Effectiveness of motivational interviewing interventions on medication adherence in adults with chronic diseases: a systematic review and meta-analysis

Background

Medication adherence is frequently suboptimal in adults with chronic diseases, resulting in negative consequences. Motivational interviewing (MI) is a collaborative conversational style for strengthening a person's motivation and commitment to change. We aimed to assess whether MI interventions are effective to enhance medication adherence in adults with chronic diseases and to explore the effect of individual MI intervention characteristics.

Methods

We searched electronic databases and reference lists of relevant articles to find randomized controlled trials (RCTs) that assessed MI intervention effectiveness on medication adherence in adults with chronic diseases. A random-effects model was used to estimate a pooled MI intervention effect size and its heterogeneity (I 2 ). We also explored the effects of individual MI characteristics on MI intervention effect size using a meta-regression with linear mixed model.

Results

: Nineteen RCTs were identified, and 16 were included in the meta-analysis. The pooled MI intervention effect size was 0.12 [95% confidence interval (CI) = (0.05, 0.20), I 2 = 1%]. Interventions that were based on MI only [β = 0.183, 95% CI = (0.004, 0.362)] or those in which interventionists were coached during intervention implementation [β = 0.465, 95% CI = (0.028, 0.902)] were the most effective. MI interventions that were delivered solely face to face were more effective than those that were delivered solely by phone [β = 0.270, 95% CI = (0.041, 0.498)].

Conclusions

This synthesis of RCTs suggests that MI interventions might be effective at enhancing of medication adherence in adults treated for chronic diseases. Further research is however warranted, as the observed intervention effect size was small.

Measures of adherence based on self-report exhibited poor agreement with those based on pharmacy records

OBJECTIVE

To assess the level of agreement between a self-reported measure of adherence with prescribed drug and a measure of adherence based on pharmacy data.

METHODS

During an in-home interview, people aged 65+ were asked to report all prescription drugs they had taken in the preceding month. For each drug, a four-item questionnaire was used to determine self-reported adherence. In the pharmacy records, each drug that had been filled at least four times was analyzed, and the percentage of days with the drug available was calculated. Two types of adherence were studied: (1) adherence by individual, and (2) adherence by drug. The level of agreement was assessed using kappa (kappa) statistics and proportions of agreement.

RESULTS

We compared the adherence measures among 189 individuals (880 drugs). Among all, 90 individuals (48%) self-reported adherence, whereas 95 individuals (50%) were adherent according to the records. The level of agreement between these two measures was slight (kappa=0.16 [95% CI: 0.02-0.30]). Individuals self-reported to be adherent for 81% of the drugs, while pharmacy records showed adherence for 83% of them (kappa=0.13 [95% CI: 0.05-0.20]).

CONCLUSION

Self-reported measures of adherence exhibited poor agreement with those based on pharmacy records.

Effectiveness of an asthma integrated care program on asthma control and adherence to inhaled corticosteroids

OBJECTIVE

To measure the effectiveness of an integrated care program for individuals with asthma aged 12-45 years, on asthma control and adherence to inhaled corticosteroids (ICS).

METHODS

Researchers used a theoretical model to develop the program and assessed effectiveness at 12 months, using a pragmatic controlled clinical trial design. Forty-two community pharmacists in Quebec, Canada recruited participants with either uncontrolled or mild-to-severe asthma. One group was exposed to the program; another received usual care. Asthma control was measured with the Asthma Control Questionnaire; ICS adherence was assessed with the Morisky medication adherence scale and the medication possession ratio. Program effectiveness was assessed with an intention-to-treat approach using multivariate generalized estimating equation models.

RESULTS

Among 108 exposed and 241 non-exposed, 52.2% had controlled asthma at baseline. At 12-months, asthma control had improved in both groups but the interaction between study groups and time was not significant (p = 0.09). The proportion of participants with good ICS adherence was low at baseline. Exposed participants showed improvement in adherence and the interaction between study groups and time was significant (p = 0.02).

CONCLUSION

An integrated intervention, with healthcare professionals collaborating to optimize asthma control, can improve ICS adherence.

Patients' beliefs about adherence to oral antidiabetic treatment: a qualitative study

PURPOSE

The purpose of this study was to elicit patients' beliefs about taking their oral antidiabetic drugs (OADs) as prescribed to inform the development of sound adherence-enhancing interventions.

METHODS

A qualitative study was performed. Adults with type 2 diabetes who had been taking an OAD for >3 months were solicited to participate in one of six focus groups. Discussions were facilitated using a structured guide designed to gather beliefs related to important constructs of the theory of planned behavior. Four coders using this theory as the theoretical framework analyzed the videotaped discussions.

RESULTS

Forty-five adults participated. The most frequently mentioned advantages for OAD-taking as prescribed were to avoid long-term complications and to control glycemia. Family members were perceived as positively influential. Carrying the OAD at all times, having the OAD in sight, and having a routine were important facilitating factors. Being away from home, not accepting the disease, and not having confidence in the physician's prescription were major barriers to OAD-taking.

CONCLUSION

This study elicited several beliefs regarding OAD-taking behavior. Awareness of these beliefs may help clinicians adjust their interventions in view of their patients' beliefs. Moreover, this knowledge is crucial to the planning, development, and evaluation of interventions that aim to improve medication adherence.

Effectiveness and Content Analysis of Interventions to Enhance Oral Antidiabetic Drug Adherence in Adults with Type 2 Diabetes: Systematic Review and Meta-Analysis

OBJECTIVES

To estimate the pooled effect size of oral antidiabetic drug (OAD) adherence-enhancing interventions and to explore which of the behavior change techniques (BCTs) applied in the intervention groups modified this pooled intervention effect size.

METHODS

We searched relevant studies published until September 3, 2013, on MEDLINE, Embase, PsycInfo, the Cochrane Library, CINAHL, Current Contents Connect, and Web of Science. Selected studies were qualitatively synthesized, and those of at least medium quality were included in the meta-analysis. A random-effects model was used to pool effectiveness (Hedges's g) and to examine heterogeneity (Higgins I(2)). We also explored the influence on the pooled effectiveness of unique intervention BCTs (those delivered to the intervention groups but not control groups in a trial) by estimating their modifying effects.

RESULTS

Fourteen studies were selected for the qualitative synthesis and 10 were included in the meta-analysis. The pooled effectiveness of the interventions was 0.21 (95% confidence interval -0.05 to 0.47; I(2) = 82%). Eight unique BCTs were analyzed. "Cope with side effects" (P = 0.003) and "general intention formation" (P = 0.006) had a modifying effect on the pooled effectiveness. The pooled effectiveness of the interventions in which "cope with side effects" was applied was moderate (0.64; 95% confidence interval 0.31-0.96; I(2) = 56%).

CONCLUSIONS

The overall effectiveness of OAD adherence-enhancing interventions that have been tested is small. Helping patients cope with side effects or formulate desired treatment outcomes could have an impact on the effectiveness of OAD adherence-enhancing interventions. Only those interventions that include helping patients to cope with side effects appear to be particularly effective in improving OAD adherence.

Psychosocial factors associated with adherence to non-insulin antidiabetes treatments

AIMS

To discern psychosocial factors of non-insulin antidiabetes drug (NIAD) adherence.

METHODS

A cross-sectional study based on the theory of planned behavior (TPB). Adults with type 2 diabetes (T2D) who were members of Diabète Québec, a provincial association of persons with diabetes, and were prescribed at least one NIAD were invited to complete a web-based questionnaire. We measured variables ascertaining TPB constructs and other factors potentially associated with NIAD adherence (e.g., habit, social support, and mental health). NIAD adherence was assessed using the 8-item Morisky Medication Adherence Scale. Factors were identified using a multivariate logistic regression model.

RESULTS

In our study, 901 participants (373 women; 515 retired; mean age: 62.7 years) with T2D for a mean of 10 years, completed the questionnaire. Participants exhibited a high intention to adhere to their NIAD treatment (mean score=5.8/6), positive attitudes toward adherence (mean score=5.5/6), and elevated perceived behavioral control in taking their medication (mean score=5.7/6). Only 405 (45%) participants reported high adherence (score=8/8). Perceived behavioral control, habit, older age, no perceived side effects, a longer period since T2D diagnosis and a lower number of NIAD daily doses were significantly associated with adherence (p<0.05).

CONCLUSION

We identified several factors that may be modified for NIAD adherence and thereby provided insight into future adherence-enhancing intervention targets.

Impact of pharmacists' interventions on the pharmacotherapy of patients with complex needs monitored in multidisciplinary primary care teams

OBJECTIVES

Recently, pharmacists have joined multidisciplinary healthcare teams within family medicine groups (FMG) in Quebec Province, Canada. This study assessed the impact of their interventions on the pharmacotherapy of patients with complex needs monitored in FMGs.

METHODS

We performed a pre/post real-life intervention study among patients with complex needs referred to the FMG pharmacist in four FMGs in Quebec City. Pharmacists collected data at baseline, during follow-up and up to 6 months after the first encounter. They recorded all drug-related problems (DRPs) identified, interventions made and recommendations that were accepted by physicians. The researchers used the data collected to compare the medication regimen complexity index (MRCI) and medication adherence (using the proportion of days covered (PDC)) before and after the pharmacist's interventions. Descriptive statistics and paired sample t-tests were computed.

KEY FINDINGS

Sixty-four patients (median age: 74.5 years) were included; four patients were lost to follow-up. Pharmacists detected 300 DRPs (mean: 7.2 per patient) during the study period for which they made an intervention. The most common DRP was 'drug use without indication' (27%). The physicians accepted 263 (87.7%) of those interventions. The mean number of prescribed drugs per patient decreased from 13.8 (95% confidence interval (CI): 12.24 to 15.29) to 12.4 (95% CI: 10.92 to 13.90). The mean MRCI decreased from 47.18 to 41.74 (-5.44; 95% CI: 1.71 to 9.17), while the mean PDC increased from 84.4% to 90.0% (+5.6%; 95% CI: 2.7% to 8.4%).

CONCLUSION

Family medicine groups pharmacists can detect and resolve DRPs and can reduce medication regimen complexity and non-adherence to treatment in patients with complex needs monitored in FMGs.

Incidence of Depression and Associated Factors in Patients With Type 2 Diabetes in Quebec, Canada: A Population-Based Cohort Study

It has been reported that the risk of depression is higher among people with type 2 diabetes compared with a nondiabetic population. Among diabetic patients, depression has been associated with worse self-care behaviors, poor glycemic control, and an increased risk of diabetes complications. Identifying factors associated with the occurrence of depression may help physicians identify earlier diabetic patients at a high risk of developing depression, improve prevention, and accelerate proper treatment. To our knowledge, very few population-based studies have reported on the incidence of clinically diagnosed depression as a consequence of type 2 diabetes over a long follow-up period. The objective of this study was to estimate the incidence of clinically diagnosed depression among type 2 diabetic patients newly treated with oral antidiabetic drugs (ADs) and to identify factors associated with the occurrence of depression.Administrative claims data from the public health insurance plan were used to identify a cohort of new oral AD users aged ≥18 years between 2000 and 2006. Patients were followed from oral AD treatment initiation until the diagnosis of depression, ineligibility for the public drug plan, death, or the end of the study, whichever came first. Incidence rates were determined using person-time analysis. Factors associated with depression were identified using multivariable Cox regression analysis.We identified 114,366 new oral AD users, of which 4808 had a diagnosis of depression. The overall incidence rate of depression was 9.47/1000 person-years (PYs) (10.72/1000 PYs for women and 8.27/1000 PYs for men). The incidence of depression was higher during the year after oral AD treatment initiation. Independent factors associated with depression included having had mental disorders other than depression, hospitalization, a higher number of different drugs taken and of physicians visited during the year before oral AD initiation. Moreover, we observed a statistically significant age-by-socioeconomic status interaction.The incidence of diagnosed depression is higher during the first year after oral AD treatment initiation. Clinicians could pay particular attention to women, patients starting an AD at a young age, those with a low socioeconomic status, and especially those with a history of anxiety or dementia.

Chronic pain patients' willingness to share personal identifiers on the web for the linkage of medico-administrative claims and patient-reported data: The chronic pain treatment cohort

PURPOSE

The linkage between patient-reported data and medico-administrative claims is of great interest for epidemiologic research. The goal of this study was to assess the willingness of people living with chronic pain to share personal identifiers on the web for the linkage of medico-administrative and patient-reported data.

METHODS

This methodological investigation was achieved in the context of the implementation of the chronic pain treatment (COPE) cohort. A web-based recruitment initiative targeting adults living with chronic pain was conducted in the province of Quebec (Canada).

RESULTS

A total of 1935 participants completed the questionnaire (mean age: 49.86 ± 13.27; females: 83.69%), 921 (47.60%) of which agreed to data linkage and shared their personal identifiers (name, date of birth, health insurance number online). The most common reasons for refusal were: (1) concerns regarding data security/privacy (25.71%) and (2) the belief that the requested data were too personal/intrusive (13.52%). Some participants did not understand the relevance of data linkage (11.81%). Participants from the COPE cohort and those from the subsample who agreed to data linkage were comparable to other random samples of chronic pain individuals in terms of age and pain characteristics.

CONCLUSIONS

Although approximately half of the participants refused data linkage, our approach allowed for the implementation of a data platform that contains a diverse and substantial sample. This investigation has also led to the formulation of recommendations for web-based data linkage, including placing items designed to assess willingness to share personal identifiers at the end of the questionnaire, adding explanatory videos, and using a mixed-mode questionnaire.

Physician and Pharmacist Medication Decision-Making in the Time of Electronic Health Records: Mixed-Methods Study

Background

Primary care needs to be patient-centered, integrated, and interprofessional to help patients with complex needs manage the burden of medication-related problems. Considering the growing problem of polypharmacy, increasing attention has been paid to how and when medication-related decisions should be coordinated across multidisciplinary care teams. Improved knowledge on how integrated electronic health records (EHRs) can support interprofessional shared decision-making for medication therapy management is necessary to continue improving patient care.

Objective

The objective of our study was to examine how physicians and pharmacists understand and communicate patient-focused medication information with each other and how this knowledge can influence the design of EHRs.

Methods

This study is part of a broader cross-Canada study between patients and health care providers around how medication-related decisions are made and communicated. We visited community pharmacies, team-based primary care clinics, and independent-practice family physician clinics throughout Ontario, Nova Scotia, Alberta, and Quebec. Research assistants conducted semistructured interviews with physicians and pharmacists. A modified version of the Multidisciplinary Framework Method was used to analyze the data.

Results

We collected data from 19 pharmacies and 9 medical clinics and identified 6 main themes from 34 health care professionals. First, Interprofessional Shared Decision-Making was not occurring and clinicians made decisions based on their understanding of the patient. Physicians and pharmacists reported indirect Communication, incomplete Information specifically missing insight into indication and adherence, and misaligned Processes of Care that were further compounded by EHRs that are not designed to facilitate collaboration. Scope of Practice examined professional and workplace boundaries for pharmacists and physicians that were internally and externally imposed. Physicians decided on the degree of the Physician-Pharmacist Relationship, often predicated by colocation.

Conclusions

We observed limited communication and collaboration between primary care providers and pharmacists when managing medications. Pharmacists were missing key information around reason for use, and physicians required accurate information around adherence. EHRs are a potential tool to help clinicians communicate information to resolve this issue. EHRs need to be designed to facilitate interprofessional medication management so that pharmacists and physicians can move beyond task-based work toward a collaborative approach.

COVID-19 - an opportunity to improve access to primary care through organizational innovations? A qualitative multiple case study in Quebec and Nova Scotia (Canada)

BACKGROUND

COVID-19 catalyzed a rapid and substantial reorganization of primary care, accelerating the spread of existing strategies and fostering a proliferation of innovations. Access to primary care is an essential component of a healthcare system, particularly during a pandemic. We describe organizational innovations aiming to improve access to primary care and related contextual changes during the first 18 months of the COVID-19 pandemic in two Canadian provinces, Quebec and Nova Scotia.

METHODS

We conducted a multiple case study based on 63 semi-structured interviews (n = 33 in Quebec, n = 30 in Nova Scotia) conducted between October 2020 and May 2021 and 71 documents from both jurisdictions. We recruited a diverse range of provincial and regional stakeholders (e.g., policy-makers, decision-makers, family physicians, nurses) involved in reorganizing primary care during the COVID-19 pandemic using purposeful sampling (e.g., based on role, region). Interviews were transcribed verbatim and thematic analysis was conducted in NVivo12. Emerging results were discussed by team members to identify salient themes and organized into logic models.

RESULTS

We identified and analyzed six organizational innovations. Four of these - centralized public online booking systems, centralized access centers for unattached patients, interim primary care clinics for unattached patients, and a community connector to health and social services for older adults - pre-dated COVID-19 but were accelerated by the pandemic context. The remaining two innovations were created to specifically address pandemic-related needs: COVID-19 hotlines and COVID-dedicated primary healthcare clinics. Innovation spread and proliferation was influenced by several factors, such as a strengthened sense of community amongst providers, decreased patient demand at the beginning of the first wave, renewed policy and provider interest in population-wide access (versus attachment of patients only), suspended performance targets (e.g., continuity ≥80%) in Quebec, modality of care delivery, modified fee codes, and greater regional flexibility to implement tailored innovations.

CONCLUSION

COVID-19 accelerated the uptake and creation of organizational innovations to potentially improve access to primary healthcare, removing, at least temporarily, certain longstanding barriers. Many stakeholders believed this reorganization would have positive impacts on access to primary care after the pandemic. Further studies should analyze the effectiveness and sustainability of innovations adapted, developed, and implemented during the COVID-19 pandemic.

Factors associated with antidiabetic medication non-adherence in patients with incident comorbid depression

AIM

To identify factors associated with antidiabetic drug (AD) non-adherence among patients with type 2 diabetes and depression.

STUDY DESIGN AND SETTINGS

We conducted a population-based retrospective cohort study among new AD users with a diagnosis of depression following AD initiation. We used public health insurance data from Quebec. The dependent variable was non-adherence (i.e., <90% of days covered by ≥1AD) in the year after a depression diagnosis. Different sociodemographic, clinical and medication-related variables were assessed as potential factors of non-adherence to AD treatment. We performed univariate and multivariate logistic regressions.

RESULTS

We identified 3106 new users of ADs with a diagnosis of depression between 2000 and 2006. Of these individuals, 52% were considered non-adherent to their ADs. Baseline non-adherence, younger age, the addition of another AD to the initial treatment, <4 drug claims, visits with several different physicians, high socioeconomic status, and a small number of diabetes complications were associated with AD non-adherence.

CONCLUSIONS

The factors identified in the present study may help clinicians recognize patients with type 2 diabetes and incident depression at increased risk for non-adherence. In these patients, close follow-up and targeted interventions could help improve adherence to AD treatment, improve glycemic control and reduce complications.

Predicting Noninsulin Antidiabetic Drug Adherence Using a Theoretical Framework Based on the Theory of Planned Behavior in Adults With Type 2 Diabetes: A Prospective Study

Understanding the process behind noninsulin antidiabetic drug (NIAD) nonadherence is necessary for designing effective interventions to resolve this problem. This study aimed to explore the ability of the theory of planned behavior (TPB), which is known as a good predictor of behaviors, to predict the future NIAD adherence in adults with type 2 diabetes. We conducted a prospective study of adults with type 2 diabetes. They completed a questionnaire on TPB variables and external variables. Linear regression was used to explore the TPB's ability to predict future NIAD adherence, which was prospectively measured as the proportion of days covered by at least 1 NIAD using pharmacy claims data. The interaction between past NIAD adherence and intention was tested. The sample included 340 people. There was an interaction between past NIAD adherence and intention to adhere to the NIAD (P = 0.032). Intention did not predict future NIAD adherence in the past adherers and nonadherers groups, but its association measure was high among past nonadherers (β = 5.686, 95% confidence interval [CI] -10.174, 21.546). In contrast, intention was mainly predicted by perceived behavioral control both in the past adherers (β = 0.900, 95% CI 0.796, 1.004) and nonadherers groups (β = 0.760, 95% CI 0.555, 0.966). The present study suggests that TPB is a good tool to predict intention to adhere and future NIAD adherence. However, there was a gap between intention to adhere and actual adherence to the NIAD, which is partly explained by the past adherence level in adults with type 2 diabetes.

Improving medication adherence among community-dwelling seniors with cognitive impairment: a systematic review of interventions

Background Medication non-adherence may lead to poor therapeutic outcomes. Cognitive functions deteriorate with age, contributing to decreased adherence. Interventions have been tested to improve adherence in seniors with cognitive impairment or Alzheimer disease (AD), but high-quality systematic reviews are lacking. It remains unclear which interventions are promising. Objectives We conducted a systematic review to identify, describe, and evaluate interventions aimed at improving medication adherence among seniors with any type of cognitive impairment. Methods Following NICE guidance, databases and websites were searched using combinations of controlled and free vocabulary. All adherence-enhancing interventions and study designs were considered. Studies had to include community dwelling seniors, aged 65 years or older, with cognitive impairment, receiving at least one medication for a chronic condition, and an adherence measure. Study characteristics and methodological quality were assessed. Results We identified 13 interventions, including six RCTs. Two studies were of poor, nine of low/medium and two of high quality. Seven studies had sample sizes below 50 and six interventions focused on adherence to AD medication. Six interventions tested a behavioral, four a medication oriented, two an educational and one a multi-faceted approach. Studies rarely assessed therapeutic outcomes. All but one intervention showed improved adherence. Conclusion Three medium quality studies showed better adherence with patches than with pills for AD treatment. Promising interventions used educational or reminding strategies, including one high quality RCT. Nine studies were of low/moderate quality. High quality RCTs using a theoretical framework for intervention selection are needed to identify strategies for improved adherence in these seniors.

Case Management in Primary Care for Frequent Users of Health Care Services: A Realist Synthesis

PURPOSE

Case management (CM) is a promising intervention for frequent users of health care services. Our research question was how and under what circumstances does CM in primary care work to improve outcomes among frequent users with chronic conditions?

METHODS

We conducted a realist synthesis, searching MEDLINE, CINAHL, Embase, and PsycINFO (1996 to September 2017) for articles meeting the following criteria: (1) population: adult frequent users with chronic disease, (2) intervention: CM in a primary care setting with a postintervention evaluation, and (3) primary outcomes: integration of services, health care system use, cost, and patient outcome measures. Academic and gray literature were evaluated for relevance and robustness. Independent reviewers extracted data to identify context, mechanism, and outcome (CMO) configurations. Analysis of CMO configurations allowed for the modification of an initial program theory toward a refined program theory.

RESULTS

Of the 9,295 records retrieved, 21 peer-reviewed articles and an additional 89 documents were retained. We evaluated 19 CM interventions and identified 11 CMO configurations. The development of a trusting relationship fostering patient and clinician engagement in the CM intervention was recurrent in many CMO configurations.

CONCLUSION

Our refined program theory proposes that in the context of easy access to an experienced and trusted case manager who provides comprehensive care while maintaining positive interactions with patients, the development of this relationship fosters the engagement of both individuals and yields positive outcomes when the following mechanisms are triggered: patients and clinicians feel supported, respected, accepted, engaged, and committed; and patients feel less anxious, more secure, and empowered to self-manage.

Effort-Reward Imbalance at Work and the Prevalence of Unsuccessfully Treated Hypertension Among White-Collar Workers

We examined the association between effort-reward imbalance (ERI) exposure at work and unsuccessfully treated hypertension among white-collar workers from a large cohort in Quebec City, Canada. The study used a repeated cross-sectional design involving 3 waves of data collection (2000-2009). The study sample was composed of 474 workers treated for hypertension, accounting for 739 observations. At each observation, ERI was measured using validated scales, and ambulatory blood pressure (BP) was measured every 15 minutes during the working day. Unsuccessfully treated hypertension was defined as daytime ambulatory BP of at least 135/85 mm Hg and was further divided into masked and sustained hypertension. Adjusted prevalence ratios and 95% confidence intervals were estimated. Participants in the highest tertile of ERI exposure had a higher prevalence of unsuccessfully treated hypertension (prevalence ratio = 1.45, 95% confidence interval: 1.16, 1.81) after adjustment for gender, age, education, family history of cardiovascular diseases, body mass index, diabetes, smoking, sedentary behaviors, and alcohol intake. The present study supports the effect of adverse psychosocial work factors from the ERI model on BP control in treated workers. Reducing these frequent exposures at work might lead to substantial benefits on BP control at the population level.

The Association between Depression and Medication Nonpersistence in New Users of Antidiabetic Drugs

OBJECTIVES

To measure the association between depression and nonpersistence with antidiabetic drugs (ADs) among new users of oral ADs and to estimate factors associated with nonpersistence among these new users with depression.

METHODS

We used administrative claims data to identify an adult cohort (≥18 years) of new oral AD users who were free of depression. We followed the patients from AD initiation until either discontinuation, ineligibility for the public drug plan, death, or the end of the study. A proportional hazard Cox regression model with depression as a time-dependent variable was used to compute the adjusted hazard ratio of nonpersistence. A proportional hazard Cox regression model was also used to identify factors associated with nonpersistence in the subcohort of patients with depression.

RESULTS

We identified 114,366 new oral AD users, of whom 4,808 were diagnosed with depression during the follow-up. A greater proportion (55.4%) of patients with depression (vs. 42.5% without depression) discontinued their treatment during the follow-up. The adjusted hazard ratio of nonpersistence with ADs was 1.52 (95% confidence interval 1.41-1.63). Among patients with depression, independent factors associated with nonpersistence included younger age at oral AD initiation (<45 years) and starting treatment with drugs other than metformin (especially polytherapy with insulin).

CONCLUSIONS

Patients with depression are more likely to discontinue their treatment. Health care professionals should pay attention to patients on AD therapy who also suffer from depression, especially if the patients are young or are using insulin because these patients are at an increased risk of nonpersistence.

Factors associated with adherence to asthma treatment with inhaled corticosteroids: A cross-sectional exploratory study

BACKGROUND

Understanding factors at the patient, provider or organizational level associated with inhaled corticosteroids (ICSs) adherence is important when planning adherence-enhancing interventions.

OBJECTIVE

To explore factors associated with adherence to ICS among patients with asthma aged 12-45 years.

METHODS

A cross-sectional study was conducted among patients with asthma reporting ICS prescription during the baseline interview of an intervention study. Three methods were used to measure ICS adherence: a 4-item self-report questionnaire, a single question (SQ) measuring past 7-day exposure to ICS and a medication possession ratio (MPR, i.e., the sum of ICS days of supply/365). We assessed 46 potential factors of ICS adherence derived from the Predisposing, Reinforcing and Enabling Constructs in Educational Diagnosis and Evaluation (PRECEDE) model. Their association with ICS adherence was measured using multivariate logistic regressions.

RESULTS

Among the 319 participants included, 16.0% were deemed adherent according to the 4-item questionnaire. This proportion was 43.0% and 9.1% for the SQ and the MPR method, respectively. Ten factors were associated with good ICS adherence. Among these factors, four were associated with adherence through one of the measuring methods: a low family income level, a high number of asthma drugs used, a good knowledge of asthma pathophysiology and the perception that following the ICS prescription was easy. Two factors emerged through more than one measure: perceiving asthma severity as moderate to very severe and perceiving a high risk of death if ICSs are not taken as prescribed.

CONCLUSION

ICS adherence was poor in those individuals with asthma. Future adherence-enhancing interventions could target the identified modifiable risk factors.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT02093013.

The impact of incident depression on medication adherence in patients with type 2 diabetes

BACKGROUND

Depression has been correlated with suboptimal adherence to antidiabetic drugs (ADs). Most studies on this topic were cross-sectional; thus, the directionality of this relationship could not be established. The objective of this study was to measure the association between incident depression and AD nonadherence among newly treated patients with diabetes.

METHODS

We performed a population-based cohort study among new AD users using the Quebec public health insurance data. To avoid immortal time bias, we carried out depression diagnosis-time distribution matching by assigning a date of depression diagnosis to individuals without depression. Nonadherence (i.e.,<90% of days covered by≥1 AD) during the year following depression diagnosis (real or assigned date) was the outcome. Multivariate logistic regression analyses that adjusted for baseline adherence and other confounders were used to estimate the adjusted effect of depression on AD nonadherence.

RESULTS

Between 2000 and 2006, we identified 3,106 new AD users with a subsequent diagnosis of depression and 70,633 without depression, of which 52% and 49% became non-adherent to AD treatment, respectively. Among patients with depression, 52.0% were considered AD non-adherent in the year after depression diagnosis compared with 49.0% of matched patients without depression. Depression was associated with AD nonadherence after accounting for baseline adherence and other confounders with an adjusted odds ratio of 1.24 (95% confidence interval: 1.13-1.37).

CONCLUSIONS

The results suggest that depression is an independent risk factor for AD nonadherence. Patients with type 2 diabetes and depression might benefit from adherence-enhancing interventions.

Association between interpersonal continuity of care and medication adherence in type 2 diabetes: an observational cohort study

BACKGROUND

Prior studies have shown that, compared to patients with a low level of interpersonal continuity of care, patients with a high level of continuity of care have a lower likelihood of hospital admission and emergency department visits, and a higher likelihood of patient satisfaction. We sought to determine whether higher levels of continuity of care are associated with medication persistence and compliance among new users of oral antidiabetic treatment.

METHODS

We conducted a medicoadministrative cohort study of new users of oral antidiabetics aged 18 years or more among people covered by the Quebec public drug plan. We excluded people with fewer than 730 days of treatment and those who had been in hospital for 275 days or more in the first or second year after initiation of antidiabetic treatment. We categorized continuity of care observed in the first year after treatment initiation as low, intermediate or high. The association between continuity of care and medication persistence and compliance was assessed using generalized linear models.

RESULTS

In this cohort of 60 924 new users of oral antidiabetic treatment, compared to patients with a high level of continuity of care, those with an intermediate and a low level of continuity of care were less likely to be persistent (adjusted prevalence ratio 0.97 [95% confidence interval (CI) 0.96-0.98] and 0.96 [95% CI 0.95-0.97], respectively) and compliant (adjusted prevalence ratio 0.98 [95% CI 0.97-0.99] and 0.95 [0.94-0.97], respectively) with their antidiabetic treatment.

INTERPRETATION

A higher level of interpersonal continuity of care was associated with a higher likelihood of drug persistence and compliance. Since the strength of this association was weak, further research is required to determine whether continuity of care plays a role in medication adherence.

Case management in primary care for frequent users of healthcare services with chronic diseases and complex care needs: an implementation and realist evaluation protocol

INTRODUCTION

Significant evidence in the literature supports case management (CM) as an effective intervention to improve care for patients with complex healthcare needs. However, there is still little evidence about the facilitators and barriers to CM implementation in primary care setting. The three specific objectives of this study are to: (1) identify the facilitators and barriers of CM implementation in primary care clinics across Canada; (2) explain and understand the relationships between the actors, contextual factors, mechanisms and outcomes of the CM intervention; (3) identify the next steps towards CM spread in primary care across Canada.

METHODS AND ANALYSIS

We will conduct a multiple-case embedded mixed methods study. CM will be implemented in 10 primary care clinics in five Canadian provinces. Three different units of analysis will be embedded to obtain an in-depth understanding of each case: the healthcare system (macro level), the CM intervention in the clinics (meso level) and the individual/patient (micro level). For each objective, the following strategy will be performed: (1) an implementation analysis, (2) a realist evaluation and (3) consensus building among stakeholders using the Technique for Research of Information by Animation of a Group of Experts method.

ETHICS AND DISSEMINATION

This study, which received ethics approval, will provide innovative knowledge about facilitators and barriers to implementation of CM in different primary care jurisdictions and will explain how and why different mechanisms operate in different contexts to generate different outcomes among frequent users. Consensual and prioritised statements about next steps for spread of CM in primary care from the perspectives of all stakeholders will be provided. Our results will offer context-sensitive explanations that can better inform local practices and policies and contribute to improve the health of patients with complex healthcare needs who frequently use healthcare services. Ultimately, this will increase the performance of healthcare systems and specifically mitigate ineffective use and costs.