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.

Association Between Loyalty to Community Pharmacy and Medication Persistence and Compliance, and the Use of Guidelines-Recommended Drugs in Type 2 Diabetes: A Cohort Study

Pharmacists record data on all drugs claimed and may build a personal relationship with their clients. We hypothesized that loyalty to a single pharmacy could be associated with a better quality of drug use.To assess the association between pharmacy loyalty and quality of drug use among individuals treated with oral antidiabetes drugs (OADs).This is a cohort study using Quebec Health Insurance Board data. Associations were assessed using multivariable logistic regression.New OAD users, aged ≥18 years.Individuals who filled all their prescription drugs in the same pharmacy during the first year of treatment were considered loyal. During year 2 of treatment we assessed 4 quality indicators of drug use: persistence with antidiabetes treatment, compliance with antidiabetes treatment among those considered persistent, use of an angiotensin-converting enzyme inhibitor or of an angiotensin II receptor blocker (ACEi/ARB), and use of a lipid-lowering drug.Of 124,009 individuals, 59.75% were identified as loyal. Nonloyal individuals were less likely to persist with their antidiabetes treatment (adjusted odds ratio = 0.89; 95% CI: 0.86-0.91), to comply with their antidiabetes treatment (0.82; 0.79-0.84), to use an ACEi/ARB (0.85; 0.83-0.88) and to use a lipid-lowering drug (0.83; 0.80-0.85). Quality of drug use decreased as the number of different pharmacies increased (linear contrast tests <0.001).Results underscore the important role pharmacists could play in helping their clients with chronic diseases to better manage their drug treatments. Further research is needed to determine to what extent the positive effects associated with pharmacy loyalty are specifically due to pharmacists.

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.

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.

Quality of hypertension pharmacotherapy in Quebec: a population-based study

BACKGROUND

Choosing the initial pharmacotherapy for new antihypertensive users and ensuring adherence to therapy can be problematic.

OBJECTIVES

We sought to assess the quality of pharmacotherapy among new users of antihypertensives in Quebec, and to measure persistence with treatment in the short and longer term.

METHODS

Using provincial administrative databases, a historical population-based study was conducted with a cohort of Quebec adults who filled their first antihypertensive prescription between January 1, 2007, and December 31, 2009. We described antihypertensive treatment for those with a diagnosis of hypertension (HTN) in the 5 years preceding initiation of drug therapy. Conformity with criteria for optimal use based on the 2006 Canadian Hypertension Education Program (CHEP) was evaluated. Persistence with treatment was estimated at 3 months, 1 year and 2 years after pharmacotherapy initiation.

RESULTS

Among the 79,181 new antihypertensive users with HTN who started treatment between 2007 and 2009, 82.5% were first prescribed only one drug, usually an angiotensin II receptor blocker or an angiotensin-converting enzyme inhibitor and rarely a diuretic. 24.2% of newly treated hypertensive persons aged 60 or older in our sample received a beta-blocker, which is not recommended practice. The initial treatment conformed to CHEP recommendations for 72.8% of those with uncomplicated HTN. After 3 months, 69.8% of new users still persisted with their treatment. This proportion remained stable after 1 year (69.1%) and 2 years (69.2%).

CONCLUSION

Conformity of antihypertensive treatment with CHEP criteria, and patient persistence with therapy, was fairly high for new users in the province of Quebec. Research is needed, however, on how to further improve pÉÉharmacotherapy quality and persistence in new users.

Important treatment gaps in vascular protection for the elderly after type 2 diabetes therapy initiation

BACKGROUND

Canadian practice guidelines recommend the use of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) for vascular protection in individuals with diabetes who are at high risk of cardiovascular events, including those ≥ 65 years. We estimated the proportion of elderly persons who initiated an ACEI or an ARB in the year after beginning oral antidiabetes (OAD) treatment, and we identified factors associated with this initiation.

METHODS

Using the Quebec Health Insurance Board (RAMQ) databases, we conducted a population-based cohort study of individuals ≥ 65 years recently prescribed an OAD. We excluded those who were already taking an ACEI or ARB. Factors associated with ACEI or ARB initiation were identified using multivariate logistic regression.

RESULTS

Among 43,700 individuals, 13,621 (31.2%) initiated an ACEI or ARB in the year after beginning OAD. Individuals were more likely to begin an ACEI or an ARB if they initially received both metformin and a sulfonylurea, lived in a rural region, began OAD treatment between 2001 and 2006, were hospitalized, or had ≥ 22 medical visits in the year before OAD initiation. Individuals ≥ 75 years, those who were prescribed an OAD by a general practitioner, initially received a sulfonylurea, or received ≥ 4 different medications in the year before OAD initiation were less likely to begin an ACEI or ARB.

CONCLUSIONS

In the elderly not already taking ACEIs or ARBs, a low proportion of those undertaking OAD treatment are prescribed the recommended cardioprotection of an ACEI or ARB in the following year. Interventions are needed to close this treatment gap.

Pharmacy Record Registration of Acetyl Salicylic Acid (ASA) Prescriptions in Quebec

Purpose: To determine the extent of which acetyl salicylic acid (ASA) use is included in patients’ pharmacy records. Methods: During an in-home interview, people aged ≥65 years were asked to report all of the medications they had used at least once, including over-the-counter drugs, during the preceding month. Researchers recorded information on the drug name, reason for its use, and whether a physician prescribed it. From the pharmacy records, the drug names, prescription fill dates, quantities supplied, and the numbers of days’ supply were recorded. The level of agreement for ASA use across data sources was assessed using proportions of agreement and kappa coefficients. Results: Of 193 individuals interviewed, 86 reported the use of ASA, including 76 ASA users (88.4%) who said it was prescribed by a physician. Pharmacy medication records indicated that there were 74 users of ASA. The proportion of agreement for ASA use was 93.8%, and kappa coefficient was 0.87 (95% confidence interval: 0.80-0.94). The sensitivity, specificity, and positive predictive value of the pharmacy data were all high. Conclusions: A large proportion of ASA use is documented in pharmacy records in Quebec. Thus, the information regarding ASA use in pharmacy records is reliable. This result may not be reproducible in other settings where pharmaceutical reimbursement rules are different. This article is open to POST-PUBLICATION REVIEW. Registered readers (see “For Readers”) may comment by clicking on ABSTRACT on the issue’s contents page.

Impact of prior authorization for asthma medications on the use of emergency health services: a retrospective cohort study among newly diagnosed patients with asthma

BACKGROUND

A prior authorization process to limit the nonoptimal use of medications combining inhaled corticosteroids and long-acting bronchodilators was introduced in the province of Québec, Canada, on October 1, 2003.

OBJECTIVE

We assessed the impact of this administrative measure on the rate of asthma-related emergency department (ED) visits and hospitalizations.

METHODS

A retrospective cohort study was conducted using Régie de l'assurance maladie du Québec administrative databases. We identified all persons aged 6 to 44 years with an incident asthma diagnosis in the 2-year periods preceding (October 1, 2001-September 30, 2003) and following (October 1, 2003-September 30, 2005) the introduction of the process. Children aged < or = 5 years at the time of the first encountered diagnosis were excluded because it is difficult to make an objective asthma diagnosis until 6 years of age. People aged > or = 45 years at the time of the first encountered diagnosis were also excluded to avoid the inclusion of persons who might also have had chronic obstructive pulmonary disease. Two groups were created based on their prescription drug insurance (private or public). Publicly insured persons were considered exposed to the process while privately insured persons were considered not exposed. Cox proportional hazards regression was used to assess, for each insurance group, the hazard ratio (HR) for an asthma-related first hospitalization or ED visit between the 2 periods. The use of medication, quality of life, and visits to physicians' offices were not considered in the analysis. The interaction between group and period was assessed to test whether the change in risk between the preprocess and postprocess periods differed by insurance group; statistical models were adjusted for sex, age, region, presence of a comorbidity other than asthma, and discipline of diagnosing physician.

RESULTS

There were 47,579 publicly insured persons and 93,177 privately insured persons with incident asthma during the study period. The risk of an asthma-related first hospitalization or ED visit remained unchanged in the 2 periods evaluated among both the publicly insured (adjusted HR, 0.95 [95% CI, 0.88-1.03]) and the privately insured (adjusted HR, 1.03 [95% CI, 0.96-1.03]). The change in risk between the preprocess and postprocess periods was not significantly different between insurance groups.

CONCLUSIONS

The prior authorization process introduced to limit the nonoptimal use of combination products (formoterol/budesonide and salmeterol/fluticasone) had no apparent impact on first asthma-related hospitalization or ED visit in these patients newly diagnosed with asthma who were covered by Québec's public prescription drug insurance plan.

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.