline after 6 months. The 6month mean MPR for the PAP and Medicaid groups were 0.542 and 0.823,
respectively.
Conclusions: Providing free or low-cost medication plus customary counselling should
not be the sole interventions for the uninsured patient. In this study, PAP recipient
MMAS score change and low mean MPR suggest that additional interventions are
needed to ensure that PAP recipients adhere to prescribed therapies.
See also commentary on this paper by NM Rickles (article 86).
http://www.pharmacy.umn.edu/innovations/prod/groups/cop/@pub/@cop/@innov/docume
nts/article/cop_article_415366.pdf
259. Targeting cardiovascular medication adherence interventions
SL Cutrona, NK Choudhry, MA Fischer, AD Servi, M Stedman, JN Liberman, TA Brennan, WH
Shrank
Journal of the American Pharmacists Association May-Jun 2012;52(3):381-397
Objectives; To determine whether adherence interventions should be administered to
all medication takers or targeted to nonadherers.
Data Sources and Study Selection: Systematic search (Medline and Embase, 19662009) of randomised controlled trials of interventions to improve adherence to
medications for preventing or treating cardiovascular disease or diabetes.
Data Extraction: Articles were classified as (1) broad interventions (targeted all
medication takers), (2) focused interventions (targeted nonadherers) or (3) dynamic
interventions (administered to all medication takers; real-time adherence information
targets nonadherers as intervention proceeds). Cohen's d effect sizes were
calculated.
Data Synthesis: We identified 7190 articles; 59 met inclusion criteria. Broad
interventions were less likely (18%) to show medium or large effects compared with
focused (25%) or dynamic (32%) interventions. Of the 33 dynamic interventions, 6
used externally generated adherence data to target nonadherers. Those with
externally generated data were less likely to have a medium or large effect (20% vs
34.8% self-generated data).
Conclusions: Adherence interventions targeting nonadherers are heterogeneous but
may have advantages over broad interventions. Dynamic interventions show
promise and require further study.
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260. An introductory pharmacy practice experience on improving medication
adherence
PL Darbishire, KS Plake, ME Kiersma, JK White
American Journal of Pharmaceutical Education 2012;76(3):Art.42
Objective: To evaluate the impact of a medication adherence activity on introductory
pharmacy practice experience students' perceptions of patient adherence as well as
student development of empathy and confidence in patient counselling.
Design: Second-year students at Purdue University College of Pharmacy participated
in a personal medication simulation using a Med-E-Lert automated medication
dispenser. Students then identified a patient with nonadherence and provided
counselling on use of the dispenser. After 4 to 6 weeks, students interviewed the
patient about their experience with the dispenser and assessed changes in
adherence.
Assessment: 153 students completed the assignment and 3 surveys instruments.
Following the experience, the majority of students agreed or strongly agreed that
they developed more empathy for patients with multiple medications and felt
confident counselling a patient in the use of a dispenser (92.0% and 88.2%,
respectively). Most students (91.4%) reported feeling that their patient education
session was successful.
Conclusions: An introductory pharmacy practice experience involving an automated
medication dispenser and patient counselling to improve medication adherence
resulted in the development of empathy and improved student confidence.
http://www.ajpe.org/doi/pdf/10.5688/ajpe76342
261. Real-world impact of reminder packaging on antihypertensive treatment
adherence and persistence
L Dupclay, M Eaddy, J Jackson, A Raju, A Shim
Patient Preference and Adherence 18 Jul 2012;6:499-507
Background: Patient medication adherence is multidimensional and poses significant
concerns to health care professionals. One aspect of adherence is a patient
forgetting to take their prescribed medication, which may be improved with reminder
packaging (RP). The objective of this analysis was to assess the impact of RP on
patient adherence to antihypertensive therapy.
Methods: This retrospective, propensity score-matched study evaluated patients
switching to a single-pill combination of valsartan-hydrochlorothiazide in RP
compared with patients remaining on the combination without reminder packaging
(non-RP). Patients receiving combination therapy between 1 Apr 2009 and 31 Jul
2010 were eligible for inclusion. Patients were propensity score-matched on baseline
adherence and background demographic variables, including comorbidities.
Medication possession ratio, proportion of days covered, time to refill and time to
discontinuation were evaluated as primary measures of subsequent adherence and
persistence.
Results: In a total of 9266 matched patients (4633 participants in both cohorts),
adherence was significantly higher in the RP cohort compared with patients in the
non-RP cohort (medication possession ratio, RP 80% vs non-RP 73%; proportion of
days covered, RP 76% vs non-RP 63%; both P less than 0.001). Refill timing was 10
days for RP patients vs 16 days for non-RP patients (P less than 0.001). Similar
trends were observed with respect to time to discontinuation (RP 196 days, non-RP
174 days; P less than 0.001). A higher proportion of RP patients remained on
therapy compared with non-RP patients, with patients in the RP group being 17%
159
less likely to discontinue therapy compared with patients in the non-RP group
(hazards ratio 0.833; 95% CI, 0.793 to 0.875).
Conclusions: This real-world assessment of differences in adherence and persistence
rates demonstrated that patients receiving RP were more adherent and persistent
with their treatment regimens.
262. An explanatory randomised controlled trial of a nurse-led, consultationbased intervention to support patients with adherence to taking glucose lowering
medication for type 2 diabetes
A Farmer, W Hardeman, D Hughes, AT Prevost, Y Kim, A Craven, J Oke, S Boase, M
Selwood, I Kellar, J Graffy, S Griffin, S Sutton, AL Kinmonth
BMC Family Practice 5 Apr 2012;13:30
Background: Failure to take medication reduces the effectiveness of treatment
leading to increased morbidity and mortality. We evaluated the efficacy of a
consultation-based intervention to support objectively-assessed adherence to oral
glucose lowering medication (OGLM) compared to usual care among people with type
2 diabetes.
Methods: This was a parallel-group, randomised trial in adult patients with type 2
diabetes and HbA1c of 7.5% (58 mmol/mol) or higher, prescribed at least one
OGLM. Participants were allocated to a clinic nurse delivered, innovative
consultation-based intervention to strengthen patient motivation to take OGLM
regularly and support medicine taking through action-plans, or to usual care. The
primary outcome was the percentage of days on which the prescribed dose of
medication was taken, measured objectively over 12 weeks with an electronic
medication-monitoring device (TrackCap, Aardex, Switzerland). The primary
analysis was intention-to-treat.
Results: 211 patients were randomised between 1 Jul 2006 and 30 Nov 2008 in 13
general practices in England (primary care clinics). Primary outcome data were
available for 194 participants (91.9%). Mean (sd) percentage of adherent days was
77.4% (26.3) in the intervention group and 69.0% (30.8) in standard care (mean
difference between groups 8.4%; 95% CI, 0.2% to 16.7%; p = 0.044). There was
no significant adverse impact on functional status or treatment satisfaction.
Conclusions: This well-specified, theory-based intervention delivered in a single
session of 30 min in primary care increased objectively measured medication
adherence, with no adverse effect on treatment satisfaction. These findings justify a
definitive trial of this approach to improving medication adherence over a longer
period of time, with clinical and cost-effectiveness outcomes to inform clinical
practice.
Trial Registration: Current Controlled Trials ISRCTN30522359.
263. Prediction of peak flow values followed by feedback improves perception of
lung function and adherence to inhaled corticosteroids in children with asthma
JM Feldman, H Kutner, L Matte, M Lupkin, D Steinberg, K Sidora-Arcoleo, D Serebrisky, K
Warman
Thorax Dec 2012;67(12):1040-1045
Background: Failure to detect respiratory compromise can lead to emergency
healthcare use and fatal asthma attacks. The purpose of this study was to examine
the effect of predicting peak expiratory flow (PEF) and receiving feedback on
perception of pulmonary function and adherence to inhaled corticosteroids (ICS).
160
Methods: The sample consisted of 192 ethnic minority, inner-city children (100
Puerto Rican, 54 African-American, 38 Afro-Caribbean) with asthma and their
primary caregivers recruited from outpatient clinics in Bronx, New York, USA.
Children's PEF predictions were entered into an electronic spirometer and compared
with actual PEF across 6 weeks. Children in one study were blinded to PEF (n = 88;
no feedback) and children in a separate study were able to see PEF (n = 104;
feedback) after predictions were locked in. Dosers (MediTrack Products, Hudson,
Massachusetts, USA) were attached to asthma medication inhalers to monitor use.
Results: Children in the feedback condition displayed greater accuracy (p less than
0.001), less under-perception (p less than 0.001) and greater over-perception (p
less than 0.001) of respiratory compromise than children in the no feedback
condition. This between-group difference was evident soon after baseline training
and maintained across 6 weeks. The feedback condition displayed greater adherence
to ICS (p less than 0.01) and greater quick-relief medication use (p less than 0.01)
than the no feedback condition.
Conclusions: Feedback on PEF predictions for ethnic minority, inner-city children may
decrease under-perception of respiratory compromise and increase adherence to
controller medications. Children and their families may shift their attention to
asthma perception and management as a result of this intervention.
http://thorax.bmj.com/content/67/12/1040.full.pdf%20html
264. The effect of reminder systems on patients' adherence to treatment
SD Fenerty, C West, SA Davis, SG Kaplan, SR Feldman
Patient Preference and Adherence 10 Feb 2012;6:127-135
Background: Patient adherence is an important component of the treatment of
chronic disease. An understanding of patient adherence and its modulating factors is
necessary to correctly interpret treatment efficacy and barriers to therapeutic
success.
Purpose: This meta-analysis aims to systematically review published randomised
controlled trials of reminder interventions to assist patient adherence to prescribed
medications.
Methods: A Medline search was performed for randomised controlled trials published
between 1968 and Jun 2011, which studied the effect of reminder-based
interventions on adherence to self-administered daily medications.
Results: 11 published randomised controlled trials were found between 1999 and
2009 which measured adherence to a daily medication in a group receiving reminder
interventions compared to controls receiving no reminders. Medication adherence
was measured as the number of doses taken compared to the number prescribed
within a set period of time. Meta-analysis showed a statistically significant increase
in adherence in groups receiving a reminder intervention compared to controls
(66.61% vs 54.71%; 95% CI for mean, 0.8% to 22.4%). Self-reported and
electronically monitored adherence rates did not significantly differ (68.04% vs
63.67%, P = 1.0). Eight of 11 studies showed a statistically significant increase in
adherence for at least one of the reminder group arms compared to the control
groups receiving no reminder intervention.
Limitations: The data are limited by imperfect measures of adherence due to
variability in data collection methods. It is also likely that concomitant educational
efforts in the study populations, such as instructions regarding proper administration
and importance of correct dosing schedules, contributed to improved patient
adherence, both in reminder and control arms. The search strategy could have
missed relevant studies which were categorised by disease rather than adherence.
161
Conclusions: Reminder-based interventions may improve adherence to daily
medications. However, the interventions used in these studies, which included
reminder phone calls, text messages, pagers, interactive voice response systems,
videotelephone calls and programmed electronic audiovisual reminder devices, are
impractical for widespread implementation, and their efficacy may be optimised
when combined with alternative adherence-modifying strategies. More practical
reminder-based interventions should be assessed to determine their value in
improving patient adherence and treatment outcomes.
265. Initial impact of medication adherence of diabetes injectable medication
through pharmacist-led injection training and counseling
LE Fensterheim, MA Farley, TB Rough, MS Taitel, S Wang, AE Cannon, I Duncan
Community pharmacists are well positioned to assist patients in overcoming
medication challenges that lead to non-adherence. This is especially true when
working with diabetes patients with more complex medication regimens that may
require self-injections. In this study, pharmacists provided patients with initial
injection training followed by assessment and consultation at the patient's next refill
visit to the pharmacy.
The purpose of this study was to evaluate the effect of a pharmacist-led intervention
programme on patients prescribed liraglutide (Victoza, Novo Nordisk), an injectable
diabetes medication, by analysing the patients' initial adherence.
This study utilised a retrospective cohort design with systematic random sampling.
Patients new to liraglutide therapy from May to Jul 2011 were randomly assigned to
either a test group (n = 4586) who received one or more counselling sessions or a
control group (n = 648) who received usual care. Both groups were required to have
an initial fill of 28-34 days supply within 30 days of group assignment. Persistency
was observed at 90 days from index fill to expected refill date with a 30-day grace
period. The proportion of days covered (PDC) was assessed as percentage of days of
liraglutide therapy in the initial 90 days.
Average age of test and control patients was 52.0 (SD +/- 10.9) and 52.1 (+/- 10.8)
respectively. The test group was 56% female vs 54% in the control group.
Persistency and PDC at 90 days was higher in the test group compared to the control
group (44.5% vs 40.4%, p = 0.05) and (63.4% vs 60.8%, p = 0.01) respectively.
For patients receiving two interventions (n = 1567) compared to control patients
with at least two fills (n = 453) persistency was (71.5% vs 57.8%, p less than 0.01)
and PDC was (81.7% vs 72.6%, p less than 0.01).
Early results suggest that a pharmacist-led training and counselling programme for
liraglutide improves medication adherence and has an observable intervention dose
response.
266. Effect of electronically delivered prescriptions on compliance and pharmacy
wait time among emergency department patients
TJ Fernando, DD Nguyen, LJ Baraff
Academic Emergency Medicine Jan 2012;19(1):102-105
Objectives: The primary objectives were to assess whether electronically delivered
prescriptions lead to reduced pharmacy wait time, improved patient satisfaction and
improved compliance with prescriptions. Secondary objectives included determining
other reasons for noncompliance and if there was an association between
162
prescription noncompliance and subsequent physician and emergency department
(ED) visits.
Methods: In this prospective study, patients discharged from the Ronald Reagan
UCLA Medical Center (Los Angeles, USA) ED with prescriptions for non-narcotic
medications were randomised to a control group who were discharged with standard
written prescriptions or an intervention group who had their prescriptions
electronically delivered to the pharmacy of their choice. All study participants were
contacted 7 to 31 days after ED discharge for a structured telephone interview.
Results: Of the 454 patients enrolled, follow-up was successful for 224 patients
(52.4%). 28 patients did not fill their prescriptions (12.5% noncompliance rate).
The top three reasons patients stated for not picking up their medications were
perceiving their prescription as unnecessary (n = 11), medication affordability (n =
5) and lack of time (n = 4). There was no difference in primary prescription
noncompliance between the two study groups (p = 0.58). However, electronically
delivered prescriptions significantly reduced the median pharmacy wait time, from 15
to 0 minutes (p less than 0.001), and improved patient satisfaction at the pharmacy
(p = 0.034). Neither subsequent physician nor ED visits were increased by primary
prescription noncompliance.
Conclusions: Electronically delivered prescriptions significantly minimised pharmacy
wait time and improved patient satisfaction at the pharmacy, but did not improve
primary compliance with prescriptions.
267. Patient communication tools to enhance ART adherence counseling in low and
high resource settings
S Finocchario-Kessler, D Catley, D Thomson, A Bradley-Ewing, J Berkley-Patton, K Goggin
Patient Education and Counseling Oct 2012;89(1):163-170
Objective: Few articles have examined specific counselling tools used to increase
antiretroviral therapy (ART) adherence. We present communication tools used in the
context of Project MOTIV8, a randomised clinical trial.
Methods: We developed, piloted and evaluated pictorial images to communicate the
importance of consistent dose timing and the concept of drug resistance. Electronic
drug monitoring (EDM) review using MEMS was also used to provide visual feedback
and facilitate problem solving discussions. Adherence knowledge of all participants
(n = 204) was assessed at baseline and 48 weeks. Participant satisfaction with
counselling was also assessed.
Results: Adherence knowledge did not differ at baseline, however, at 48 weeks,
intervention participants demonstrated significantly increased knowledge compared
to controls F(1, 172) = 10.76, p = 0.001 (12.4% increase among intervention
participants and 1.8% decrease among controls). Counsellors reported that the tools
were well-received, and 80% of participants felt the counselling helped them adhere
to their medications.
Conclusions: Counselling tools were both positively received and effective in
increasing ART adherence knowledge among a diverse population.
Practice Implications: While developed for research, these counselling tools can be
implemented into clinical practice to help patients, particularly those with lower
levels of education or limited abstract thinking skills, to understand medical concepts
related to ART adherence.
Trial Registration: ClinicalTrials.gov identifier: NCT00602758.
268. Impact of a text messaging pilot program on patient medication adherence
163
KF Foreman, KM Stockl, LB Le, E Fisk, SM Shah, HC Lew, BK Solow, BS Curtis
Clinical Therapeutics May 2012;34(5):1084-1091
Background: Medication nonadherence is a well-recognised challenge associated with
poor health outcomes and increased utilisation of health care resources. Although
many different behavioural and educational strategies are available to improve
patient medication adherence, technological advances, including cell phone text
messaging, represent new and innovative modalities to improve adherence and
overall health outcomes.
Objective: To evaluate medication adherence among patients opting to receive text
message medication reminders and a well-matched control cohort.
Methods: This retrospective, observational cohort analysis compared medication
adherence of members of a US pharmacy benefit management scheme (OptumRx)
who opted-in to the text message medication reminder programme and a matched
control cohort using data from a member portal database and electronic pharmacy
claims of a national pharmacy benefit manager with commercial and Medicare
membership. Continuously enrolled members who opted to receive at least 1
medication-specific dosage reminder for a chronic oral medication of interest and had
at least 1 pharmacy claim for the same chronic oral medication of interest were
included. Matching was based on medication therapeutic class, then on propensity
score (including variables of age, sex, health plan, Chronic Disease Score, distinct
medication count, average baseline medication adherence, and duration of therapy).
The primary outcome was chronic oral medication adherence, measured as the
proportion of days covered (PDC), between 1 Jan 2011 and 31 Aug 2011. Analyses
comparing cohorts were conducted using paired t tests and the McNemar test.
Results: After implementation of the text messaging programme, the mean (+/- SD)
PDC was significantly higher for the text message cohort (n = 290) than for the
control cohort (n = 290) (0.85 +/- 0.20 vs 0.77 +/- 0.28, respectively; P less than
0.001). Of those members identified with a chronic oral antidiabetes medication, the
mean PDC was significantly higher in the text message cohort than in the control
cohort (0.91 +/- 0.14 vs 0.82 +/- 0.21; P = 0.029). Significant differences in mean
PDC were also seen in members who opted to receive text message reminders for
beta-blocker therapy over members in the control cohort (0.88 +/- 0.18 vs 0.71 +/0.29; P = 0.006).
Conclusions: Findings suggest that members opting into a text message reminder
programme have significantly higher chronic oral medication adherence compared
with members not opting to receive medication-specific text message reminders, and
that the use of a text message reminder programme assists in preserving higher
rates of adherence over time.
269. Evaluation of clinical pharmacist mediated education and counselling of
systemic lupus erythematosus patients in tertiary care hospital
MS Ganachari, S Atiya Almas
Indian Journal of Rheumatology Mar 2012;7(1):7-12
Objectives: To assess the knowledge of systemic lupus erythematosus (SLE) patients
before and after clinical pharmacist's education and compare the same with the
control group.
Methods: In this study done on patients with SLE, the test group patients were
provided with education regarding SLE and its management including lifestyle
modifications, via the distribution of patient information leaflets (PILs), while the
control group were continued with conventional therapy. A validated knowledge
assessment questionnaire was administered at baseline, first follow-up and final
164
(second) follow-up to assess the medication knowledge of SLE patients. The
Modified Morisky Scale (MMS) was used to assess the adherence at the final followup to study the influence of education.
Results: 45 patients completed the 2 months follow-up study out of 50 enrolled
patients. A significant (P less than 0.001) improvement in medication knowledge
scores and medication adherence was seen in test group compared to the control
group. The reasons for non-compliance included patients forgetfulness, high cost of
medications, patients lack of access to hospital/drug store, lack of family
support/motivation, fear of side effects, and fear of becoming dependent on
treatment.
Conclusions: The finding of this study showed that a well-structured SLE patient
counselling by a clinical pharmacist's intervention will result in improved medication
knowledge and better medication adherence.
http://www.indianjrheumatol.com/article/S0973-3698(12)60003-X/abstract
270. Mobile Assessment and Treatment for Schizophrenia (MATS): a pilot trial of
an interactive text-messaging intervention for medication adherence,
socialization, and auditory hallucinations
E Granholm, D Ben-Zeev, PC Link, KR Bradshaw, JL Holden
Schizophrenia Bulletin May 2012;38(3):414-425
Mobile Assessment and Treatment for Schizophrenia (MATS) employs ambulatory
monitoring methods and cognitive behavioral therapy interventions to assess and
improve outcomes in patients with schizophrenia through mobile phone text
messaging. Three MATS interventions were developed to target medication
adherence, socialisation and auditory hallucinations. Participants received up to 840
text messages over a 12-week intervention period. 55 patients with schizophrenia or
schizoaffective disorder were enrolled, but 13 patients with more severe negative
symptoms, lower functioning, and lower premorbid IQ did not complete the
intervention, despite repeated prompting and training. For completers, the average
valid response rate for 216 outcome assessment questions over the 12-week period
was 86%, and 86% of phones were returned undamaged. Medication adherence
improved significantly, but only for individuals who were living independently.
Number of social interactions increased significantly and a significant reduction in
severity of hallucinations was found. In addition, the probability of endorsing
attitudes that could interfere with improvement in these outcomes was also
significantly reduced in MATS. Lab-based assessments of more general symptoms
and functioning did not change significantly. This pilot study demonstrated that lowintensity text-messaging interventions like MATS are feasible and effective
interventions to improve several important outcomes, especially for higher
functioning patients with schizophrenia.
http://schizophreniabulletin.oxfordjournals.org/content/38/3/414.abstract
271. Individualised patient care as an adjunct to standard care for promoting
adherence to ocular hypotensive therapy: an exploratory randomised controlled
trial
TA Gray, C Fenerty, R Harper, AF Spencer, M Campbell, DB Henson, H Waterman
Eye Mar 2012;26(3):407-417
Purpose: To evaluate the impact of individualised patient care, as an adjunct to
standard care, on adherence to ocular hypotensive therapy.
Methods: A two-arm, single-masked exploratory randomised controlled trial recruited
patients newly prescribed ocular hypotensive therapy. The intervention involved an
individual assessment of health-care needs and beliefs and a 1-year follow-up period
165
according to need. The primary outcome was refill adherence, measured by collating
prescription and dispensing data for 12 months. Secondary outcomes included selfreported adherence, glaucoma knowledge, beliefs about illness and medicines,
quality of care, intraocular pressure (IOP) fluctuation, and changes in clinical
management assessed at 12 months. The strength of the intervention was
measured following withdrawal by reviewing clinical outcomes for a further 12
months.
Results: In all, 127 patients were recruited (91% response rate). Intervention-arm
patients collected significantly more prescriptions than control-arm patients. Selfreport adherence was significantly better in the intervention-arm for patients who
forgot drops and those who intentionally missed drops. The intervention group
demonstrated significantly more glaucoma knowledge, expressed a significantly
stronger belief in the necessity of eye drops and believed that they had more
personal control over managing their condition. Control-arm patients had more IOP
fluctuation and changes in clinical management. However, this finding only reached
significance at 24 months.
Conclusions: Modelling patient care according to health-care needs and beliefs about
illness and medicines can have a significant impact on improving adherence to
therapy for this patient group, with the potential benefit of improving clinical
outcomes.
http://www.nature.com/eye/journal/v26/n3/abs/eye2011269a.html
272. Improving blood pressure control through a clinical pharmacist outreach
program in patients with diabetes mellitus in 2 high-performing health systems:
the Adherence and Intensification of Medications cluster randomized, controlled
pragmatic trial
M Heisler, TP Hofer, JA Schmittdiel, JV Selby, ML Klamerus, HB Bosworth, M Bermann, EA
Kerr
Circulation 12 Jun 2012;125(23):2863-2872
Background: Even in high-performing health systems, some patients with diabetes
mellitus have poor blood pressure (BP) control because of poor medication
adherence and lack of medication intensification. We examined whether the
Adherence and Intensification of Medications intervention, a pharmacist-led
intervention combining elements found in efficacy studies to lower BP, improved BP
among patients with diabetes mellitus with persistent hypertension and poor refill
adherence or insufficient medication intensification in 2 high-performing health
systems in the USA.
Methods and Results: We conducted a prospective, multisite cluster randomised
pragmatic trial with randomisation of 16 primary care teams at 5 medical centres (3
US Veterans Affairs and 2 Kaiser Permanente) to the Adherence and Intensification
of Medications intervention or usual care. The primary outcome was relative change
in systolic BP (SBP), comparing 1797 intervention with 2303 control team patients,
from 6 months preceding to 6 months after the 14-month intervention period. We
examined shorter-term changes in SBP as a secondary outcome. The mean SBP
decrease from 6 months before to 6 months after the intervention period was approx
9 mm Hg in both arms. Mean SBPs of eligible intervention patients were 2.4 mm Hg
lower (95% CI, -3.4 to -1.5; P less than 0.001) immediately after the intervention
than those achieved by control patients.
Conclusions: The Adherence and Intensification of Medications programme more
rapidly lowered SBPs among intervention patients, but usual-care patients achieved
equally low SBP levels by 6 months after the intervention period. These findings
show the importance of evaluating in different real-life clinical settings programmes
166
found in efficacy trials to be effective before urging their widespread adoption in all
settings.
Clinical Trial Registration: ClinicalTrials.gov identifier: NCT00495794.
http://circ.ahajournals.org/content/125/23/2863.full.pdf+html
273. Impact of an online prescription management account on medication
adherence
JG Hou, P Murphy, AW Tang, N Khandelwal, I Duncan, CL Pegus
American Journal of Managed Care Mar 2012;18(3):e86-e90
Objectives: To assess medication adherence rates of patients utilising an online
prescription management account compared with nonusers. The online account
provides patients with access to their prescription fill history and the opportunity to
obtain automatic refills, process refills electronically and view prescription insurance
coverage. The account also gives patients the opportunity to create a customised
support page which provides information on health conditions chosen by the patient.
Study Design: A retrospective analysis was conducted using de-identified pharmacy
claims data from a US pharmacy benefit manager covering the period from 1 Apr
2009 to 31 Mar 2011. Patients who were continuously eligible throughout the study
period and who had at least one prescription fill for any of the 8 therapeutic groups
examined in the study (antidepressants, antidiabetics, antihyperlipidaemics,
antihypertensives, beta blockers, diuretics, thyroid agents and ulcer drugs) were
selected for inclusion.
Methods: Adherence was assessed by measuring the proportion of days covered
(PDC). Propensity score matching was used to minimise differences in age, gender,
chronic condition score, copay, household income and urban locality between the
user and nonuser groups. Results were reported for all therapeutic groups
combined, as well as by individual therapeutic group.
Results: Overall, patients utilising the online account had a significantly higher
weighted average PDC (73.19% vs 61.64%, P less than 0.0001). Users also had a
higher average PDC for each individual therapeutic group, although the beta-blocker
group was not statistically significant. The percentage of patients achieving an
average PDC above 80% was also found to be greater in the user group across each
therapeutic group and overall.
Conclusions: Patients who utilised an online prescription management account had
higher rates of medication adherence as compared with nonusers. Additional studies
are needed to assess which specific components of the prescription management
account have the biggest impact on adherence.
http://www.ajmc.com/articles/Impact-of-an-Online-Prescription-Management-Account-onMedication-Adherence
274. Comparative cost-effectiveness of interventions to improve medication
adherence after myocardial infarction
K Ito, WH Shrank, J Avorn, AR Patrick, TA Brennan, EM Antman, NK Choudhry
Health Services Research Dec 2012;47(6):2097-2117
Objective: To evaluate the comparative cost-effectiveness of interventions to
improve adherence to evidence-based medications among post-myocardial infarction
(MI) patients.
Data Sources/Study Setting: Cost-effectiveness analysis.
Study Design: We developed a Markov model simulating a hypothetical cohort of 65year-old post-MI patients who were prescribed secondary prevention medications.
We evaluated mailed education, disease management, polypill use and combinations
of these interventions. The analysis was performed from a societal perspective over
167
a lifetime horizon. The main outcome was an incremental cost-effectiveness ratio
(ICER) as measured by cost per quality-adjusted life year (QALY) gained.
Data Collection/Extraction Methods: Model inputs were extracted from published
literature.
Principal Findings: Compared with usual care, only mailed education had both
improved health outcomes and reduced spending. Mailed education plus disease
management, disease management, polypill use, polypill use plus mailed education
and polypill use plus disease management cost were US$74,600, $69,200,
$133,000, $113,000 and $142,900 per QALY gained, respectively. In an incremental
analysis, only mailed education had an ICER of less than $100,000 per QALY and was
therefore the optimal strategy. Polypill use, particularly when combined with mailed
education, could be cost effective, and potentially cost saving if its price decreased to
less than $100 per month.
Conclusions: Mailed education and a polypill, once available, may be the cost-saving
strategies for improving post-MI medication adherence.
275. Impact of pharmaceutical care on health outcomes in patients with COPD
AS Jarab, SG AlQudah, M Khdour, M Shamssain, TL Mukattash
International Journal of Clinical Pharmacy Feb 2012;34(1):53-62
Background: Chronic obstructive pulmonary disease (COPD) treatment goals are
often not achieved despite the availability of many effective treatments.
Furthermore, clinical pharmacist interventions to improve clinical and humanistic
outcomes in COPD patients have not yet been explored and few randomised
controlled trials have been reported to evaluate the impact of pharmaceutical care on
health outcomes in patients with COPD.
Objective: The aim of the present study was to evaluate the impact of
pharmaceutical care intervention, with a strong focus on self-management, on a
range of clinical and humanistic outcomes in patients with COPD.
Setting: Outpatient COPD Clinic at the Royal Medical Services Hospital, Amman,
Jordan.
Methods: In a randomised, controlled, prospective clinical trial, a total of 133 COPD
patients were randomly assigned to intervention or control group. Structured
education about COPD and management of its symptoms was delivered by the
clinical pharmacist for patients in the intervention group. Patients were followed up
at 6 months during a scheduled visit. Effectiveness of the intervention was assessed
in terms of improvement in health-related quality of life, medication adherence,
disease knowledge and healthcare utilisation. Data collected at baseline and at the 6
month assessment were coded and entered into SPSS software version 17 for
statistical analysis. A P value of less than 0.05 was considered statistically
significant.
Main Outcome Measures: The primary outcome measure was health-related quality
of life improvement. All other data collected including healthcare utilisation, COPD
knowledge and medication adherence formed secondary outcome measures.
Results: A total of 66 patients were randomised to the intervention group and 67
patients were randomised to the control group. Although the current study failed to
illustrate significant improvement in health-related quality of life parameters, the
results indicated significant improvements in COPD knowledge (P less than 0.001),
medication adherence (P less than 0.05), medication beliefs (P less than 0.01) and
significant reduction in hospital admission rates (P less than 0.05) in intervention
patients when compared with control group patients at the end of the study.
168
Conclusions: The enhanced patient outcomes as a result of the pharmaceutical care
programme in the present study demonstrate the value of an enhanced clinical
pharmacy service in achieving the desired health outcomes for patients with COPD.
http://link.springer.com/article/10.1007%2Fs11096-011-9585-z
276. The effectiveness of social resource intervention to promote adherence to HIV
medication in a multidisciplinary care setting in Kenya
TM Kamau, VG Olsen, GP Zipp, M Clark
International Journal of STD and AIDS Dec 2012;23(12):843-848
Adherence to HIV medication has a dramatic impact on morbidity, mortality and
health in people living with HIV. Recent studies have demonstrated good adherence
to HIV medication among people in sub-Saharan Africa, but few have investigated
factors influencing adherence.
The goal of this study was to evaluate the effectiveness of social intervention
strategies to enhance adherence to HIV medication.
A cross-sectional design study was used to obtain data through self-administered
questionnaires from 354 individuals who were prescribed HIV medication at nine
satellite centres under the auspice of the Nazareth Hospital in Kenya. Binomial
logistics were used to test the relationships between social support and its
dimensions with adherence to HIV medication.
Composite social support was predictive of adherence to HIV medication (P less than
0.05). Among the four dimensions of support, material and emotional support were
the strongest predictors.
http://ijsa.rsmjournals.com/content/23/12/843.abstract
277. Does the presence of a pharmacist in primary care clinics improve diabetes
medication adherence?
BM Kocarnik, C Liu, ES Wong, M Perkins, ML Maciejewski, EM Yano, DH Au, JD Piette, CL
Bryson
BMC Health Services Research 13 Nov 2012;12:391
Background: Although oral hypoglycaemic agents (OHAs) are an essential element of
therapy for the management of type 2 diabetes, OHA adherence is often suboptimal.
Pharmacists are increasingly being integrated into primary care as part of the move
towards a patient-centred medical home and may have a positive influence on
medication use. We examined whether the presence of pharmacists in primary care
clinics was associated with higher OHA adherence.
Methods: This retrospective cohort study analysed 280,603 diabetes patients in 196
primary care clinics within the US Veterans Affairs healthcare system. Pharmacists
presence, number of pharmacist full-time equivalents (FTEs), and the degree to
which pharmacy services are perceived as a bottleneck in each clinic were obtained
from the 2007 VA Clinical Practice Organizational Survey - Primary Care Director
Module. Patient-level adherence to OHAs using medication possession ratios (MPRs)
were constructed using refill data from administrative pharmacy databases after
adjusting for patient characteristics. Clinic-level OHA adherence was measured as
the proportion of patients with MPR of 80% or higher. We analysed associations
between pharmacy measures and clinic-level adherence using linear regression.
Results: We found no significant association between pharmacist presence and cliniclevel OHA adherence. However, adherence was lower in clinics where pharmacy
services were perceived as a bottleneck.
Conclusions: Pharmacist presence, regardless of the amount of FTE, was not
associated with OHA medication adherence in primary care clinics. The exact role of
pharmacists in clinics needs closer examination in order to determine how to most
169
effectively use these resources to improve patient-centred outcomes including
medication adherence.
278. The ability of multifamily groups to improve treatment adherence in Mexican
Americans with schizophrenia
A Kopelowicz, R Zarate, CJ Wallace, RP Liberman, SR Lopez, J Mintz
Archives of General Psychiatry Mar 2012;69(3):265-273
Context: Evidence-based interventions to improve medication adherence among
patients with schizophrenia are lacking. Although family psychoeducation has
demonstrated efficacy in improving outcomes in schizophrenia, empirical support for
its ability to enhance medication adherence is scarce.
Objective: To determine whether a culturally adapted, multifamily group (MFG)
therapy would increase medication adherence and decrease psychiatric
hospitalisations for Spanish-speaking Mexican-Americans with schizophrenia.
Design: A total of 174 Mexican-American adults with schizophrenia-spectrum
disorder and their key relatives were studied in a 3-armed, randomised controlled
trial of MFG therapy focused on improving medication adherence. Assessments
occurred at baseline and at 4, 8, 12, 18 and 24 months.
Setting: Two community mental health centres in Los Angeles, California, USA.
Participants: Patients had a diagnosis of schizophrenia or schizoaffective disorder
with a recent exacerbation of psychotic symptoms and nonadherence to medication
before enrollment.
Intervention: Patients participated in 1 of 2 MFGs (MFG-adherence or MFG-standard)
or treatment as usual. Groups convened twice monthly in 90-minute sessions for 1
year.
Main Outcome Measures: The Treatment Compliance Interview uses multiple sources
of information to quantify medication adherence. Computerised records were used
to collect information on the use of inpatient resources.
Results: At the end of the 1-year treatment, MFG-adherence was associated with
higher medication adherence than MFG-standard or treatment as usual only (F =
6.41; P = 0.003). The MFG-adherence participants had a longer time to first
hospitalisation (chi2 = 13.3; P = 0.001) and were less likely to be hospitalised than
those in MFG-standard (chi2 = 8.2; P = 0.04) and treatment as usual alone (chi2 =
11.3; P less than 0.001). Increased adherence accounted for one-third of the overall
effect of treatment on the reduced risk for psychiatric hospitalisation.
Conclusions: Multifamily group therapy specifically tailored to improve medication
adherence through a focus on the beliefs and attitudes of the target population is
associated with improved outcome for Mexican-American adults with schizophreniaspectrum disorders.
Trial Registration: ClinicalTrials.gov Identifier: NCT01125267.
http://archpsyc.jamanetwork.com/article.aspx?articleid=1107409
279. Improving medication adherence through graphically enhanced
interventions in coronary heart disease (IMAGE-CHD): a randomized controlled
trial
S Kripalani, B Schmotzer, TA Jacobson
Journal of General Internal Medicine Dec 2012;27(12):1609-1617
Background: Up to 50% of patients do not take medications as prescribed.
Interventions to improve adherence are needed, with an understanding of which
patients benefit most.
170
Objective: To test the effect of two low-literacy interventions on medication
adherence.
Design: Randomised controlled trial, 2 x 2 factorial design.
Participants: Adults with coronary heart disease in an inner-city primary care clinic.
Interventions: For 1 year, patients received usual care, refill reminder postcards,
illustrated daily medication schedules, or both interventions.
Main Measures: The primary outcome was cardiovascular medication refill
adherence, assessed by the cumulative medication gap (CMG). Patients with CMG
less than 0.20 were considered adherent. We assessed the effect of the
interventions overall and, post-hoc, in subgroups of interest.
Results: Most of the 435 participants were elderly (mean age = 63.7 years), AfricanAmerican (91%), and read below the 9th-grade level (78%). Among the 420
subjects (97%) for whom CMG could be calculated, 138 (32.9%) had CMG less than
0.20 during follow-up and were considered adherent. Overall, adherence did not
differ significantly across treatments: 31.2% in usual care, 28.3% with mailed refill
reminders, 34.2% with illustrated medication schedules and 36.9% with both
interventions. In post-hoc analyses, illustrated medication schedules led to
significantly greater odds of adherence among patients who at baseline had more
than 8 medications (OR = 2.2; 95% CI, 1.21 to 4.04) or low self-efficacy for
managing medications (OR = 2.15; 95% CI, 1.11 to 4.16); a trend was present
among patients who reported non-adherence at baseline (OR = 1.89; 95% CI, 0.99
to 3.60).
Conclusions: The interventions did not improve adherence overall. Illustrated
medication schedules may improve adherence among patients with low self-efficacy,
polypharmacy or baseline non-adherence, though this requires confirmation
http://link.springer.com/article/10.1007/s11606-012-2136-z
280. An evaluation of a pictorial asthma medication plan for Pacific children
J Kristiansen, E Hetutu, M Manukia, T Jelleyman
New Zealand Medical Journal 11 May 2012;125(1354):42-50
Background: The burden of asthma falls disproportionately on children from New
Zealand's Pacific communities. Guidelines recommend pictorial resources but these
have not been evaluated in this population.
Aims: Evaluate a pictorial asthma medication plan focusing on regular 'everyday'
inhaler use and a signs and symptoms sheet for Pacific children; the primary
outcome measure was continued use of resources after 6 months.
Methods: Resources were provided to families with face-to-face education at a
general practice or inpatient setting in West Auckland. A questionnaire about the
resources was completed after 6 weeks, and an audit regarding use after 6 months.
Results: Data from 48 children were analysed (Samoan, n = 31); 45 English and 22
first language versions (Samoan, Tongan, Tuvaluan) were used; median time to
questionnaire completion was 48 days. The pictorial asthma medication plan was
acceptable to families, effective at reinforcing the importance of 'everyday' inhalers,
and a reminder for regular use; the signs and symptoms sheets were informative
and improved self-efficacy; 93% of families were using the resources after 6 months.
An increase in 'everyday' inhaler use was observed after education.
Conclusions: The resources were effective at improving inhaler knowledge and
supporting symptom recognition. A 'less-is-more' approach, pictorial format and first
language availability are characteristics that may benefit other ethnicities.
http://journal.nzma.org.nz/journal/125-1354/5173/content.pdf
171
281. Patient-centered adherence intervention after acute coronary syndrome
hospitalization - methods paper
A Lambert-Kerzner, EJ Del Giacco, IE Fahdi, CL Bryson, D Melnyk, HB Bosworth, R Davis, H
Mun, J Weaver, C Barnett, et al. (Multifaceted Intervention to Improve Cardiac Medication
Adherence and Secondary Prevention Measures Medication Study Investigators)
Circulation: Cardiovascular Quality and Outcomes Jul 2012;5(4):571-576
Background: Adherence to cardioprotective medications in the year after acute
coronary syndrome hospitalisation is generally poor and is associated with increased
risk of rehospitalisation and mortality. Few interventions have specifically targeted
this high-risk patient population to improve medication adherence. We hypothesise
that a multifaceted patient-centred intervention could improve adherence to
cardioprotective medications.
Methods and Results: To evaluate this intervention, we propose enrolling 280
patients with a recent acute coronary syndrome event into a multicentre,
randomised, controlled trial. The intervention comprises 4 main components: (1)
pharmacist-led medication reconciliation and tailoring; (2) patient education; (3)
collaborative care between pharmacist and primary care provider/cardiologist; and
(4) 2 types of voice messaging (educational and medication refill reminder calls).
Patients in the intervention arm will visit with the study pharmacist approx 1 week
post-hospital discharge. The pharmacist will work with the patient and collaborate
with providers to reconcile medication issues. Voice messages will augment the
educational process and remind patients to refill their cardioprotective medications.
The study will compare the intervention versus usual care for 12 months. The
primary outcome of interest is adherence using the ReComp method. Secondary and
tertiary outcomes include achievement of targets for blood pressure and low-density
lipoprotein and reduction in the combined cardiovascular end points of myocardial
infarction hospitalisation, coronary revascularisation and all-cause mortality. Finally,
we will also evaluate the cost-effectiveness of the intervention compared with usual
care.
Conclusions: If the intervention is effective in improving medication adherence and
demonstrating a lower cost, the intervention has the potential to improve
cardiovascular outcomes in this high-risk patient population.
http://circoutcomes.ahajournals.org/content/5/4/571.abstract
282. Sticker charts: a method for improving adherence to treatment of chronic
diseases in children
K Luersen, SA Davis, SG Kaplan, TD Abel, WW Winchester, SR Feldman
Pediatric Dermatology Jul-Aug 2012;29(4):403-408
Poor adherence is a common problem and may be an underlying cause of poor
clinical outcomes. In paediatric populations, positive reinforcement techniques such
as sticker charts may increase motivation to adhere to treatment regimens. To
review the use of sticker charts to improve adherence in children with chronic
disease, Medline and PsycINFO searches were conducted using the key words
'positive reinforcement OR behavior therapy' and 'adherence OR patient compliance'
and 'child'. Randomised controlled retrospective cohort or single-subject-design
studies were selected. Studies reporting adherence to the medical treatment of
chronic disease in children using positive reinforcement techniques were included in
the analysis. The systematic search was supplemented by identifying additional
studies identified through the reference lists and authors of the initial articles found.
Positive reinforcement techniques such as sticker charts increase adherence to
medical treatment regimens. In several studies, this effect was maintained for
months after the initial intervention. Better adherence correlated with better clinical
172
outcomes in some, but not all, studies. Few studies examining the use of sticker
charts were identified. Although single-subject-design studies are useful in
establishing the effect of a behavioural intervention, larger randomised controlled
trials would help determine the precise efficacy of sticker chart interventions.
Adherence to medical treatments in children can be increased using sticker charts or
other positive reinforcement techniques. This may be an effective means to
encourage children with atopic dermatitis to apply their medications and improve
clinical outcomes.
283. Medication adherence improvements in employees participating in a
pharmacist-run risk reduction program
MC McKenzie, TL Lenz, ND Gillespie, JJ Skradski
Innovations in Pharmacy 2012;3(4): (6pp.)
Objective: To evaluate the medication adherence of individuals participating in a
pharmacist-run employee health cardiovascular and diabetes risk reduction
programme.
Design: Retrospective analysis of medication adherence using pharmacy refill data.
Setting: A medium-sized university located in the Midwest USA and the
organisation's outpatient pharmacy.
Participants: 38 participants 18 years of age or older, employed and receiving their
health insurance through the organisation, and having a diagnosis of hypertension,
hyperlipidaemia, diabetes mellitus or a combination thereof.
Intervention: Participation in the risk reduction programme that emphasises
medication therapy management (MTM), lifestyle medicine and care coordination.
Main Outcome Measures: The proportion of days covered (PDC) and the medication
possession ratio (MPR).
Results: PDC and MPR analysis showed a statistically significant improvement in
medication adherence for 180 days and 360 days post enrollment versus the 180
days prior to enrollment (P less than 0.01). The PDC analysis demonstrated a
statistically significant improvement in the number of medications that achieved a
PDC of 80% or higher (high adherence) for the 180 days post enrollment versus the
180 days prior to enrollment (+30%, P less than 0.01). The MPR analysis showed a
non-statistically significant improvement in the number of medications that achieved
an MPR of 80% or higher (high adherence) pre enrollment versus post enrollment
(+10%, P = 0.086). The percentage of participants in the programme that reached
a PDC and MPR adherence rate of 80% or above at 180 days post enrollment was
78.9% and 94.4%, respectively which exceeds that of a matched cohort that reached
a PDC and MPR adherence rate of 80% or above of 66.4% and 82.8%, respectively.
Conclusions: Pharmacists can improve medication adherence as measured by PDC
and MPR when working with employees enrolled in a novel pharmacist-run employee
health risk reduction programme. Medication adherence was shown to be
sustainable for at least 1 year and was shown to be better when compared to a
matched cohort of similar age, condition and region.
284. Patient education and counselling for promoting adherence to treatment for
tuberculosis
J Machoki M'Imunya, T Kredo, J Volmink
Cochrane Library 16 May 2012;(5):CD006591
173
Background: Non-adherence to tuberculosis treatment can lead to prolonged periods
of infectiousness, relapse, emergence of drug-resistance, and increased morbidity
and mortality. In this review, we assess whether patient education or counselling, or
both, promotes adherence to tuberculosis treatment.
Objectives: To evaluate the effects of patient education or counselling, or both, on
treatment completion and cure in people requiring treatment for active or latent
tuberculosis.
Search Methods: Without language restriction, we searched for eligible studies in the
Cochrane Infectious Diseases Group Specialized Register, Cochrane Central Register
of Controlled Trials, MEDLINE, EMBASE, and LILACS; checked reference lists of
relevant articles; and contacted relevant researchers and organisations up to 24 Nov
2011.
Selection Criteria: Randomised controlled trials examining the effects of education or
counselling, or both, on treatment completion and cure in people with clinical
tuberculosis; and treatment completion and clinical tuberculosis in people with latent
disease.
Data Collection and Analysis: We independently screened identified studies for
eligibility, assessed methodological quality and extracted data; with differences
resolved by consensus. We expressed study results as risk ratios (RRs) with 95%
confidence intervals (CI).
Main Results: We found three trials, with a total of 1437 participants, which
examined the effects of different educational and counselling interventions on
adherence to treatment for latent tuberculosis.
All three trials reported the proportion of people who successfully completed
treatment for latent tuberculosis. Overall, education or counselling interventions
may increase successful treatment completion but the magnitude of benefit is likely
to vary depending on the nature of the intervention, and the setting (data not
pooled, 923 participants, 3 trials, low quality evidence).
In a 4-arm trial in children from Spain, counselling by nurses via telephone increased
the proportion of children completing treatment from 65% to 94% (RR 1.44; 95%
CI, 1.21 to 1.72; 157 participants, 1 trial), and counselling by nurses through home
visits increased completion to 95% (RR 1.46; 95% CI, 1.23 to 1.74; 156
participants, 1 trial). Both of these interventions were superior to counselling by
physicians at the tuberculosis clinic (RR 1.20; 95% CI, 0.98 to 1.47; 159
participants, 1 trial).
In the USA, a programme of peer counselling for adolescents failed to show an effect
on treatment completion rates at 6 months (RR 1.01; 95% CI, 0.90 to 1.13; 394
participants, 1 trial). In this trial treatment completion was around 75% even in the
control group.
In the third study, in prisoners from the USA, treatment completion was very low in
the control group (12%), and although counselling significantly improved this,
completion in the intervention group remained low at 24% (RR 1.94; 95% CI, 1.03
to 3.68; 211 participants, 1 trial).
None of these trials aimed to assess the effect of these interventions on the
subsequent development of active tuberculosis, and we found no trials that assessed
the effects of patient education or counselling on adherence to treatment for active
tuberculosis.
Authors' Conclusions: Educational or counselling interventions may improve
completion of treatment for latent tuberculosis. As would be expected, the
magnitude of the benefit is likely to depend on the nature of the intervention, and
the reasons for low completion rates in the specific setting.
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006591.pub2/pdf
174
285. Hospital survival skills DSME DVD improves post discharge medication
adherence
MF Magee, NH Khan, CM Nassar
oral presentation abstract 76-OR
Diabetes self-management education (DSME) improves knowledge, clinical
outcomes, e.g. A1C, and costs. While the hospital may be considered a suboptimal
environment in which to provide DSME, admissions present an opportunity to deliver
education. The ADA (Standards of Care 2012) suggests 'survival skills' education as
a feasible approach to inpatient DSME. Evidence is needed to define strategies for
hospital DSME delivery.
We have piloted a diabetes survival skills instructional DVD entitled 'Diabetes-To-Go'
in an urban teaching hospital in the USA. Content was aligned with ADA suggested
areas for hospital DSME. The primary goal was to reduce readmissions. Patients
with uncontrolled diabetes (BG above 200mg/dL or below 40mg/dL) admitted to the
hospital were eligible for inclusion. Knowledge and diabetes medication adherence
were assessed at baseline, 2 and 3 months post-discharge. Patients were directed to
watch DVD sections corresponding to survey identified knowledge deficits prior to
discharge.
115 patients consented and were enrolled in this IRB approved study. Interim data
analysis has been performed for 72 programme completers (mean age 59 +/- 13
years; 68% female; 86% African-American; mean BG 282 + 141mg/dL; mean A1C
9.7 + 2.8%). A targeted survival skills DSME DVD offered in the hospital
demonstrated preliminary evidence of knowledge improvement, an increase in
medication adherence (Morisky scale) from baseline to 2 weeks which persisted until
3 months, and a trend toward reduction in hospital readmissions.
http://www.abstractsonline.com/Plan/ViewAbstract.aspx?sKey=9c9e1458-f093-4256-9da9523c416b960c&cKey=e12c234f-6098-4df8-9dc5-6949950cb3d1&mKey={0F70410F-8DF349F5-A63D-3165359F5371}
286. How do we improve patient compliance and adherence to long-term statin
therapy?
P Maningat, BR Gordon, JL Breslow
Current Atherosclerosis Reports Dec 2012;15:291
Statins are highly effective drugs prescribed to millions of people to lower LDLcholesterol and decrease cardiovascular risk. The benefits of statin therapy seen in
randomised clinical trials will only be replicated in real-life if patients adhere to the
prescribed treatment regimen. However, about half of patients discontinue statin
therapy within the first year, and adherence decreases with time. Patient, physician
and healthcare system-related factors play a role in this problem. Recent studies
have focused more on the patient's perspectives on non-adherence. Adverse events
are cited as the most common cause of statin discontinuation; thus, the healthcare
provider must be willing to ally and dialogue with patients to address concerns and
assess the risks and benefits of continued statin therapy.
287. Effect on adherence to nicotine replacement therapy of informing smokers
their dose is determined by their genotype: a randomised controlled trial
TM Marteau, P Aveyard, MR Munafo, AT Prevost, GJ Hollands, D Armstrong, S Sutton, C Hill,
E Johnstone, AL Kinmonth
PLoS ONE 11 Apr 2012;7(4):e35249. doi:10.1371/journal.pone.0035249
175
Background: The behavioural impact of pharmacogenomics is untested. We tested
two hypotheses concerning the behavioural impact of informing smokers their oral
dose of NRT is tailored to analysis of DNA.
Methods and Findings: We conducted an RCT with smokers in smoking cessation
clinics (N = 633), recruited from primary care practices in Birmingham and Bristol.
In combination with NRT patch, participants were informed that their doses of oral
NRT were based either on their mu-opioid receptor (OPRM1) genotype, or their
nicotine dependence questionnaire score (phenotype). The proportion of prescribed
NRT consumed in the first 28 days following quitting was not significantly different
between groups: (68.5% of prescribed NRT consumed in genotype vs 63.6%,
phenotype group, difference = 5.0%; 95% CI, -0.9 to 10.8; p = 0.098). Motivation
to make another quit attempt among those (n = 331) not abstinent at 6 months was
not significantly different between groups (p = 0.23). Abstinence at 28 days was not
different between groups (p = 0.67); at 6 months was greater in genotype than
phenotype group (13.7% vs 7.9%, difference = 5.8%; 95% CI, 1.0 to 10.7; p =
0.018).
Conclusions: Informing smokers their oral dose of NRT was tailored to genotype not
phenotype had a small, statistically non-significant effect on 28-day adherence to
NRT. Among those still smoking at 6 months, there was no evidence that saying
NRT was tailored to genotype adversely affected motivation to make another quit
attempt. Higher abstinence rate at 6 months in the genotype arm requires
investigation.
Trial Registration: Controlled-Trials.com ISRCTN14352545.
http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0035249
288. Results of a randomized controlled trial to assess the effects of a mobile
SMS-based intervention on treatment adherence in HIV/AIDS-infected Brazilian
women and impressions and satisfaction with respect to incoming messages
T Martini da Costa, BJ Peres Barbosa, DA Gomes e Costa, D Sigulem, H de Fatima Marin, A
Castelo Filho, I Torres Pisa
International Journal of Medical Informatics Apr 2012;81(4):257-269
Objective: To assess whether a warning system based on mobile SMS messages
increases the adherence of HIV-infected Brazilian women to antiretroviral drug-based
treatment regimens, and their impressions and satisfaction with respect to incoming
messages.
Design: A randomised, controlled trial was conducted from May 2009 to Apr 2010
with HIV-infected Brazilian women. All participants (n = 21) had a monthly
multidisciplinary attendance; each participant was followed over a 4-month period,
when adherence measures were obtained. Participants in the intervention group (n
= 8) received SMS messages 30 min before their last scheduled time for a dose of
medicine during the day. The messages were sent every Saturday and Sunday and
on alternate days during the working week. Participants in the control group (n =
13) did not receive messages.
Measurements: Self-reported adherence, pill counting, microelectronic monitors
(MEMS) and an interview about the impressions and satisfaction with respect to
incoming messages.
Results: The HIV Alert System (HIVAS) was developed over 7 months during 2008
and 2009. After the study period, self-reported adherence indicated that 11
participants (85%) remained compliant in the control group (adherence exceeding
95%), whereas all 8 participants in the intervention group (100%) remained
compliant. In contrast, the counting pills method indicated that the number of
compliant participants was 5 (38%) for the control group and 4 (50%) for the
176
intervention group. Microelectronic monitoring indicated that 6 participants in the
control group (46%) were adherent during the entire 4-month period compared to 6
participants in the intervention group (75%). According to the feedback of the 8
participants who completed the research in the intervention group, along with the
feedback of 3 patients who received SMS for less than 4 months, that is, did not
complete the study, 9 (82%) believed that the SMS messages aided them in
treatment adherence and 10 (91%) responded that they would like to continue
receiving SMS messages.
Conclusions: SMS messaging can help Brazilian women living with HIV/AIDS to
adhere to antiretroviral therapy for a period of at least 4 months. In general, the
results are encouraging because the SMS messages stimulated more participants in
the intervention group to be adherent to their treatment, and the patients were
satisfied with the messages received, which were seen as reminders, incentives and
signs of affection by the health clinic for a marginalised population.
http://www.ijmijournal.com/article/S1386-5056(11)00204-8/abstract
289. Adherence and knowledge of treatment in hypothyroid patients from a
community pharmacy in Seville. A pilot study
(Adherencia y conocimiento del tratamiento en pacientes hipotiroideos desde una farmacia
comunitaria en Sevilla. Estudio piloto)
MC Mingorance Mingorance, E Garcia-Jimenez
Atencion Primaria Sep 2012;44(9):563-565
Letter describing a before-after quasi-experimental study (with no control group)
carried out from Sep 2010 to Jun 2011 in a community pharmacy in El Cuervo,
Seville, Spain, to investigate the effect of pharmaceutical care and patient education
on patients knowledge of and adherence to levothyroxine therapy.
http://www.elsevier.es/es/revistas/atencion-primaria-27/adherencia-conocimientotratamiento-pacientes-hipotiroideos-una-farmacia-90151795-cartas-al-director-2012?bd=1
290. Impact of pharmacist provided education on medication adherence behaviour
in HIV/AIDS patients treated at a non-government secondary care hospital in
India
KV Mini, A Ramesh, G Parthasarathi, SN Mothi, VT Swamy
Journal of AIDS and HIV Research Apr 2012;4(4):94-99
A single group pre-post test study evaluated the impact of a pharmacist provided
education session (together with patient information leaflets) on medication
adherence behaviour in 104 HIV/AIDS patients receiving highly active antiretroviral
therapy at a non-government AIDS care and research center in Mysore, South India.
A brief medication questionnaire was administered to eligible patients at baseline and
follow up to assess their reported medication adherence and barriers to adherence.
The number of subjects reporting greater than 95% adherence increased
significantly between baseline (n = 39 (43%)) and final follow up (n = 79 (80%).
Pharmacist provided education sessions were found effective in improving medication
adherence behaviour in HIV/AIDS patients.
http://www.academicjournals.org/jahr/PDF/Pdf2012/April/Mini%20et%20al.pdf
291. User engagement with and attitudes towards an interactive SMS reminder
system for patients with tuberculosis
S Mohammed, O Siddiqi, O Ali, A Habib, F Haqqi, M Kausar, AJ Khan
Journal of Telemedicine and Telecare Oct 2012;18(7):404-408
177
We conducted a qualitative study to understand user perceptions, acceptability and
engagement with an interactive SMS reminder system designed to improve
treatment adherence for patients with tuberculosis (TB) in Pakistan.
Patients received daily reminders and were asked to respond after taking their
medication. Non-responsive patients were sent up to three reminders a day. We
enrolled 30 patients with TB who had access to a mobile phone and observed their
engagement with the system for a 1-month period. We also conducted semistructured interviews with 24 patients to understand their experience with the
system.
Most patients found the reminders helpful and encouraging. The average response
rate over the study period was 57%. However, it fell from a mean response rate of
62% during the first 10 days to 49% during the last 10 days. Response rates were
higher amongst females, participants with some schooling, and participants who had
sent an SMS message the week prior to enrolment. Non-responsiveness was
associated with a lack of access to the owner of the mobile phone, problems with the
mobile phone itself and literacy.
Our pilot study suggests that interactive SMS reminders are an acceptable and
appreciated method of supporting patients with TB in taking their medication.
http://jtt.rsmjournals.com/content/18/7/404.abstract
292. A short message service (SMS)-based strategy for enhancing adherence to
antipsychotic medication in schizophrenia
JM Montes, E Medina, M Gomez-Beneyto, J Maurino
Psychiatry Research 30 Dec 2012;200(2-3):89-95
Background: The aim of this study was to assess the impact of a short message
service (SMS)-based strategy on adherence to antipsychotic treatment.
Methods: A multicentre, randomised, open-label, controlled, 6-month study with
clinically stabilised outpatients with schizophrenia was conducted in Spain. The
patients assigned to the intervention received daily SMS reminders to take their
medication for 3 months. Self-reported medication adherence was determined using
the Morisky Green Adherence Questionnaire (MAQ). Secondary outcomes were
severity of illness, attitude towards medication, insight into illness and health-related
quality of life.
Results: A total of 254 patients were analysed. A significantly greater improvement
in adherence was observed among patients receiving SMS text messages compared
with the control group. The mean change in MAQ total score from baseline to month
3 was -1.0 (95% CI, -1.02 to -0.98) and −0.7 (95% CI, -0.72 to -0.68), respectively
(P = 0.02). Greater improvement in negative, cognitive and global clinical
symptoms at month 3 was observed. Attitude towards medication also significantly
improved across the study in the intervention group versus the controls.
Conclusions: An SMS-based intervention seems feasible and acceptable for
enhancing medication adherence. Further studies are needed to confirm whether
this kind of intervention could be a complementary strategy to optimise adherence in
schizophrenia.
293. Multidisciplinary perspective on support for antiretroviral therapy adherence
in Andalusia. Andhalusida study
(Perspectiva multidisplicinaria del apoyo a la adherencia antirretroviral en Andalucía. Estudio
Andhalusida)
R Morillo Verdugo, R Jimenez Galan, C Almeida Gonzalez
Farmacia Hospitalaria Sep-Oct 2012;36(5):410-423
178
Objective: To analyse physicians', pharmacists' and nurses' perspectives on the
importance of different antiretroviral treatment adherence support activities and
identify the main obstacles to meeting established recommendations which health
professionals encounter.
Method: Cross-sectional observational and analytical study. Three questionnaires
were designed based on 2008 GESIDA/SEFH/PNS recommendations for improving
treatment adherence: 'ideal measures' (IM), 'real measures' (RM) and 'adherence
support problems' (ASP). Cronbach's Alpha index was determined to analyse
questionnaire reliability and correlation coefficients between the MI and MR scales.
We applied the Chi-squared test or Monte Carlo method to analyse the correlation
between health providers and items on the three questionnaires.
Results: Participants consisted of 58 health professionals. The response rate was
76%. The Cronbach Alpha indices for the IM, RM and ASP questionnaires were
0.852, 0.933 and 0.818 respectively. The resulting intraclass correlation coefficient
was 0.280. Significant differences were found for multiple comparisons of IM and RM
questionnaires among physicians and pharmacists. The analysis of relationships
between providers also found significant differences for one of the answers on the IM
questionnaire, three on the RM and five on the ASP.
Conclusions: We observed that several health professionals have different
perspectives on measures of support for treatment adherence, with differences
arising mainly due to lack of time and training.
294. Efficacy of interventions to improve adherence to inhaled corticosteroids in
adult asthmatics: impact of using components of the chronic care model
G Moullec, G Gour-Provencal, SL Bacon, TS Campbell, KL Lavoie
Respiratory Medicine Sep 2012;106(9):1211-1225
Background: Adherence to inhaled corticosteroids (ICS) remains poor among
asthmatics, yet little is known about the efficacy of interventions to improve
adherence. Implementing the Chronic Care Model (CCM) components among
patients with respiratory disorders has been associated with an improvement in
outcomes, yet little is known about its effects on ICS adherence in asthmatics.
Objective: We conducted a systematic review to assess the efficacy of interventions
to improve ICS adherence among adult-asthmatics, and whether the use of CCM
components (i.e. teaching self-management skills, providing decision support,
delivery system design, and clinical information systems) resulted in greater ICS
adherence.
Methods: All English language articles testing the efficacy of an intervention including
ICS medication on outcome from MEDLINE and PsychINFO databases through Aug2010 were reviewed. Interventions were categorised based on the inclusion of CCM
components. We standardised treatment effects to obtain effect-sizes (ESs) and we
combined the ESs of studies according to the number of CCM components included in
their interventions.
Results: 18 studies met inclusion criteria. Inclusion of a greater number of CCM
components within interventions was associated with stronger effects on ICS
adherence outcomes, with interventions featuring 1, 2 and 4 CCM components
having medium (ES = 0.29; 95% CI, 0.16 to 0.42), large (0.53; 0.40 to 0.66) and
very large (0.83; 0.69 to 0.98) effects respectively.
Conclusions: Findings provide support for using the CCM as a framework for the
design and implementation of interventions to improve adherence among adultasthmatics.
http://www.resmedjournal.com/article/S0954-6111(12)00198-9/abstract
179
295. The influence of health literacy level on an educational intervention to
improve glaucoma medication adherence
KW Muir, A Ventura, SS Stinnett, A Enfiedjian, RR Allingham, PP Lee
Patient Education and Counseling May 2012;87(2):160-164
Objective: To test an educational intervention targeted to health literacy level with
the goal of improving glaucoma medication adherence.
Methods: 127 veterans with glaucoma in the USA were randomised to glaucoma
education or standard care. The intervention included a video scripted at a 4th, 7th
or 10th grade level, depending on the subject's literacy level. After 6 months, the
number of days without glaucoma medicine (DWM) according to pharmacy records
for the intervention and control groups was compared.
Results: The number of DWM in the 6 months following enrollment was similar for
control and intervention groups (intervention, n = 67, DWM = 63 +/- 198; standard
care, n = 60, DWM = 65 +/- 198; p = 0.708). For each subgroup of literacy
(adequate, marginal, inadequate), subjects in the intervention group experienced
fewer mean DWM than subjects in the control group and the effect size (ES)
increased as literacy decreased: adequate literacy, ES 0.069; marginal, ES 0.183,
inadequate, ES 0.363. Decreasing health literacy skills were associated with
decreasing self-reported satisfaction with care (slope = 0.017, SE = 0.005, p =
0.002).
Conclusions: Patients with decreased health literacy skills may benefit from
educational efforts tailored to address their health literacy level and learning style.
http://www.pec-journal.com/article/S0738-3991(11)00517-9/abstract
296. Risk factors for drug nonadherence in antidepressant-treated patients and
implications of pharmacist adherence instructions for adherence improvement
A Murata, T Kanbayashi, T Shimizu, M Miura
Background: The aim of this study was to determine the characteristics of drug
adherence in antidepressant-treated versus antidepressant-naive patients using Drug
Attitude Inventory (DAI)-10 scores for nonadherence, to examine the contribution of
patient variables such as age, gender, education, prescription contents, side effects
and type of depression (melancholic, nonmelancholic, bipolar) to the reported DAI10 score and to examine the efficacy of pharmacist adherence instruction on
adherence with antidepressant therapy.
Methods: The subjects were 71 antidepressant-treated inpatients (17 with
melancholic depression, 35 with nonmelancholic depression, and 19 with bipolar
depression) and 80 antidepressant-naive inpatients. In the antidepressant-treated
patients, self-management of drug intake and pharmacist adherence instruction was
initiated after depressive symptoms were in remission, and pharmacist adherence
instruction was conducted until the day of discharge.
Results: There were no significant differences in baseline characteristics between
antidepressant-naïve and antidepressant-treated patients. In antidepressant-treated
patients, the mean DAI-10 total score was significantly lower and awareness of side
effects was significantly higher than in antidepressant-naive patients who have never
taken antidepressants, nor been referred to psychiatry services (according to
pharmacist interviews and medical records). On the first day of self-management of
drug intake, the DAI-10 total score in patients with melancholic and bipolar
depression was significantly lower than that in patients with nonmelancholic
depression. On the day of discharge, there was a significant improvement of DAI-10
total score in all antidepressant-treated patients, and the DAI-10 total score in
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patients with melancholic depression was significantly lower than that in patients
with nonmelancholic depression. The limitation of the study was the small sample
size and the fact that we followed only acute phase inpatients. However, the
findings seem particularly robust in view of this.
Conclusions: Risk factors for nonadherence included side effects of antidepressant
treatment and type of depression. The results presented here suggest that patients
with melancholic depression may be more vulnerable to nonadherence, and that
pharmacist adherence instruction may improve nonadherence in antidepressanttreated patients according to type of depression.
297. Intervention to improve adherence to lipid-lowering medication and lipidlevels in patients with an increased cardiovascular risk
PT Nieuwkerk, MC Nierman, MN Vissers, M Locadia, P Greggers-Peusch, LPM Knape, JJP
Kastelein, MAG Sprangers, HC de Haes, ESG Stroes
American Journal of Cardiology 1 Sep 2012;110(5):666-672
Low levels of statin adherence may compromise treatment outcomes. The aim of
this study was to investigate whether nurse-led cardiovascular risk-factor counselling
could improve statin adherence and lipid levels without increasing patients' anxiety.
Patients with indications for statin therapy for primary or secondary prevention of
cardiovascular disease were randomly assigned to receive routine care or extended
care (EC) at baseline and at months 3, 9 and 18. Patients in the EC group received a
personalised risk-factor passport, showing modifiable and unmodifiable individual risk
factors and a graphical presentation of their calculated absolute 10-year
cardiovascular disease risk as well as the target risk that could be reached if all
modifiable risk factors were optimally treated. Lipid levels were assessed at each
visit. Carotid intima-media thickness was measured at baseline and at month 18.
Adherence, anxiety, quality of life, symptoms and smoking status were assessed
using a self-administered questionnaire at each visit. A total of 201 patients were
included in the study. Statin adherence was significantly higher (p less than 0.01)
and anxiety was significantly lower (p less than 0.01) in the EC group than in the
routine care group. Low-density lipoprotein cholesterol was statistically significantly
lower in the EC group than in the routine group (2.66 vs 3.00 mmol/L, respectively,
p = 0.024) in primary prevention patients only. Intima-media thickness improved
significantly from baseline (p less than 0.01) in all patients, irrespective of group
assignment. In conclusion, cardiovascular risk-factor counselling resulted in
improved lipid profiles in primary prevention patients and higher levels of adherence
to statins and lower levels of anxiety in all patients.
298. A randomized controlled trial of positive-affect intervention and medication
adherence in hypertensive African Americans
GO Ogedegbe, C Boutin-Foster, MT Wells, JP Allegrante, AM Isen, JB Jobe, ME Charlson
Archives of Internal Medicine 27 Feb 2012;172(4):322-326
Background: Poor adherence explains poor blood pressure (BP) control; however
African-Americans suffer worse hypertension-related outcomes.
Methods: This randomised controlled trial evaluated whether a patient education
intervention enhanced with positive-affect induction and self-affirmation (PA) was
more effective than patient education (PE) alone in improving medication adherence
and BP reduction among 256 hypertensive African-Americans followed up in 2
primary care practices. Patients in both groups received a culturally tailored
181
hypertension self-management workbook, a behavioural contract, and bimonthly
telephone calls designed to help them overcome barriers to medication adherence.
Also, patients in the PA group received small gifts and bimonthly telephone calls to
help them incorporate positive thoughts into their daily routine and foster selfaffirmation. The main outcome measures were medication adherence (assessed with
electronic pill monitors) and within-patient change in BP from baseline to 12 months.
Results: The baseline characteristics were similar in both groups: the mean BP was
137/82 mm Hg; 36% of the patients had diabetes; 11% had stroke; and 3% had
chronic kidney disease. Based on the intention-to-treat principle, medication
adherence at 12 months was higher in the PA group than in the PE group (42% vs
36%, respectively; P = 0.049). The within-group reduction in systolic BP (2.14 mm
Hg vs 2.18 mm Hg; P = 0.98) and diastolic BP (-1.59 mm Hg vs -0.78 mm Hg; P =
0.45) for the PA group and PE group, respectively, was not significant.
Conclusions: A PE intervention enhanced with PA led to significantly higher
medication adherence compared with PE alone in hypertensive African-Americans.
Future studies should assess the cost-effectiveness of integrating such interventions
into primary care.
See also a comment on this paper by GC Williams and CP Niemiec (p.327-328).
299. Systematic review of pharmacist interventions to improve adherence to oral
antidiabetic medications in people with Type 2 diabetes
D Omran, LM Guirguis, SH Simpson
Canadian Journal of Diabetes Oct 2012;36(5):292-299
Objective: Poor adherence is an important challenge to healthcare professionals
because it jeopardises treatment success and increases the risk of serious
complications, especially in patients with chronic diseases like diabetes. The purpose
of this study was to summarise the effects of pharmacist interventions aimed at
enhancing adherence to oral antidiabetic medications in patients with type 2 diabetes
mellitus.
Methods: 5 electronic databases were searched up to 12 Mar 2011 to identify
controlled trials reporting the effects of pharmacist interventions to improve
medication adherence rates in adults with type 2 diabetes. Components of the
intervention were categorised as educational, behavioural, affective or providertargeted strategies. In addition to the impact on medication adherence rates, we
recorded any reported effects on health outcomes.
Results: 8 studies were included in this review. Education-related strategies were
the most frequent (7 of 8 studies), and 6 of 8 studies used a combination of 2 or
more strategies for the adherence intervention. Change in adherence rate was
assessed using a variety of measurement methods, and 6 studies reported the effect
of pharmacist intervention on clinical, economic or humanistic outcomes. Compared
to a control group, 5 studies reported significant improvements in adherence rate
with pharmacist intervention; however, glycaemic control improved significantly in
only 2 studies.
Conclusions: Pharmacist interventions to improve medication adherence in diabetes
generally use an educational component combined with behavioural, affective or
provider-targeted strategies. Although these interventions appear to improve
adherence, the effect on health outcomes has not been established.
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300. The 'New York Times' readers' opinions about paying people to take their
medicine
JD Park, J Metlay, JM Asch, DA Asch
Health Education and Behavior Dec 2012;39(6):725-731
Background: There has been considerable interest in using financial incentives to
help people improve their health. However, paying people to improve their health
touches on strongly held views about personal responsibility.
Method: The 'New York Times' printed two articles in Jun 2010 about patient financial
incentives, which resulted in 394 comments from the paper's online audience. The
authors systematically analysed those online responses to news media in order to
understand the range of themes that were expressed regarding the use of financial
incentives to improve health.
Results: The 'New York Times' online readers revealed a broad range of attitudes
about paying individuals to be healthy. Many comments reflected disdain for
financial incentives, describing them as 'absurd' or 'silly'. Other comments reflected
the notion that financial incentives reward individuals for being irresponsible toward
their health. Many individuals communicated concerns that paying individuals for
healthy behaviours may weaken their internal drive to be healthy. A smaller set of
comments conveyed support for financial incentives, recognising it as a small sum to
pay to prevent or offset higher costs related to chronic diseases.
Conclusions: Although a measurable group of individuals supported financial
incentives, most readers revealed negative perceptions of these approaches and an
appeal for greater personal responsibility for individual health. Despite experimental
success of financial incentives, negative perceptions may limit their public
acceptability and uptake.
http://heb.sagepub.com/content/39/6/725.abstract
301. Does adherence-related support from physicians and partners predict
medication adherence for vasculitis patients?
JK Pepper, DM Carpenter, RF DeVellis
Journal of Behavioral Medicine Apr 2012;35(2):115-123
Few studies have explored mediators between medication-related support and
medication adherence for individuals with rare, systemic autoimmune conditions.
Using the Information-Motivation-Behavioral Skills model, we tested whether
depressive symptomatology and medication adherence self-efficacy mediated the
relationship between adherence support and changes in medication adherence
among vasculitis patients, and whether support from physicians and partners
differentially affected medication adherence. Vasculitis patients (n = 172) completed
baseline and follow-up questionnaires about their medication adherence and
perceived adherence support. Bootstrapped mediation analyses tested the effects of
physician and partner support on changes in medication adherence. Adherence selfefficacy mediated the relationship between physician support and changes in
medication adherence (beta = 0.05; SE = 0.03; 95% CI, 0.01 to 0.13). Neither selfefficacy nor depressive symptomatology mediated the effects of partner support.
Although physicians spend little time with patients, they can increase patients'
confidence about taking medications correctly and potentially improve health
outcomes by bolstering medication adherence.
302. Clozapine repackaged into dose administration aids: a common practice in
Australian hospitals
S Perks, S Robertson, A Haywood, B Glass
183
International Journal of Pharmacy Practice Feb 2012;20(1):4-8
Objectives: Clozapine is an atypical antipsychotic used in the treatment of
schizophrenia. Due to the patient profile there is a high rate of repackaging of
clozapine into dose administration aids (DAAs). Because of reports from hospital
pharmacists about discolouration of returned clozapine tablets that have been
repackaged into DAAs, the aim of this study was to evaluate the chemical, physical
and photostability of these tablets repackaged into a DAA.
Method: Clozapine tablets were repackaged into DAAs and evaluated for
physicochemical stability over a 6-week period at a controlled room temperature (25
± 1C; 60 ± 1.5% relative humidity (RH)) and accelerated conditions (40 ± 1C; 75 ±
1.5% RH). In addition, photostability studies were performed according to the
International Committee on Harmonisation (ICH) guidelines.
Key Findings: Chemical stability was confirmed for all storage conditions, including
for those photostability (ICH conditions), with the clozapine content occurring within
the British Pharmacopoeial (BP) range of 90-110%. Although the physical stability
was confirmed for all tests at room temperature (weight uniformity, hardness,
friability, disintegration and dissolution), under accelerated conditions the
disintegration test did not meet BP requirements. However, the subsequent
dissolution test was successful with 85% of clozapine dissolving in 45 min.
Conclusions: This study illustrates that clozapine, when correctly repackaged,
maintains its physical and chemical stability for 6 weeks. As no discolouration of the
tablets was observed, it is assumed that the reports received were as a result of
improper handling by patients. Based on these findings, it is recommended that
patients be advised on the correct handling and storage of their DAAs.
303. Financial reinforcers for improving medication adherence: findings from a
meta-analysis
NM Petry, CJ Rash, S Byrne, S Ashraf, WB White
American Journal of Medicine Sep 2012;125(9):888-896
Background: Increasingly, financial reinforcement interventions based on behavioural
economic principles are being applied in health care settings, and this study
examined the use of financial reinforcers for enhancing adherence to medications.
Methods: Electronic databases and bibliographies of relevant references were
searched, and a meta-analysis of identified trials was conducted. The variability in
effect size and the impact of potential moderators (study design, duration of
intervention, magnitude of reinforcement, and frequency of reinforcement) on effect
size were examined.
Results: 15 randomised studies and 6 non-randomised studies examined the efficacy
of financial reinforcement interventions for medication adherence. Financial
reinforcers were applied for adherence to medications for tuberculosis, substance
abuse, human immunodeficiency virus, hepatitis, schizophrenia and stroke
prevention. Reinforcement interventions significantly improved adherence relative to
control conditions with an overall effect size of 0.77 (95% CI, 0.70 to 0.84; P less
than 0.001). Non-randomised studies had a larger average effect size than
randomised studies, but the effect size of randomised studies remained significant at
0.44 (95% CI, 0.35 to 0.53; P less than 0.001). Interventions that were longer in
duration, provided an average reinforcement of US$50 or more per week and
reinforced patients at least weekly resulted in larger effect sizes than those that were
shorter, provided lower reinforcers and reinforced patients less frequently.
Conclusions: These results demonstrate the efficacy of medication adherence
interventions and underscore principles that should be considered in designing future
184
adherence interventions. Financial reinforcement interventions hold potential for
improving medication adherence and may lead to benefits for both patients and
society.
See also editorial by WH Frishman referring to this paper, p.841-842.
304. Remember your MEDS: Medication Education Delivers Success
KM Rife, SE Ginty, EM Hohner, HR Stamper, KF Sobota, DR Bright
Innovations in Pharmacy 2012;3(1):Art.67
Background: A student project at Ohio Northern University Raabe College of
Pharmacy. Medication adherence is one of the largest barriers to better patient
outcomes today. As pharmacists and student pharmacists expand their roles with
community outreach projects, they have the potential to make a huge impact on
improving adherence.
Objective: To improve medication adherence through patient counselling and
constructive resources, and to determine patient preferences for adherence tools.
Methods: Student pharmacists partnered with a 340B Drug Pricing Program-certified
pharmacy to promote the importance of medication adherence. Patients were
counselled in an initial 10 minute session, and then given the opportunity to receive
one or more of the following adherence tools: a pill box, timer, reminder refrigerator
magnets, calendar stickers, refill reminder phone calls and/or text message
reminders. A pre-survey was conducted to establish the patients' baseline
medication adherence using the validated Morisky Medication Adherence Scale
(MMAS-8). After 3 months, students conducted the post-survey via the MMAS-8 by
calling the patients and asking them questions about the helpfulness of the
adherence tools as well as the effectiveness of the initial counselling visit.
Results: 65 patients with hypertension enrolled in the study, and 51 patients
completed both the pre- and post-surveys. Patients improved from a 6.02 (SD +/1.62) average pre-score to a 6.83 (SD +/-1.25) average post score (p less than
0.001). Pill boxes, text message reminders and calendar stickers were respectively
ranked as the top 3 most helpful tools studied. The refrigerator magnets were also
considered helpful by most patients who used them. The timers were ranked the
least helpful, mostly due to difficulty of use.
Conclusions: Student pharmacists can have a positive impact on medication
adherence through simple counselling and offering effective adherence tools.
305. Evaluation of a pharmacist intervention on patients initiating
pharmacological treatment for depression: a randomized controlled superiority
trial
M Rubio-Valera, M March Pujol, A Fernandez, MT Penarrubia-Maria, P Trave, Y Lopez del
Hoyo, A Serrano-Blanco
European Neuropsychopharmacology 2012;doi: 10.10.16/j.euroneuro.2012.11.006
(published early online 6 Dec 2012)
Major depression is associated with high burden, disability and costs. Nonadherence limits the effectiveness of antidepressants. Community pharmacists (CP)
are in a privileged position to help patients cope with antidepressant treatment. The
aim of this study in Spain was to evaluate the impact of a CP intervention on primary
care patients who had initiated antidepressant treatment.
Newly diagnosed primary care patients were randomised to usual care (UC) (92) or
pharmacist intervention (87). Patients were followed up at 6 months and evaluated
185
three times (baseline, and at 3 and 6 months). Outcome measurements included
clinical severity of depression (PHQ-9), health-related quality of life (HRQOL)
(Euroqol-5D) and satisfaction with pharmacy care. Adherence was continuously
registered from the computerised pharmacy records. Non-adherence was defined as
refilling less than 80% of doses or having a medication-free gap of more than 1
month.
Patients in the intervention group were more likely to remain adherent at 3 and 6
months follow-up but the difference was not statistically significant. Patients in the
intervention group showed a statistically significant greater improvement in HRQOL
compared with UC patients both in the main analysis and PP analyses. No
statistically significant differences were observed in clinical symptoms or satisfaction
with the pharmacy service.
The results of this study indicate that a brief intervention in community pharmacies
does not improve depressed patients' adherence or clinical symptoms. This
intervention helped patients to improve their HRQOL, which is an overall measure of
patient status.
http://www.sciencedirect.com/science/article/pii/S0924977X12003185
306. Customized adherence enhancement for individuals with bipolar disorder
receiving antipsychotic therapy
M Sajatovic, J Levin, C Tatsuoka, W Micula-Gondek, TD Williams, CS Bialko, KA Cassidy
Psychiatric Services Feb 2012;63(2):176-178
Objective: A 3-month prospective trial of a psychosocial intervention - customised
adherence enhancement (CAE) - was conducted with 43 medication-nonadherent
individuals with bipolar disorder.
Methods: CAE modules were administered as indicated by a screen that identifies
reasons for nonadherence. The primary outcome was change in adherence to moodstabilising medications as measured by the Tablet Routines Questionnaire and pill
counts. Secondary outcomes included change in symptoms, measured by the
Hamilton Rating Scale for Depression (HAM-D), Young Mania Rating Scale (YMRS),
and Brief Psychiatric Rating Scale (BPRS).
Results: Participants completed 76% of sessions. Dropout at 3 months was 13
(30%). Adherence improved from a baseline mean +/- SD of 34% +/- 27% of
tablets missed in the past month to only 10% +/- 15% (p less than 0.001). BPRS,
HAM-D and YMRS scores all indicated significant improvement at 3-month follow-up
(p less than 0.05).
Conclusions: Although conclusions must be tempered by the uncontrolled design,
CAE appeared to be well accepted and was associated with improvements in
adherence, symptoms and functioning.
307. Pharmaceutical intervention on hospital discharge to reinforce
understanding of and adherence to pharmacological treatment
(Intervención farmacéutica al alta hospitalaria para reforzar la comprensión y cumplimiento
del tratamiento farmacológico)
A Sanchez Ulayar, S Gallardo Lopez, N Pons Llobet, A Murgadella Sancho, L Campins
Bernadas, R Merino Mendez
Farmacia Hospitalaria May-Jun 2012;36(3):118-123
Objective: To determine the effectiveness of a pharmaceutical intervention in
patients being discharged from hospital, to improve their understanding of their
pharmaceutical treatment and, as a consequence, to improve their adherence to
186
prescribed regimens at home. To observe whether this intervention has an impact
on the number of hospital admissions.
Methods: Experimental, controlled, randomised study with two parallel groups. 100
internal medicine patients on multiple medications at a hospital in Barcelona, Spain,
were included. Routine clinical practice was performed on the control group. For the
intervention group, a pharmacist explained the drugs prescribed to either the patient
or his or her carer (in the case of dependent patients), giving the patient a
personalised medication timetable. Furthermore, the pharmacist explained why each
drug had been prescribed, how to take it and why it was important to take the
medication correctly. After 7 days, all patients or their carers were asked to
complete a questionnaire about their treatment by telephone. The responses
obtained were compared with the discharge prescriptions and discrepancies were
recorded. We consulted the hospital's computer records to check for admissions up
to 30 and 60 days following discharge.
Results: A week following hospital discharge, 70.7% of the intervention group were
taking all of their medication in accordance with the prescribed regimen, whereas
19.5% of the control group were (P less than 0.001). 3 (7.3%) patients from the
intervention group and 10 patients (24.4%) from the control group were readmitted
within 1 month after hospital discharge (P less than 0.05). After 2 months, 3 (7.2%)
patients from the intervention group and 13 (31.7%) from the control group had
been readmitted (P less than 0.01).
Conclusions: The pharmacist's intervention on discharge has helped increase the
percentage of patients who understood their medications and took them correctly in
accordance with their prescription. The number of hospital readmissions in the
intervention group was also reduced.
308. Conveying medication benefits to ulcerative colitis patients: what thresholds
for adherence are applied?
C Selinger, Y Kinjo, J McLaughlin, A Robinson, R Leong
Gut Jul 2012;61(Suppl.2):A172-A173
Poster PMO-241 presented at the Digestive Disorders Federation Meeting, Liverpool, 17-20
Jun 2012.
Introduction: Non-adherence to maintenance 5-ASA occurs in at least 30% of
ulcerative colitis (UC) patients and is associated with adverse health outcomes and
increased healthcare expenditure. Targeted strategies to convey information about
benefits of medication to patients may improve adherence. We undertook to
discover the preferred mode of information delivery among UC patients; the
thresholds of benefit that would produce adherence were also assessed.
Methods: Four methods of displaying information about the benefits of maintenance
therapy in remission were explained to UC patients in remission, during face to face
structured interviews. These were largely conventional numerical approaches:
relative risk reduction (RR), absolute risk reduction (AR), number needed to treat
(NNT). The fourth was an optical representation via Cates plot (CP)). Patients'
understanding and preference for each approach were recorded. Patients were
asked to state the minimum thresholds required to adhere to a hypothetical
medication (with 5-ASA like properties) for the benefits of relapse and cancer
reduction respectively. Thresholds were determined for each method of display.
Results: Of 50 participants (mean age 50 years; 58% male), 48% preferred data
presentation by RR over CP (28%), AR (20%) and NNT (4%). 94% found RR easy to
understand, better than CP (74%), AR (88%) or NNT (48%). Thresholds required
for adherence also differed between methods. For bowel cancer prevention, 94%
187
indicated adherence for benefit levels of 61% RR or lower but only 57% would
adhere when presented with the corresponding CP (p less than 0.001). For relapse
prevention, 78% of patients chose a threshold of 40% or lower but only 43% chose
the corresponding CP (p less than 0.001). When presented with RR, adherence
minimum thresholds equivalent or lower to the actual 5-ASA benefits were applied by
98% of patients for cancer reduction and 78% for flare reduction.
Conclusions: Ulcerative colitis patients prefer RR and CP as methods to display
medication benefit. NNT is poorly understood and unpopular. Patients apply
significantly higher thresholds for adherence when presented with CP in comparison
to RR. Presented with information in this way, most patients would choose to adhere
to 5-ASA medication when offered the actual benefit profile. Reduction of cancer risk
may be a stronger motivator than maintenance of remission. Interventions to
improve 5-ASA adherence should use RR and convey benefits for cancer and flare
prevention.
http://gut.bmj.com/content/61/Suppl_2/A172.3.abstract
309. Under-prescribing and non-adherence to medications after coronary bypass
surgery in older adults: strategies to improve adherence
D Sengstock, P Vaitkevicius, A Salama, RM Mentzer
Drugs and Aging Feb 2012;29(2):93-103
The focus for this clinical review is under-prescribing and non-adherence to
medication guidelines in older adults after coronary artery bypass grafting (CABG)
surgery. Non-adherence occurs in all age groups, but older adults have a unique set
of challenges including difficulty hearing, comprehending and remembering
instructions; acquiring and managing multiple medications; and tolerating drug-drug
and drug-disease interactions. None the less, non-adherence leads to increased
morbidity, mortality, and costs to the healthcare system. Factors contributing to
non-adherence include failure to initiate therapy before hospital discharge; poor
education about the importance of each medication by hospital staff; poor education
about medication side effects; polypharmacy; multiple daily dosing; excessive cost;
and the physician's lack of knowledge of clinical indicators for use of medications. To
improve adherence, healthcare systems must ensure that (i) all patients are
prescribed the appropriate medications at discharge; (ii) patients fill and take these
medications post-operatively; and (iii) patients continue long-term use of these
medications. Interventions must target central administrative policies within
healthcare institutions, the difficulties facing providers, as well as the concerns of
patients. Corrective efforts need to be started early during the hospitalisation and
involve practitioners who can follow patients after the date on which surgical care is
no longer needed. A solid, ongoing relationship between patients and their primarycare physicians and cardiologists is essential. This review summarises the postoperative medication guidelines for CABG surgery, describes barriers that limit the
adherence to these guidelines, and suggests possible avenues to improve medication
adherence in older cardiac surgery patients.
http://link.springer.com/article/10.2165/11598500-000000000-00000
310. '+CLICK': pilot of a web-based training program to enhance ART adherence
among HIV-positive youth
R Shegog, CM Markham, AD Leonard, TC Bui, ME Paul
AIDS Care Mar 2012;24(3):310-318
Youth account for almost half of all new HIV infections in the United States.
Adherence to antiretroviral treatment (ART) is critical for successful management,
yet reported adherence rates for youth are often low. This study pilot-tested
188
'+CLICK', an innovative, web-based, adherence intervention for HIV-positive youth
as an adjunct to traditional clinic-based, self-management education. The theorybased application, developed for HIV-infected youth, 13-24 years of age, provides
tailored activities addressing attitudes, knowledge, skills and self-efficacy related to
ART adherence. HIV-positive youth (N = 10) pilot-tested +CLICK to assess usability
(ease of use, credibility, understandability, acceptability, motivation) and short-term
psychosocial outcomes (importance and self-efficacy related to ART adherence) using
a single-group, pre-/post-test study design in a hospital-based paediatric clinic (n =
8) and home (n = 2) location. Youth were mostly female (80%) and Black (80%).
Mean age was 17.8 years (SD 2.65, range 14-22). All were infected perinatally and
had been living with HIV all their lives. Most learned their HIV status by age 10
years. 60% reported an undetectable viral load, whilst 10% reported a viral load of
over 50,000. Half (50%) reported a normal CD4 count, whilst 20% reported having
low CD4 (below 200). Usability ratings indicated +CLICK was very easy to use
(70%), trustworthy and understandable (both over 90%). Most (70%) indicated
they would use +CLICK again. Short-term psychosocial outcomes indicate significant
increase in medication adherence self-efficacy (p less than 0.05), perceived
importance of taking antiretroviral medicine close to the right time every day (p less
than 0.05) and knowledge about HIV and adherence (p less than 0.01). Other
psychosocial variables and behavioural intentions were not significantly impacted.
Results suggest that +CLICK has the potential to affect psychological antecedents to
ART adherence. Further research on long-term and behavioural effects is indicated
prior to broader dissemination into clinical practice.
http://www.tandfonline.com/doi/abs/10.1080/09540121.2011.608788
311. Warnings without guidance: patient responses to an FDA warning about
ezetimibe
WH Shrank, NK Choudhry, A Tong, J Myers, MA Fischer, K Swanton, J Slezak, TA Brennan,
JN Liberman, S Moffit, J Avorn, D Carpenter
Medical Care Jun 2012;50(6):479-484
Background: In Jan 2008, the US Food and Drug Administration (FDA)
communicated concerns about the efficacy of ezetimibe, but did not provide clear
clinical guidance, and substantial media attention ensued. We investigated the
proportion of patients who discontinued therapy and switched to a clinically
appropriate alternative after the FDA communication.
Methods: Using claims data from a national pharmacy benefits manager, we created
a rolling cohort of new users of ezetimibe between Jan 2006 and Aug 2008 and
created a supply diary for each patient in the year after cohort entry. A patient was
identified as nonpersistent if a gap of 90 days was seen in the diary. Using
segmented linear regression, we compared rates of nonpersistence before and after
the FDA communication and assessed patient-level characteristics associated with
discontinuation. Among nonpersistent patients, we determined whether a patient
made a clinically appropriate switch in the subsequent 90 days by adding a new
cholesterol-lowering medication or by increasing the dose of an existing one. We
used a weighted t-test to compare the rates of appropriate switching before and
after the communication.
Results: Among 867,027 new ezetimibe users, 407,006 (46.9%) were nonpersistent
in the first year. After the FDA communication, the monthly level of ezetimibe
nonpersistence increased by 5.7 percentage points (P less than 0.0001). Younger
patients, those who lived in low-income zip codes and female patients were less
likely to discontinue therapy (P less than 0.0001 for all). Among nonpersistent
189
patients, rates of clinically appropriate switching increased from 10.8% before to
16.5% after the FDA warning (P = 0.004).
Conclusions: A substantial increase in ezetimibe nonpersistence rates was seen after
an FDA communication regarding its efficacy and following associated media
attention, and a small proportion of patients made a clinically appropriate switch
after discontinuation. Further consideration is needed to deliver messages that
promote appropriate use of chronic therapy rather than simply reduce use.
http://journals.lww.com/lwwmedicalcare/Abstract/2012/06000/Warnings_Without_Guidance__Patient_Responses_to_an
.3.aspx
312. Osteoporosis telephonic intervention to improve medication-regimen
adherence: a large, pragmatic, randomized controlled trial
DH Solomon, MD Iversen, J Avorn, T Gleeson, MA Brookhart, AR Patrick, L Rekedal, WH
Shrank, J Lii, E Losina, JN Katz
Archives of Internal Medicine 26 Mar 2012;172(6):477-483
Background: Multiple studies demonstrate poor adherence to medication regimens
prescribed for chronic illnesses, including osteoporosis, but few interventions have
been proven to enhance adherence. We examined the effectiveness of a telephonebased counselling programme rooted in motivational interviewing to improve
adherence to a medication regimen for osteoporosis.
Methods: We conducted a 1-year randomised controlled clinical trial. Participants
were recruited from a large pharmacy benefits programme for US Medicare
beneficiaries. All potentially eligible individuals had been newly prescribed a
medication for osteoporosis. Consenting participants were randomised to a
programme of telephone-based counselling (n = 1046) using a motivational
interviewing framework or a control group (n = 1041) that received mailed
educational materials. Medication regimen adherence was the primary outcome
compared across treatment arms and was measured as the median (interquartile
range) medication possession ratio, calculated as the ratio of days with filled
prescriptions to total days of follow-up.
Results: The groups were balanced at baseline, with a mean age of 78 years; 93.8%
were female. In an intention-to-treat analysis, median adherence was 49%
(interquartile range, 7%-88%) in the intervention arm and 41% (2%-86%) in the
control arm (P = 0.07, Kruskal-Wallis test). There were no differences in selfreported fractures.
Conclusions: In this randomised controlled trial, we did not find a statistically
significant improvement in adherence to an osteoporosis medication regimen using a
telephonic motivational interviewing intervention.
See also correspondence referring to this study from KL Lavoie, TS Campbell and SL
Bacon and response from the original authors (Arch Intern Med 24 Sep
2012;172(17):1351-1352).
313. MAP study: RCT of a medication adherence program for patients with type 2
diabetes
P Soule Odegard, DB Christensen
190
Objective: To evaluate the impact of a community pharmacy-based medication
adherence detection and intervention protocol on medication adherence for patients
with diabetes.
Design: Randomised, controlled trial.
Setting: Four community chain pharmacies in the Seattle, WA, USA, area from Apr
2008 to Oct 2009.
Patients: Patients with diabetes (n = 265) who were taking oral diabetes medications
and late for refills by 6 days or more.
Intervention: Telephone-initiated adherence support by pharmacists following
computer-generated missed refill alerts. Patients were randomised at the pharmacy
level with pharmacists blinded to randomisation.
Main Outcomes Measures: Changes in medication adherence (i.e. days late at first
refill, percentage with a refill gap of 6 days or more at first refill, medication
possession ratio (MPR) at 6 and 12 months) measured during three time periods.
Results: Baseline MPR (previous 12 months) of oral diabetes medications for study
versus control participants was relatively high and similar (0.86 and 0.84,
respectively). At 12 months, MPR was significantly improved for the study group (P
= 0.004) compared with the control group (difference between groups, P = 0.01).
The intervention showed greater effect for patients with baseline MPR less than 80%
(difference between groups, P = 0.02). The likelihood of MPR above 80% at the 12month follow-up for any patient significantly favoured the intervention group (odds
ratio 4.77; 95% CI, 2.00 to 11.40).
Conclusions: A brief missed refill intervention programme involving urban community
chain pharmacies was effective in achieving improved diabetes medication
adherence, particularly among individuals with baseline MPR of 0.80 or less.
http://japha.org/data/Journals/JAPhA/25506/JAPhA_52_6_753.pdf
314. Electronic monitoring and feedback to improve adherence in pediatric asthma
SA Spaulding, KA Devine,
Journal of Pediatric Psychology Jan-Feb 2012;37(1):64-74
Objective: To evaluate the effectiveness of electronic monitoring and feedback to
improve adherence in children taking daily asthma controller medications.
Method: Five patients with asthma who were considered nonadherent participated.
Inhalers were electronically monitored with the MDILogII (TM) device and feedback
was given by medical staff. Using a nonconcurrent multiple-baseline design, patients
and their parents received bimonthly feedback regarding medication use. Following
treatment, feedback was withdrawn and effects of monitoring alone were observed.
Results: Three participants showed improvements in adherence following treatment,
with more notable increases when baseline adherence was low. Improvements in
the inhaler technique occurred for all patients. Some patients demonstrated
improvements in lung functioning and functional severity. When feedback was
withdrawn, adherence decreased for some participants, but technique improvements
maintained.
Conclusions: Results support the use of objective monitoring devices for assessing
paediatric asthma patients' adherence and indicate that feedback from medical staff
may improve and maintain medication adherence for some patients.
http://jpepsy.oxfordjournals.org/content/37/1/64.abstract
315. Impact of an extensive pharmacist-delivered counseling program on patient
adherence to target and nontarget chronic medications
MS Taitel, C Chen, LE Fensterheim, MA Farley, TB Rough, RJ Sanchez, J Mardekian
Journal of Managed Care Pharmacy Sep 2012;18(7):550
191
Poster presented at the Academy of Managed Care Pharmacy 2012 Educational Conference,
3-5 Oct 2012, Cincinnati, Ohio, USA.
Post hoc analysis of a retail pharmacy pilot study in a pharmacy chain in the USA
that randomly enrolled patients filling atorvastatin, pregabalin and tolterodine
between Oct 2008 and Mar 2009 to an intervention group or a usual care control
group. Patients in the intervention group received enhanced pharmacist counselling
that included adherence education, coaching and reminder aids. Those who were
new-to-therapy (NTT) received a NTT counselling session and were eligible for a first
refill counselling session, and continuing therapy patients received one counselling
session.
3329 intervention and 2313 control patients (average age 55.7 and 54.1 years,
respectively) were included in the analysis. For target medications, the proportion of
days covered (PDC) at 1 year was 0.40 for the intervention group and 0.30 for the
control group (P less than 0.001). For nontarget chronic medications, the PDC was
0.42 for the intervention group versus 0.37 for the control group (P less than 0.001).
These results show that patients receiving counselling had 32.7% greater adherence
to target medications than patients in the control group; they also exhibited 12.2%
greater adherence to nontarget chronic medications.
Concludes that patients participating in an extensive pharmacist-delivered
counselling programme demonstrated improved adherence to target medications.
Furthermore, patients generalised their improved adherence behaviour, to a lesser
extent, to nontarget chronic medications that were not directly addressed by the
intervention.
The research was funded by Walgreen Co., Deerfield, IL, USA, and Pfizer Inc., New
York, NY, USA.
316. The impact of pharmacist face-to-face counseling to improve medication
adherence among patients initiating statin therapy
M Taitel, J Jiang, K Rudkin, S Ewing, I Duncan
Patient Preference and Adherence 5 Apr 2012;6:323-329
Purpose: To evaluate the impact of a community-based pharmacist-led face-to-face
counselling programme on medication adherence for patients who were new to
therapy (NTT) for statin medications.
Patients and Methods: This retrospective cohort study evaluated a programme that
was implemented in 76 national community pharmacies located in the midwest USA.
It consisted of two face-to-face patient counselling sessions with a pharmacist that
addressed patient barriers to adherence. A group of 2056 NTT statin patients was
identified between 1 Sep 2010 and 31 Oct 2010, and was followed for 12 months.
The intervention group consisted of 586 patients, and the comparison group
comprised 516 patients. Outcomes were measured using the continuous medication
possession ratio (MPR), categorical MPR and medication persistence.
Results: After adjusting for covariates, the intervention group had statistically
greater MPR than the comparison group at every month measured. For example, at
12 months the intervention group had an adjusted MPR of 61.8% (95% CI, 54.5% to
69.2%) and the comparison group had a MPR of 56.9% (95% CI, 49.5% to 64.3%);
this 4.9% difference is significant (P less than 0.01). The 12-month categorical MPR
also showed significant differences between groups (chi2 = 6.12, P less than 0.05);
40.9% of the intervention group and 33.7% of comparison group had a MPR of 80%
or higher. Finally, the intervention group had significantly greater persistency with
their medication therapy than the comparison group at 60, 90, 120 and 365 days.
192
Conclusions: Patients who participated in brief face-to-face counselling sessions with
a community pharmacist at the beginning of statin therapy demonstrated greater
medication adherence and persistency than a comparison group. This brief targeted
intervention at the initiation of maintenance drug therapy moderates the high risk of
nonadherence and discontinuation; it helps patients establish a routine of daily selfmedication and potentially improves their long-term clinical outcomes.
317. Provider views about responsibility for medication adherence and content of
physician-older patient discussions
DM Tarn, TJ Mattimore, DS Bell, RL Kravitz, NS Wenger
Journal of the American Geriatrics Society Jun 2012;60(6):1019-1026
Objectives: To investigate provider opinions about responsibility for medication
adherence and examine physician-patient interactions to illustrate how adherence
discussions are initiated.
Design: Focus group discussions with healthcare providers and audio taped
outpatient office visits with a separate group of providers.
Setting: Focus group participants were recruited from multispecialty practice groups
in New Jersey and Washington, District of Columbia, USA. Outpatient office visits
were conducted in primary care offices in Northern California, USA.
Participants: 22 healthcare providers participated in focus group discussions. 100
patients aged 65 and older and 28 primary care physicians had their visits audio
taped.
Measurements: Inductive content analysis of focus groups and audio taped
encounters.
Results: Focus group analyses indicated that providers feel responsible for assessing
medication adherence during office visits and for addressing mutable factors
underlying nonadherence, but they also believed that patients were ultimately
responsible for taking medications and voiced reluctance about confronting patients
about nonadherence. The 100 patients participating in audio taped encounters were
taking a total of 410 medications. Of these, 254 (62%) were discussed in a way that
might address adherence; physicians made simple inquiries about current patient
medication use for 31.5%, but they made in-depth inquiries about adherence for
only 4.3%. Of 39 identified instances of nonadherence, patients spontaneously
disclosed 51%.
Conclusions: The lack of intrusive questions about medication taking during office
visits may reflect poor provider recognition of the questions needed to assess
adherence fully. Alternatively, provider beliefs about patient responsibility for
adherence may hinder detailed queries. A paradigm of joint provider-patient
responsibility may be needed to better guide discussions about medication
adherence.
318. Strategies for increasing treatment adherence in bipolar disorder
ME Thase
Journal of Clinical Psychiatry Feb 2012;73(2):e08
Although bipolar disorder cannot be cured, effective medications are available that
can shorten the duration of illness episodes and reduce the rates of relapse.
Unfortunately, treatment nonadherence is common among patients with bipolar
disorder. Factors contributing to nonadherence vary, and nonadherence can be
deliberate or accidental. Strategies to improve medication adherence include
forming a strong alliance with patients, educating patients and their caregivers about
193
the disorder and the importance of adherence, simplifying medication regimens,
monitoring tolerability and proactively addressing adverse effects, and treating
comorbid illnesses.
http://www.psychiatrist.com/abstracts/abstracts0212.asp?abstract=201202/0212e08.htm
319. Guidelines for improving entry into and retention in care and antiretroviral
adherence for persons with HIV: evidence-based recommendations from an
International Association of Physicians in AIDS Care panel
MA Thompson, MJ Mugavero, KR Amico, VA Cargill, et al.
Annals of Internal Medicine 5 Jun 2012;156(11):817-833
The International Association of Physicians in AIDS Care convened a panel to develop
evidence-based recommendations to optimise entry into and retention in care and
antiretroviral therapy (ART) adherence for people with HIV infection. This article
discusses the panel-s recommendations, which cover entry into and retention in HIV
medical care; monitoring ART adherence; ART strategies; adherence tools for
patients; education and counselling interventions; health system and service delivery
interventions; and issues pertaining to pregnant women, incarcerated individuals,
homeless and marginally housed individuals, children and adolescents, as well as
substance use and mental health disorders.
320. Nurse-led education and counselling to enhance adherence to phosphate
binders
YP Van Camp, SA Huybrechts, B Van Rompaey, MM Elseviers
Journal of Clinical Nursing May 2012;21(9-10):1304-1313
Aims and objectives: To investigate whether nurse-led education and counselling
enhance phosphate binder adherence in chronic dialysis patients.
Background: One in two chronic dialysis patients experiences difficulties in adhering
to phosphate binders. The reasons for non-adherence are multifactorial and
accordingly require a multifaceted strategy. To date, investigations have been
confined primarily to single interventions to promote adherence. This study
examines the effect of a multifaceted approach.
Design: The design was interventional.
Method: Adherence to phosphate binders was blindly and electronically monitored for
17 consecutive weeks with the Medication Event Monitoring System (MEMS). After 4
weeks baseline monitoring, the effects of the intervention were studied for an
additional 13 weeks. In week 5, the study nurse gave all 41 participating patients
education on phosphate binders. Thereafter, the study nurse gave bi-weekly
personalised counselling to enhance adherence to phosphate binders. The evolution
of adherence over time was assessed and compared with historical control data.
Secondary outcome variables included serum values of phosphate, calcium and
parathyroid hormone and phosphate binder knowledge.
Results: In week 1, mean adherence was 83% in this study (intervention group),
compared with 86% in the historical control group. In the intervention group, mean
adherence increased from 83 to 94% after 13 weeks. By contrast, in the historical
control group, mean adherence declined from 86 to 76%. In the intervention group,
serum phosphate values decreased from 4.9 to 4.3 mg/dL and phosphate binder
knowledge increased from a mean score of 53 to 75%.
Conclusions: Combining education and continuous counselling holds promise in
enhancing phosphate binder adherence. Large-scale and long-term field studies are
indicated to determine which nurse-led practices lead to an integral and sustained
medication adherence management.
194
321. Interventions promoting adherence to cardiovascular medicines
J van Dalem, I Krass, P Aslani
International Journal of Clinical Pharmacy Apr 2012;34(2):295-311
Background: Cardiovascular diseases (CVDs) are a large burden on the healthcare
system. Medicines are the primary treatment for these diseases; however,
adherence to therapy is low. To optimise treatment and health outcomes for
patients, it is important that adherence to cardiovascular medicines is maintained at
an optimal level. Therefore, identifying effective interventions to improve adherence
and persistence to cardiovascular therapy is of great significance.
Aim of the Review: This paper presents a review of the literature on interventions
used in the community setting which aim to improve adherence to cardiovascular
medicines in patients with hypertension, dyslipidaemia, congestive heart failure or
ischaemic heart disease.
Methods: Several databases (Medline, EMBASE, PsychINFO, IPA, CINAHL, Pubmed,
Cochrane) were searched for studies which were published from 1979 to 2009,
evaluated interventions intended to improve adherence to cardiovascular medicines
in the community setting, had at least one measure of adherence, and consisted of
an intervention and comparison/control group.
Results: Among 36 eligible studies (consisting of 7 informational, 15 behavioural, 1
social and 13 combined strategy interventions), 17 (1 informational, 10 behavioural
and 6 combined) reported a significant improvement in adherence and/or
persistence. Behavioural interventions were the most successful. 21 studies (4
informational, 9 behavioural and 8 combined) also demonstrated improvements in
clinical outcomes, though effects were frequently variable, contradictory and not
related to changes in adherence.
Conclusions: Several types of interventions are effective in improving adherence
and/or persistence within the CVD area and in the community setting. Behavioural
interventions have shown the greatest success (compared to other types of
interventions); and adding informational strategies has not resulted in further
improvements in adherence. Improving adherence and persistence to cardiovascular
medicines is a dynamic process that is influenced by many factors, and one which
requires long-term multiple interventions to promote medicine taking in patients.
322. A randomized trial comparing in person and electronic interventions for
improving adherence to oral medications in schizophrenia
D Velligan, J Mintz, N Maples, L Xueying, S Gajewski, H Carr, C Sierra
Schizophrenia Bulletin 2012;doi: 10.1093/schbul/sbs116 (published early online 19 Oct
2012)
Poor adherence to medication leads to symptom exacerbation and interferes with the
recovery process for patients with schizophrenia.
Following baseline assessment, 142 patients in medication maintenance at a
community mental health centre in the USA were randomised to one of three
treatments for 9 months: (1) PharmCAT, supports including pill containers, signs,
alarms, checklists and the organisation of belongings established in weekly home
visits from a PharmCAT therapist; (2) Med-eMonitor (MM), an electronic medication
monitor that prompts use of medication, cues the taking of medication, warns
patients when they are taking the wrong medication or taking it at the wrong time,
record complaints, and, through modem hookup, alerts treatment staff of failures to
195
take medication as prescribed; (3) Treatment as Usual (TAU). All patients received
the Med-eMonitor device to record medication adherence. The device was
programmed for intervention only in the MM group. Data on symptoms, global
functioning, and contact with emergency services and police were obtained every 3
months.
Repeated measures analyses of variance for mixed models indicated that adherence
to medication was significantly better in both active conditions than in TAU (both p
less than 0.0001). Adherence in active treatments ranged from 90 to 92%
compared to 73% in TAU based on electronic monitoring.
In-person and electronic interventions significantly improved adherence to
medication, but that did not translate to improved clinical outcomes. Implications for
treatment and health care costs are discussed.
http://schizophreniabulletin.oxfordjournals.org/content/early/2012/10/18/schbul.sbs116.ab
stract
323. The effectiveness of interventions using electronic reminders to improve
adherence to chronic medication: a systematic review of the literature
M Vervloet, AJ Linn, JCM van Weert, DH de Bakker, ML Bouvy, L van Dijk
Journal of the American Medical Informatics Association Sep 2012;19(5):696-704
Background: Many patients experience difficulties in adhering to long-term
treatment. Although patients' reasons for not being adherent are diverse, one of the
most commonly reported barriers is forgetfulness. Reminding patients to take their
medication may provide a solution. Electronic reminders (automatically sent
reminders without personal contact between the healthcare provider and patient) are
now increasingly being used in the effort to improve adherence.
Objective: To examine the effectiveness of interventions using electronic reminders
in improving patients' adherence to chronic medication.
Methods: A comprehensive literature search was conducted in PubMed, Embase,
PsycINFO, CINAHL and Cochrane Central Register of Controlled Trials. Electronic
searches were supplemented by manual searching of reference lists and reviews.
Two reviewers independently screened all citations. Full text was obtained from
selected citations and screened for final inclusion. The methodological quality of
studies was assessed.
Results: 13 studies met the inclusion criteria. Four studies evaluated short message
service (SMS) reminders, 7 audiovisual reminders from electronic reminder devices
(ERD) and two pager messages. Best evidence synthesis revealed evidence for the
effectiveness of electronic reminders, provided by 8 (4 high, 4 low quality) studies
showing significant effects on patients' adherence, 7 of which measured short-term
effects (follow-up period less than 6 months). Improved adherence was found in all
but one study using SMS reminders, 4 studies using ERD and one pager intervention.
In addition, one high quality study using an ERD found subgroup effects.
Conclusions: This review provides evidence for the short-term effectiveness of
electronic reminders, especially SMS reminders. However, long-term effects remain
unclear.
http://jamia.bmj.com/content/19/5/696.abstract
324. SMS reminders improve adherence to oral medication in type 2 diabetes
patients
M Vervloet, L van Dijk, J Santen-Reestman, B van Vlijmen, P van Wingerden, ML Bouvy, DH
de Bakker
International Journal of Medical Informatics Sep 2012;81(9):594-604
196
Background: Poor adherence to oral antidiabetics has a negative influence on
glycaemic control in type 2 diabetes patients. Real Time Medication Monitoring
(RTMM) combines real time monitoring of patients' medication use with SMS
reminders sent only if patients forget their medication, aiming to improve adherence.
This study aimed to investigate the effect of these SMS reminders on adherence to
oral antidiabetics in patients using RTMM and investigate patients’ experiences with
RTMM.
Methods: Data were collected in a RCT involving 104 type 2 diabetes patients with
suboptimal adherence to oral antidiabetics. 56 patients were randomised to receive
SMS reminders if they forgot their medication, 48 patients received no reminders.
Primary outcome measure was adherence to oral antidiabetics registered with RTMM,
measured as: (1) days without dosing; (2) missed doses; (3) doses taken within
predefined standardized time windows. Patients' experiences were assessed with
written questionnaires.
Results: Over the 6-month study period, patients receiving SMS reminders took
significantly more doses within predefined time windows than patients receiving no
reminders: 50% vs 39% within a 1-hour window (p = 0.003) up to 81% vs 70%
within a 4-hour window (p = 0.007). Reminded patients tended to miss doses less
frequently than patients not reminded (15% vs 19%, p = 0.065). Days without
dosing were not significantly different between the groups. The majority of patients
reported positive experiences with RTMM and SMS reminders.
Conclusions: RTMM with SMS reminders improves adherence of type 2 diabetes
patients, especially the precision with which patients follow their prescribed regimen,
and is well accepted by patients.
http://www.ijmijournal.com/article/S1386-5056(12)00091-3/abstract
325. Interventions to improve adherence to self-administered medications for
chronic diseases in the United States: a systematic review
M Viswanathan, CE Golin, CD Jones, M Ashok, SJ Blalock, RCM Wines, EJL CokerSchwimmer, DL Rosen, P Sista, KN Lohr
Annals of Internal Medicine 4 Dec 2012;157(11):785-795
Background: Suboptimum medication adherence is common in the United States and
leads to serious negative health consequences but may respond to intervention.
Purpose: To assess the comparative effectiveness of patient, provider, systems and
policy interventions that aim to improve medication adherence for chronic health
conditions in the United States.
Data Sources: Eligible peer-reviewed publications from MEDLINE and the Cochrane
Library indexed to 4 Jun 2012 and additional studies from reference lists and
technical experts.
Study Selection: Randomised, controlled trials of patient, provider or systems
interventions to improve adherence to long-term medications and nonrandomised
studies of policy interventions to improve medication adherence.
Data Extraction: Two investigators independently selected, extracted data from, and
rated the risk of bias of relevant studies.
Data Synthesis: The evidence was synthesised separately for each clinical condition;
within each condition, the type of intervention was synthesised. Two reviewers
graded the strength of evidence by using established criteria. From 4124 eligible
abstracts, 62 trials of patient-, provider- or systems-level interventions evaluated 18
types of interventions; another 4 observational studies and 1 trial of policy
interventions evaluated the effect of reduced medication copayments or improved
prescription drug coverage. Clinical conditions amenable to multiple approaches to
improving adherence include hypertension, heart failure, depression and asthma.
197
Interventions that improve adherence across multiple clinical conditions include
policy interventions to reduce copayments or improve prescription drug coverage,
systems interventions to offer case management, and patient-level educational
interventions with behavioural support.
Limitations: Studies were limited to adults with chronic conditions (excluding HIV,
AIDS, severe mental illness and substance abuse) in the United States. Clinical and
methodological heterogeneity hindered quantitative data pooling.
Conclusions: Reduced out-of-pocket expenses, case management and patient
education with behavioural support all improved medication adherence for more than
1 condition. Evidence is limited on whether these approaches are broadly applicable
or affect long-term medication adherence and health outcomes. (168 refs.)
http://annals.org/data/Journals/AIM/28737/0000605-201212040-00006.pdf
326. Pharmacist-based Donepezil Outpatient Consultation Service to improve
medication persistence
N Watanabe, K Yamamura, Y Suzuki, H Umegaki, K Shigeno, R Matsushita, Y Sai, K
Miyamoto, K Yamada
Patient Preference and Adherence 28 Aug 2012;6:605-611
Aim: Donepezil is widely used to delay the progression of cognitive dysfunction in
patients with Alzheimer's disease (AD), but the efficacy of pharmacotherapy is often
reduced by poor adherence to medication. In order to improve adherence by
providing information about AD and the significance of pharmacotherapy, the
Donepezil Outpatient Consultation Service (DOCS) was set up in Japan. The
influence of this service on medication persistence was assessed in the present
study.
Methods: Among outpatients starting donepezil therapy, we enrolled 59 patients
between Apr 2008 and Sep 2010 before establishment of the DOCS (non-DOCS
group) and 52 patients between Oct 2010 and Mar 2012 who attended the DOCS
(DOCS group). Each patient's and their caregiver's understanding about the clinical
features of AD and pharmacotherapy with donepezil were also assessed. Their
understanding was compared before and after the DOCS, and the 1-year medication
persistence rate and the reasons for discontinuation were also investigated.
Results: The 1-year medication persistence rate was significantly higher in the DOCS
group than in the non-DOCS group (73.1% vs 49.2%, P = 0.008). We examined the
association of medication persistence with age, sex, clinical dementia rating, living
alone, and attending the DOCS. As a result, medication persistence was significantly
higher in patients attending the DOCS. The main reasons for discontinuation of
donepezil were transfer elsewhere (11) and gastrointestinal side effects (5) in the
non-DOCS group, and transfer (9) and gastrointestinal side effects (3) in the DOCS
group. The overall score for understanding was 2.5 +/- 1.7 before attending the
DOCS and it increased significantly to 5.7 +/- 0.7 afterwards (P less than 0.001).
Conclusions: The DOCS consultation provided by hospital pharmacists for AD
patients and their caregivers improved understanding about the clinical features of
dementia and provided pharmacological knowledge about antidementia drugs,
leading to better adherence to pharmacotherapy that could maximise its effect.
327. 'Only two months destroys everything': a case study of communication about
nonadherence to antiretroviral therapy in a South African HIV pharmacy context
J Watermeyer, C Penn
Health Communication Aug 2012;27(6):602-611
198
Adherence to antiretroviral treatment (ART) is a complex phenomenon and patients
do not always adhere for a variety of reasons. The quality of communication and the
therapeutic relationship between health professionals and patients have an important
influence on adherence, as do contextual and environmental factors. Little
qualitative research exists that examines health care interactions in the context of
adherence counselling.
This article presents a case study of a discussion about nonadherence between a
pharmacy assistant and a patient in a South African HIV context. A hybrid analytical
approach revealed various themes such as how the topic of nonadherence is
addressed, participants' responses to the patient's nonadherence, and the process of
negotiating a new commitment to adherence. The case provides insight into the
impact of contextual factors on the interaction and challenges involved in discussing
nonadherence - in particular, the patient's attempts to save face, the pharmacy
assistant's irritation and anger and the patient's expressed regrets.
This case raises questions around issues of patient agency. Health professionals are
encouraged to consider the influence of context, lifeworld and culture on patients'
ability to adhere to treatment regimens. By working to improve communication
processes and strengthen the therapeutic relationship, patients may be empowered
to achieve better adherence levels.
http://www.tandfonline.com/doi/abs/10.1080/10410236.2011.618436?journalCode=hhth20
328. The association of pharmacy drug-delivery services with adherence in an
urban HIV population
RF Yeh, SA Gupta, DN Sangani, SS Sansgiry
Journal of Pharmaceutical Health Services Research Dec 2012;3(4):185-190
Objective: The aim of this study was to examine the effect of drug-distribution
methods on antiretroviral medication adherence in HIV-positive patients.
Methods: This was a longitudinal, retrospective study of an independent retail
pharmacy in the USA providing complementary delivery services. Patients of 18
years of age or older receiving antiretroviral therapy were evaluated from 1 Jan to
30 Jun 2004. Patients were included if they had a minimum of one prescription claim
for any antiretroviral medication during the study period and received state
medication assistance. Using data obtained from computerized pharmacy records a
medication possession ratio was calculated to assess adherence measured by
pharmacy refill history over 6 months. To assess the consistency of adherence over
time a modified medication possession ratio, termed the compliance/non-compliance
index (CNI) at each refill, was developed and compared between each group.
Findings: Of the 181 patients included in the study, those who had medications
delivered had significantly better adherence (90.3% compared with 82.6%,
P = 0.001) and CNI value (73.5% compared with 57.9%, P = 0.001) in comparison
with those who picked up their medications. After controlling for age, gender, drug
class, insurance type and time and distance from the pharmacy, use of medicationdelivery services was significantly associated with adherence (P less than 0.0001)
and CNI score (P = 0.012).
Conclusions: Complementary medication-delivery services by pharmacies
significantly increased adherence at each refill for antiretroviral therapy in HIVpositive patients. Further research is needed on how medication-distribution
strategies can be implemented universally and the economic impact on cost of care
to increase medication adherence in this high-risk population.
199
329. Addressing gaps in care: impact of barrier-specific medication adherence
intervention
RA Zabinski, EP Skinner, EK Buysman, CR Cantrell
Objectives: To determine the impact of an interactive voice response (IVR)administered barriers survey and barrier-specific 'helpful hints' on addressing
medication adherence-related gaps in care.
Design: Prospective cohort study.
Methods: Data from a large claims database were used to select patients who were
employed by 1 out of 3 large US employers, who had 1 or more of 12 targeted
chronic conditions during the previous year and who were nonadherent with 1 or
more medications. All eligible patients were exposed to a letter-based adherence
intervention. Patients from 2 of the employers were then invited to participate in an
IVR-administered telephone survey and were categorised into the IVR cohort (n =
276) or the unable-to-engage cohort (n = 6558) on the basis of whether or not they
participated. Patients from the third employer, not given the chance to participate in
the IVR-administered telephone survey, constituted the letter-only cohort (n =
2220).
Results: During the 180-day follow-up period, the average proportion of days
covered (PDC), the frequency of adherence improvement and the frequency of
adherence success were highest in the IVR cohort (P less than 0.05 among groups
for each comparison). Patients in the IVR cohort compared with patients in the
letter-only cohort were 42% more likely to demonstrate adherence improvement and
45% more likely to demonstrate adherence success from baseline to follow-up.
Conclusions: The results of this study show that an IVR-administered intervention
was associated with significant improvements in both continuous and categorical
measures of PDC compared with controls.
Financial support for the study was provided by GlaxoSmithKline.
http://www.ajpblive.com/media/pdf/AJPB_12julaug_Zabinski_e109to117.pdf
330. Evaluation of specialized medication packaging combined with medication
therapy management: adherence, outcomes, and costs among Medicaid patients
AJ Zillich, HAW Jaynes, ME Snyder, J Harrison, KS Hudmon, C de Moor, DD French
Medical Care Jun 2012;50(6):485-493
Background: This study evaluates the effect of a programme combining specialised
medication packaging and telephonic medication therapy management on medication
adherence, health care utilisation and costs among US Medicaid patients.
Research Design: A retrospective cohort design compared Medicaid participants who
voluntarily enrolled in the programme (n = 1007) compared with those who did not
(n = 13,614). Main outcome measures were medication adherence at 12 months,
hospital admissions and emergency department visits at 6 and 12 months, and total
paid claim costs at 6 and 12 months. Multivariate regression models were used to
adjust for the effect of age, sex, race, comorbidities and 12-month pre-enrollment
health care utilisation.
Results: Measures of medication adherence were significantly improved in the
programme cohort compared with the usual care cohort. At 6 months, adjusted allcause hospitalisation was marginally less in the programme cohort compared with
the usual care cohort (odds ratio = 0.73; 95% CI, 0.54 to 1.0; P = 0.05). No
statistically significant differences were observed between the 2 cohorts for any of
the other adjusted utilisation endpoints at 6 or 12 months. Adjusted total cost at 6
and 12 months were higher in the programme cohort (6-month cost ratio = 1.76;
95% CI, 1.65 to 1.89; 12-month cost ratio = 1.84; 95% CI, 1.72 to 1.97), primarily
200
because of an increase in prescription costs. Emergency department visits and
hospitalisation costs did not differ between groups.
Conclusions: The programme improved measures of medication adherence, but the
effect on health care utilisation and non-pharmacy costs at 6 and 12 months was not
different from the usual care group. Reasons for these findings may reflect
differences in the delivery of the specialised packaging and the medication therapy
management programme, health care behaviours in this Medicaid cohort, unadjusted
confounding or time required for the benefit of the intervention to manifest.
http://journals.lww.com/lwwmedicalcare/Abstract/2012/06000/Evaluation_of_Specialized_Medication_Packaging.4.aspx
331. Development and content of a group-based intervention to improve
medication adherence in non-adherent patients with rheumatoid arthritis
H Zwikker, B van den Bemt, C van den Ende, W van Lankveld, A den Broeder, F van den
Hoogen, B van de Mosselaar, S van Dulmen
Patient Education and Counseling Oct 2012;89(1):143-151
Objective: To describe the systematic development and content of a short
intervention to improve medication adherence to disease-modifying anti-rheumatic
drugs in non-adherent patients with rheumatoid arthritis (RA).
Methods: The intervention mapping (IM) framework was used to develop the
intervention. The following IM steps were conducted: (1) a needs assessment; (2)
formulation of specific intervention objectives; (3) inventory of methods and
techniques needed to design the intervention and (4) production and piloting of the
intervention.
Results: The intervention (consisting of two group sessions led by a pharmacist, a
homework assignment, and a follow-up call) aims to improve the balance between
necessity and concern beliefs about medication, and to resolve practical barriers in
medication taking. The central communication method used is motivational
interviewing.
Conclusions: By applying the IM framework, we were able to create a feasible, timeefficient and promising intervention to improve medication adherence in nonadherent RA patients. Intervention effects are currently being assessed in a
randomised controlled trial.
Practice Implications: This paper could serve as a guideline for other health care
professionals when developing similar interventions. If the RCT demonstrates
sufficient effectiveness of this intervention in reducing medication non-adherence in
RA patients, the intervention could be embedded in clinical practice.
201
Subject Index
Acute disease
76, 208
Adherence in Diabetes Questionnaire
see Questionnaires
Adherence ratios
22
Administrative data, use to assess
16
Adolescents
24, 45, 99, 101, 136, 170, 310
Adverse effects, factor in nonadherence
54, 62, 112, 159, 166, 296, 311
Adverse effects, result of nonadherence
239
Age-related differences in adherence
121, 189, 191, 225
AIDS
see HIV and AIDS
Alcohol drinking, effect of
125, 142, 162
Alendronate
see Bisphosphonates
Alzheimer’s disease
169, 326
5-Aminosalicylic acid
80, 220, 308
Angiotensin receptor blockers
see Antihypertensives
Anti-androgens
59
Antibiotics
37, 94, 208
Antidepressants
106, 150, 164, 193, 242, 244, 253, 296, 305
Antidiabetics, oral
47, 85, 167, 175, 210, 262, 277, 299, 313, 324
Antiemetics
Antihypertensives
202
20, 28, 56, 83, 84, 90, 96, 113, 115, 120, 122,
137, 138, 161, 167, 168, 191, 195, 204, 222, 224,
232, 236, 240, 241, 261
Antilipaemics (see also Statins)
137, 167, 189
Antimalarials
177
202
Antiparkinsonian agents
55, 107
Antiplatelet agents
69, 222
Antipsychotics
27, 48, 53, 61, 82, 155, 159, 199, 206, 210, 292,
302, 306, 322
Antiretrovirals
45, 72, 86, 101, 102, 125, 126, 128, 130, 131,
135, 142, 143, 180, 185, 221, 223, 226, 233, 267,
276, 293, 310, 319, 327, 328
Antirheumatic agents
218
Antituberculars
153, 284, 291
Antivirals
60
Anxiety, effect of comorbidity
89, 90, 113, 193
5, 15, 24, 71, 78, 112, 121, 145, 165, 178, 184,
186, 211, 216, 228, 263, 280, 294, 314
Asthma
Atenolol
see Beta blockers
Atrial fibrillation
58, 98
Attention deficit hyperactivity disorder
51, 136
Beclomethasone dipropionate
see Corticosteroids, inhaled
Behaviour, interventions targeting
7
Behaviour traits, effect of
171
61, 82, 93, 112, 125, 127, 146, 152, 160, 172,
271, 331
Beliefs about medicines
Benefits of medicines, presentation
308
Beta agonists, long-acting
112, 121, 123, 228
Beta blockers
176, 222
Bicalutamide
see Anti-androgens
Biomarkers, use to assess
5
203
Bipolar disorder
156, 183, 234, 296, 306, 318
Bisphosphonates
32, 66, 73, 81, 109
Blister packaging
39
Blood glucose, effect on
157, 163, 170, 251, 252
Blood pressure, effect on
40, 168, 204, 236
Breast cancer
49, 74, 202
Cannabis use, effect of
162
Capecitabine
49
Cardiovascular agents
68, 79, 87, 140, 158, 160, 250, 321
Cardiovascular disorders
259, 297
Cardiovascular events, effect on occurrence
235
Care givers
Children
21, 99, 151, 177, 326
21, 23, 30, 34, 47, 71, 86, 88, 99, 116, 136, 145,
151, 165, 177, 178, 186, 196, 197, 211, 227, 263,
280, 282, 314
Cholesterol, LDL, effect on
33
Cholesterol lowering agents (see also Statins)
14, 82, 105, 190
Chronic Care Model
294
Chronic obstructive pulmonary disease
123, 127, 237, 275
Cinacalcet
254
Clinical decisions, failure to consider adherence
227
Clinical trials, adherence in
188, 238
Clozapine
see Antipsychotics
Cognitive impairment
2, 181
Collaborative care, effect of
277, 281
204
Colorectal cancer
49
Common Sense Model
132
Communication
Community pharmacy
93, 135, 177, 178, 267
38, 102, 128, 131, 175, 184, 189, 243, 245, 249,
250, 289, 305, 313, 315, 316
Complementary therapies, effect of use
165, 187
Compliance aids (see also Reminder packaging)
260, 302, 304, 322, 323
Condoms
248
Conflict, victims of
226
Contraceptives, oral
154, 188, 248
Copayments
57, 118, 161, 189
Coping strategies, effect of
116, 122, 135, 154
Coronary disease (see also Myocardial infarction)
89, 279
Coronary bypass surgery
Corticosteroids, inhaled
309
34, 42, 71, 78, 112, 121, 123, 211, 216, 228, 263,
294
Corticosteroids, intranasal
200
Cost effectiveness of interventions
212, 274
Cost of healthcare, effect on
7, 206, 207, 211, 212, 213, 224, 237, 247, 330
Cost-related nonadherence
118, 134, 143, 157, 161, 188, 194, 215
Cost sharing
see Copayments
Cough, acute
208
Crohn’s disease
201
Cyclooxygenase-2 inhibitors, adherence to
gastroprotection during treatment with
239
205
Cyclophosphamide
74
Cystic fibrosis
23, 116
Dementia, effect of
169
Depression, adherence in
164, 193, 296
Depression, effect of comorbidity
89, 90, 113, 127, 141
Dermatitis, atopic
282
Developing countries
Diabetes
52
21, 44, 47, 50, 63, 85, 92, 105, 120, 140, 149,
157, 163, 170, 171, 190, 203, 207, 217, 225, 245,
249, 251, 252, 262, 265, 272, 277, 285, 299, 313,
324
Diagnostic Adherence to Medication Scale
(DAMS)
see Questionnaires
Dialysis
320
Disability, effect on
218
Disease flare, effect on
220
Dispensing databases, use to assess
19, 28, 33, 38, 42, 167, 220
Dispensing quantities, effect of
164
Displaced populations
see Refugees
Dizziness, effect of
181
Doctor-patient relationships
93, 117, 135, 179, 301, 309, 317, 318
Doctors, assessment of adherence
28, 29
Doctors, views on interventions
293
Donepezil
326
Dose administration aids
see Compliance aids
Dose frequency, effect of
66, 80, 87, 94, 104, 168
206
Drug delivery services, pharmacy
328
Drug stability
302
Early identification of non-adherence
19
eCAPs
see Electronic monitoring devices
Ecological models
91
Economic models, inclusion of adherence
219
Effectiveness of treatment, effect of
223
Electronic medical records, use to assess
31, 33, 39
12, 14, 15, 20, 23, 26, 30, 34, 40, 45, 104, 115,
158, 206, 233, 262, 288, 314, 320, 322, 324
Electronic monitoring devices
Electronic prescriptions
266
Emergency departments
108, 266
Emotional support
276
Employment, effect on
215, 218, 241
Empowerment, patient
120
Enoxaparin
see Heparins, low molecular weight
Epilepsy
151, 209, 227
Erythrocyte level, use to assess
46
Ethnic differences in adherence
83, 115, 145, 157, 168, 193, 197
Europe, medicines adherence policy
256
Eye drops
271
Ezetimibe
311
Face-to-face counselling
316, 322
Family, support by
86, 149, 165, 174, 234, 278, 301
207
Feedback of adherence
314
Feedback of test results, effect of
263, 287
Financial incentives
300, 303
First-fill nonadherence
see Primary nonadherence
Fixed-dose combinations (see also Polypill)
96, 102, 126
Food and Drug Administration warnings
311
Friends, support by
174
Gastroprotection
239
Gender differences in adherence
see Sex differences in adherence
Generic drugs
57
Genotype based dose calculation
287
Glatiramer acetate
75
Glaucoma
271, 295
Group-based interventions
331
Guideline-concordant therapy
60
Guidelines for adherence interventions
319
Half-life of medicine
199
Health care utilisation, effect on
64, 330
Health coaching
120, 246
Health literacy, effect of
103, 139, 140, 158, 295
Health-related quality of life
26, 67, 232, 305
Heart failure
158, 160, 169, 224
Heparins, low molecular weight
70
Hepatitis B
60
208
Herbal medicines, effect of use
HIV and AIDS
138
45, 52, 86, 99, 101, 102, 125, 128, 130, 131, 135,
143, 180, 192, 233, 257, 267, 276, 288, 290, 310,
319, 327, 328
Home visits
322
Hospital discharge
103, 129, 139, 246, 285, 307
Hospitalisation, effect on
7, 199, 201, 206, 209, 210, 211, 217, 234, 237
Hyperlipidaemia
137, 189
Hyperparathyroidism
Hypertension
254
20, 25, 28, 40, 41, 96, 111, 113, 115, 137, 138,
148, 168, 176, 179, 195, 204, 232, 236, 240, 241,
247, 272, 298
Hypoglycaemics
see Cholesterol lowering agents
Hypothyroidism
289
Ibandronate
see Bisphosphonates
Immigrants
106, 153
Immunosuppressants
67, 173, 255
Impulsivity, effect of
162
Individualised patient care
271
Inflammatory bowel disease
187, 201
Infliximab
201
Information sources used by patients
130, 179
Inhalers
15, 34, 78, 280
Insulin analogues
50
Insulins
163, 252
209
Insurance, health
4, 57, 103, 124, 134, 137
Intensification of therapy
28, 204, 230, 240
Intentional non-adherence
50, 55, 125, 133, 139, 271
Interactions, drug
125
Interactive voice response
253, 329
Interferon beta
62, 75
Interviews
27
Ipratropium bromide
123
Ivermectin
97
Kidney disease
30
Kidney transplantation
see Transplantation, kidney
Lack of effectiveness, factor in nonadherence
62
Latent Class Analysis
214
Leukaemia, acute lymphoblastic
197
Leukaemia, chronic myeloid
6
Leukotriene inhibitors
211
Levothyroxine
289
Life events, effect of
122
Liraglutide
265
Liver transplantation
see Transplantation, liver
Long-acting formulations
136
Mail order pharmacy
128, 184, 249
Marijuana
see Cannabis
Med-E-Lert automated medication dispenser
see Compliance aids
210
Med-eMonitor
see Compliance aids
Medical records, recording non-adherence
28
Medication Adherence Individual ReviewScreening Tool
see Questionnaires
Medication Event Monitoring System (MEMS)
Medication reconciliation
281
Mental illness
82, 166
Mercaptopurine
197
Methotrexate
26, 46
Methylphenidate
see Stimulants, psychiatric
Metoprolol
see Beta blockers
Migrants
see Immigrants, Refugees
Morisky-Green-Levine Medication Adherence
Scale
see Questionnaires
Morisky Medication Adherence Scale
see Questionnaires
Mortality, effect on
203, 205, 222, 229
Motivation of patients
149, 258, 262
Motivational interviewing, effect of
20, 131, 245, 312, 331
Multiple sclerosis
62, 75, 213
Myocardial infarction, adherence following
68, 129, 222, 274, 281
Myocardial infarction, effect on occurrence
235
Nausea, effect on
202
Nebivolol
see Beta blockers
Nebulisers
23
211
Neurocognition
95
Nicotine replacement therapy
287
Nurse-patient relationships
119
Nurses, interventions by
262, 320
Nurses, views on interventions
Older people
293
2, 35, 77, 113, 114, 119, 122, 139, 140, 147, 181,
215, 309, 317
On-line prescription management
273
Opioids
13
Osteoporosis
Outcomes, effect on (see also individual
outcomes)
32, 65, 81, 212, 242, 312
198, 205, 208, 216, 221, 223, 225, 226, 228, 235,
322
Outcomes, patient reported, effect on
244
Outpatient visits, effect on
161, 200
Outpatients, hospital
127, 194, 202, 254
Over-active bladder
63, 114
Oxybutynin
114
Package inserts
117
Palatability, effect of
88
Paliperidone
see Antipsychotics
Parents
34, 116, 186
Parkinson’s disease
55, 107
Partners
see Family
Patient assistance programmes
258
Patient centred prescribing, effect of
150
212
Patient counselling
177, 257, 265, 267, 269, 284, 296, 297, 307, 312,
320, 326
Patient education
54, 158, 171, 245, 248, 251, 252, 274, 275, 281,
284, 285, 289, 290, 295, 304, 318, 320, 325
Patient empowerment
5, 93, 120, 171, 251, 327
Patient information leaflets
130
Patient involvement
1, 3, 286
Patient knowledge
179
Peak flow measurements
263
Penicillin V
see Antibiotics
Perceptions of illness
92, 132, 144, 148, 152, 214, 263, 271
Percutaneous coronary intervention, adherence
post
172
Pharmaceutical care, effect of
275, 289
Pharmacist-patient relationships
327
Pharmacists, in primary care clinics
277
Pharmacists, interventions by
158, 243, 244, 245, 246, 249, 251, 252, 254, 255,
257, 265, 269, 272, 275, 281, 283, 290, 296, 299,
305, 307, 315, 316, 326
Pharmacists, views on interventions
128, 293
Pharmacokinetics, population, effect on
233
Pharmacy bottlenecks
277
Phosphate binders
320
Pictorial communication
267, 279, 280
“Pill burden”, effect of
48, 102, 195
Pill count, use to assess
10, 18, 40, 45, 288
213
Placebo, adherence to
229
Plasma level, use to assess
10
Polypharmacy
77, 147, 168, 181, 250
“Polypill”
79, 250, 274
Positive reinforcement
282, 298
Postmarketing surveillance, effect on
238
Postnatal period
70
Poverty
188
Pregnancy, adherence during
70
Prescription databases, use to assess
18
Primary (first-fill) nonadherence
56, 76, 196
Prior adherence, predictive value of
103, 152, 189
Pro re nata (prn) dosing
51
Productivity, work, effect on
241
Prostate cancer
59
Psoriasis
46
Psychiatric medications (see also
Antidepressants, Antipsychotics, etc.)
166
Psychiatrists, assessment of nonadherence
183
Psychological factors
154
Psychosocial interventions
306
Psychotic disorders (see also Schizophrenia)
48
Quality indicators, inclusion in
8, 240
Questionnaires, use to assess
9, 17, 21, 25, 32, 35, 44, 84, 194, 214
214
Refugees
226
Regimen complexity, effect of
147, 182
Relapse, effect of nonadherence on
197, 206, 213
Religion (see also Spirituality)
116, 142
Reminder based interventions
264, 279
Reminder packaging
261, 330
Respiratory tract infections
208
Responsibility for adherence
86, 317
Rheumatoid arthritis
73, 218, 331
Rhinitis, allergic
200
Rural areas, effect of
173, 191
Satisfaction with treatment
110
Schizoaffective disorder
Schizophrenia
27, 156, 214
16, 27, 48, 53, 95, 155, 159, 199, 206, 210, 214,
270, 278, 292, 322
Selective serotonin reuptake inhibitors
242
Self affirmation
298
Self assessment of adherence
Self efficacy
29
20, 21, 41, 98, 111, 116, 120, 178, 185, 279, 280,
301, 310
Self management education
285, 294, 298, 310
Self neglect
77
Self reporting, use to assess
10, 11, 14, 30, 36, 41, 44, 288
Sex differences in adherence
47, 58, 64, 92, 115, 121, 153, 168, 191, 203
Sexual assault, prophylaxis
52
215
Sexual function, medicines affecting
166
Side effects
see Adverse effects
Simvastatin
see Statins
Single-tablet therapy
180, 247
Sirolimus
30
Smart Blister
SmartTrack
SMS messaging
see Text messaging
Smoking cessation
10, 287
Smoking, effect of
127, 203
Social support
174, 276, 278, 301
Sociodemographic factors
129
Socioeconomic factors
108, 109
Software, pharmacy
243
Spirituality (see also Religion)
116
Statins
22, 31, 33, 54, 57, 100, 118, 124, 152, 189, 205,
230, 231, 235, 286, 297, 316
Sticker charts
282
Stimulants, psychiatric
51, 136
Stroke
69, 98, 205
Structural equation modelling
144
Students, adherence to simulated regimen
182
Students, interventions by
260, 304
Symptoms, attitude to
155
216
Systemic lupus erythematosus
26, 269
Tacrolimus
30, 173
Targeting of interventions
5, 170, 243, 259
Taste
see Palatability
Taxonomy, adherence
43
Telephone messages
42, 253, 264, 281, 298, 312, 313, 329, 330
Terminology, adherence
43
Text messaging
24, 37, 264, 268, 270, 288, 291, 292, 323, 324
Therapeutic inertia, association of adherence
with
225
Thromboembolism, idiopathic venous
231
Tolterodine
114
Transplantation
173
Transplantation, kidney
30, 67, 255
Transplantation, liver
67
Travel costs, effect of
143
Travelling, adherence while
192
Treatment Adherence Questionnaire for Patients
with Hypertension
see Questionnaires
Tremor, essential
141
Trust in medical system
111
Tuberculosis
153, 284, 291
Tyrosine kinase inhibitors
6
Ulcerative colitis
80, 220, 308
Urine level, use to assess
11, 13
217
Varenicline
10
Vasculitis
301
Vomiting, effect on
202
Warfarin
58, 98
Web-based training
310
“White coat” adherence
151
Women, interventions for
257
Work
see Employment
Workplace programmes
283
Young adults
24, 162
Zoledronate
see Bisphosphonates
218

Adherence with prescribed medications

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