Interventions for enhancing medication adherence

The effectiveness of interventions using electronic reminders to improve adherence to chronic medication: a systematic review of the literature

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

Thirteen studies met the inclusion criteria. Four studies evaluated short message service (SMS) reminders, seven audiovisual reminders from electronic reminder devices (ERD), and two pager messages. Best evidence synthesis revealed evidence for the effectiveness of electronic reminders, provided by eight (four high, four low quality) studies showing significant effects on patients' adherence, seven of which measured short-term effects (follow-up period <6 months). Improved adherence was found in all but one study using SMS reminders, four studies using ERD and one pager intervention. In addition, one high quality study using an ERD found subgroup effects.

CONCLUSION

This review provides evidence for the short-term effectiveness of electronic reminders, especially SMS reminders. However, long-term effects remain unclear.

A new taxonomy for describing and defining adherence to medications

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 conceptualized, 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 April 2009. The objective was to identify the different conceptual approaches to adherence research. Definitions were analyzed 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.

An explanatory randomised controlled trial of a nurse-led, consultation-based intervention to support patients with adherence to taking glucose lowering medication for type 2 diabetes

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 HbA_1c≥7.5% (58 mmol/mol), 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 July 1, 2006 and November 30, 2008 in 13 British general practices (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% confidence interval 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

Accuracy of measures of medication adherence in a cholesterol-lowering regimen

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.

A systematic review of barriers to medication adherence in the elderly: looking beyond cost and regimen complexity

BACKGROUND

Medication nonadherence is a common problem among the elderly.

OBJECTIVE

To conduct a systematic review of the published literature describing potential nonfinancial barriers to medication adherence among the elderly.

METHODS

The PubMed and PsychINFO databases were searched for articles published in English between January 1998 and January 2010 that (1) described "predictors," "facilitators," or "determinants" of medication adherence or that (2) examined the "relationship" between a specific barrier and adherence for elderly patients (ie, ≥65 years of age) in the United States. A manual search of the reference lists of identified articles and the authors' files and recent review articles was conducted. The search included articles that (1) reviewed specific barriers to medication adherence and did not solely describe nonmodifiable predictors of adherence (eg, demographics, marital status), (2) were not interventions designed to address adherence, (3) defined adherence or compliance and specified its method of measurement, and (4) involved US participants only. Nonsystematic reviews were excluded, as were studies that focused specifically on people who were homeless or substance abusers, or patients with psychotic disorders, tuberculosis, or HIV infection, because of the unique circumstances that surround medication adherence for each of these populations.

RESULTS

Nine studies met inclusion criteria for this review. Four studies used pharmacy records or claims data to assess adherence, 2 studies used pill count or electronic monitoring, and 3 studies used other methods to assess adherence. Substantial heterogeneity existed among the populations studied as well as among the measures of adherence, barriers addressed, and significant findings. Some potential barriers (ie, factors associated with nonadherence) were identified from the studies, including patient-related factors such as disease-related knowledge, health literacy, and cognitive function; drug-related factors such as adverse effects and polypharmacy; and other factors including the patient-provider relationship and various logistical barriers to obtaining medications. None of the reviewed studies examined primary nonadherence or nonpersistence.

CONCLUSION

Medication nonadherence in the elderly is not well described in the literature, despite being a major cause of morbidity, and thus it is difficult to draw a systematic conclusion on potential barriers based on the current literature. Future research should focus on standardizing medication adherence measurements among the elderly to gain a better understanding of this important issue.

Osteoporosis telephonic intervention to improve medication regimen adherence: a large, pragmatic, randomized controlled trial

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 telephone-based counseling program rooted in motivational interviewing to improve adherence to a medication regimen for osteoporosis.

METHODS

We conducted a 1-year randomized controlled clinical trial. Participants were recruited from a large pharmacy benefits program for Medicare beneficiaries. All potentially eligible individuals had been newly prescribed a medication for osteoporosis. Consenting participants were randomized to a program of telephone-based counseling (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 = .07, Kruskal-Wallis test). There were no differences in self-reported fractures.

CONCLUSION

In this randomized controlled trial, we did not find a statistically significant improvement in adherence to an osteoporosis medication regimen using a telephonic motivational interviewing intervention.

Adherence to varenicline among African American smokers: an exploratory analysis comparing plasma concentration, pill count, and self-report

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 self-report 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 randomized 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 < .05) were found between plasma varenicline concentration and pill count (r = .56), 3-day recall (r = .46), and VAS (r = .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 = .01) and had 88% sensitivity (95% CI = 75.0-95.0) and 80% specificity (95% CI = 30.0-99.0) 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 maximize smoking cessation pharmacotherapy use and improve abstinence rates.

Medication adherence in the asthmatic child and adolescent

Asthma is a common inflammatory condition affecting more than 7 million children in the United States alone, and tens of millions more globally. Despite effective preventive medications, medication nonadherence in children and adolescents is alarmingly high. Nonadherence can result in poor asthma control, which leads to decreased quality of life, lost productivity, increased health care utilization, and even the risk of death. Nonadherence in children and adolescents deserves special attention because they face unique barriers to adherence that change with age. Young children depend on adults for the delivery of asthma care, and their care is strongly influenced by parental motivation and attitudes and the home environment. As these children enter adolescence, they typically assume responsibility for their asthma care at the same time that they are claiming their independence and possibly experimenting with high-risk behaviors. Morbidity and mortality, as well as nonadherence, appear to be greatest among adolescents and minority children. Although no perfect tool for measuring adherence exists, objective methods, such as electronic monitoring, can provide valuable information to health care providers. Beyond asthma self-management and education, no specific resource-heavy adherence interventions have proven consistently helpful. However, large-scale, well-designed studies on this subject are lacking. In light of the fact that nonadherence is a potentially modifiable factor that impacts on morbidity and mortality, it is worth pursuing further research to determine better interventions. It is likely, however, that no one answer exists, and interventions will need to be tailored to specific at-risk populations.

A multifactorial intervention to improve blood pressure control in co-existing diabetes and kidney disease: a feasibility randomized controlled trial

AIMS

The aim of this study was to test the feasibility and impact of an intervention consisting of self-monitored blood pressure, medicine review, a Digital Versatile Disc, and motivational interviewing telephone calls to help people with diabetes and kidney disease improve their blood pressure control and adherence to prescribed medications.

BACKGROUND

People with co-existing diabetes, kidney disease and hypertension require multiple medications to manage their health. About 50% of people are non-adherent to their prescribed medications with non-adherence increasing in the presence of chronic conditions.

DESIGN

Randomized controlled trial.

METHODS

Patients aged ≥18 years with diabetes, chronic kidney disease and systolic hypertension were recruited from nephrology and diabetes outpatients' clinics of an Australian metropolitan hospital between 2008-2009. Participants were randomly allocated on a 1:1 basis to one of two groups in a randomized controlled trial: the intervention delivered over 3 months (n = 39) and usual care (n = 41), with follow-up at 3, 6 and 9 months postintervention. People collecting data and assessing outcomes were blinded to group assignment.

RESULTS

  Seventy-five participants completed the study. The intervention was acceptable and feasible for this cohort. There were no statistically significant differences between groups, although the mean systolic blood pressure reduction in the intervention group (n = 36) was -6·9 mmHg 95% CI (-13·8, -0·02) at 9 months postintervention.

CONCLUSION

The study was feasible and statistically significant differences may be determinable in a larger sample to overcome the variability between groups, paying attention to recommendations for further research.

TRIAL REGISTRATION

  The trial was prospectively registered with the Australian and New Zealand Clinical Trials Register (ACTRN12607000044426).

Investigating adherence promoters in evidence-based mental health interventions with children and adolescents

The effectiveness of Evidence-Based Practice (EBP) interventions in child and adolescent mental health is undermined by poor client adherence to treatment protocols. To counter this trend, adherence promoters, supplemental interventions to facilitate client adherence to treatment protocols, have evolved to increase adherence. This study investigates patterns of adherence promoting interventions employed in conjunction with RCT of interventions for child and adolescent mental health problems. An 85 question survey on adherence promoters was sent to 85 researchers who published randomized controlled trials on three psychosocial interventions (Cognitive Behavioral Therapies (CBT), Interpersonal Therapy (IPT), and Psychoeducational (PE)) in the area of child and adolescent mental health, between January 2000 and March 31, 2008. Forty-six (54%) researchers completed the survey. Most researchers reported using multiple adherence promoting interventions throughout the duration of their studies. The intensity of adherence promoting efforts was increased for interventions targeting disruptive behavior disorders and for family based interventions. On average, respondents reported using little more than one promoter per session and devoting approximately 12 min per session on all adherence promoters. Clinical researchers expend considerable resources in active efforts to promote adherence to treatment among research participants. Findings of this study support best practice literature on adherence promotion and open new avenues for research into the adherence to evidence-based interventions for child and adolescent mental health problems.

The role of prospective memory in medication adherence: a review of an emerging literature

Although neurocognitive impairment is an established risk factor for medication nonadherence, standard neurocognitive tests developed for clinical purposes may not fully capture the complexities of non-adherence behavior or effectively inform theory-driven interventions. Prospective memory, an innovative cognitive construct describing one's ability to remember to do something at a later time, is an understudied factor in the detection and remediation of medication non-adherence. This review orients researchers to the construct of prospective memory, summarizes empirical evidence for prospective memory as a risk factor for non-adherence, discusses the relative merits of current measurement techniques, and highlights potential prospective memory-focused intervention strategies. A comprehensive literature review was conducted of published empirical studies investigating prospective memory and medication adherence. Overall, reviewed studies suggest that prospective memory is an important component of medication adherence, providing incremental ecological validity over established predictors. Findings indicate that prospective memory-based interventions might be an effective means of improving adherence.

Recent educational interventions for improvement of asthma medication adherence

Poor adherence to asthma medication treatment is a dilemma as it decreases the chance of achieving and maintaining a proper asthma control. Another dilemma is that there seems to be a small range of functional interventions that enhance adherence to long-term medication treatments. The aim was to review the last five years of published educational interventions for improving adherence to asthma medication. Through systematic database searches 20 articles were identified, which matched the inclusion criteria and described educational interventions to improve asthma self-management including adherence. The current review showed that addressing unintentional non-adherence in terms of incorrect inhaler technique by recurrent education improved the technique among many patients, but not among all. Phoning patients, as a means to remove medication beliefs as adherence barriers, seemed to be an effective educational strategy, shown as increased adherence. Involving patients in treatment decisions and individualising or tailoring educational support also seemed to have favourable effect on adherence. To conclude, addressing specific adherence barriers such as poor inhaler technique or medication beliefs could favour adherence. To change adherence behavior, the current review proposes that educational adherence support should be a collaborative effort between the patient and the health-care professional based on each individual patient's needs and patient factors, including elements such as personality traits.

A randomized controlled trial of positive-affect intervention and medication adherence in hypertensive African Americans

BACKGROUND

Poor adherence explains poor blood pressure (BP) control; however African Americans suffer worse hypertension-related outcomes.

METHODS

This randomized 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 hypertension self-management workbook, a behavioral 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 self-affirmation. 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 =.049). The within-group reduction in systolic BP (2.14 mm Hg vs 2.18 mm Hg; P = .98) and diastolic BP (-1.59 mm Hg vs -0.78 mm Hg; P = .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. Trial Registration clinicaltrials.gov Identifier: NCT00227175.

Health behavior change: can genomics improve behavioral adherence?

The National Human Genome Research Institute recommends pursuing "genomic information to improve behavior change interventions" as part of its strategic vision for genomics. The limited effectiveness of current behavior change strategies may be explained, in part, by their insensitivity to individual variation in adherence responses. The first step in evaluating whether genomics can inform customization of behavioral recommendations is evidence reviews to identify adherence macrophenotypes common across behaviors and individuals that have genetic underpinnings. Conceptual models of how biological, psychological, and environmental factors influence adherence also are needed. Researchers could routinely collect biospecimens and standardized adherence measurements of intervention participants to enable understanding of genetic and environmental influences on adherence, to guide intervention customization and prospective comparative effectiveness studies.

Effective discharge communication in the emergency department

Communication at discharge is an important part of high-quality emergency department (ED) care. This review describes the existing literature on patient understanding and implementation of discharge instructions, discusses previous interventions aimed at improving the discharge process, and recommends best practices and future research. MEDLINE and Cochrane databases were searched, using combinations of key terms. Literature from both the adult and pediatric ED populations was reviewed. Multiple reports have shown deficient comprehension at discharge, with patients or parents frequently unable to report their diagnosis, management plan, or reasons to return. Interventions to improve discharge communication have been, at best, moderately successful. Patients need structured content, presented verbally, with written and visual cues to enhance recall. Written instructions need to be provided in the patient's language and at an appropriate reading level. Understanding should be confirmed before the patient leaves the ED. Further research is needed to describe the optimal content, channel, and timing for the ED discharge process and the relationship between discharge process and outcomes.

Positive impact of hepatitis C virus (HCV) treatment on antiretroviral treatment adherence in human immunodeficiency virus-HCV coinfected patients: one more argument for expanded access to HCV treatment for injecting drug users

AIMS

Treatment for the hepatitis C virus (HCV) may be delayed significantly in human immunodeficiency virus (HIV)/HCV coinfected patients on antiretroviral treatment (ART) for fear that its burden could compromise ART adherence. However, the effect such treatment has on ART adherence in observational settings remains largely unknown. Longitudinal data were used to investigate the relationship between initiating HCV treatment and adherence to ART in HIV/HCV coinfected patients.

DESIGN

The French national prospective cohort of patients coinfected with HIV and HCV (ANRS-CO-13-HEPAVIH) is a multi-centre cohort.

SETTING

Seventeen out-patient hospital services delivering HIV and HCV care in France.

PARTICIPANTS

HIV/HCV coinfected patients on ART (n = 593 patients, 976 visits).

MEASUREMENTS

Self-administered questionnaires and medical records. A mixed logistic regression model based on generalized estimates equations (GEE) to identify factors associated with non-adherence to ART.

FINDINGS

Among the 593 patients, 36% were classified as non-adherent to ART at the enrolment visit and 12% started HCV treatment during follow-up. ART adherence was not associated statistically with HCV treatment initiation. The proportion of patients maintaining adherence or becoming adherent to ART for those starting HCV treatment was higher than in the rest of the sample (P = 0.07). After multiple adjustment for known correlates, such as poor housing conditions, binge drinking, recent drug use and depressive symptoms, patients who initiated HCV treatment were less likely to be non-adherent to ART [odds ratio (95% confidence interval) = 0.41 (0.24-0.71)].

CONCLUSIONS

Engaging human immunodeficiency virus/hepatitis C virus coinfected individuals in hepatitis C virus treatment is associated with high adherence to antiretroviral treatment. Physicians should prioritize hepatitis C virus treatment as part of a multi-disciplinary approach.

Improving patient-physician dialog: commentary on the results of the MS Choices survey

Achieving good long- and short-term adherence to treatment for chronic diseases is important if patients are to gain the full benefits of treatment. Several barriers to adherence in multiple sclerosis (MS) have been identified and the healthcare team should work with patients to help them to overcome these obstacles. The MS Choices survey explored patient and physician perspectives on key aspects of MS diagnosis, treatment adherence, and disease management with the aim of improving understanding of the factors that influence patient behavior regarding treatment adherence. The survey found some important differences between patient and physician responses and here these findings are discussed in the context of personal clinical experience. Further, the possible implications of these findings for routine practice have been considered, and strategies that should be employed by MS physicians and nurses to help patients to adhere to their prescribed treatment are suggested.

Secondary analysis of electronically monitored medication adherence data for a cohort of hypertensive African-Americans

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 capitalize more fully on their richness.

METHODS

Recently developed adaptive statistical modeling methods were used to analyze EMD data collected with medication event monitoring system (MEMS™) caps in a clinical trial testing the effects of motivational interviewing on adherence to 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, categorized 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.

CONCLUSION

Adaptive statistical modeling methods can provide novel insights into patients' medication-taking behavior, which can inform development of innovative approaches for tailored interventions to improve medication adherence.

The moderating effect of adherence-promoting interventions with clients on evidence-based practices for children and adolescents with mental health problems

Poor adherence of children and adolescents to evidence-based psychosocial interventions remains a fundamental impediment to treatment effectiveness. To maintain client adherence, researchers and clinicians have employed a number of adherence-promoting strategies, from telephone calls and letters to providing transportation costs and child care to motivational enhancement therapies. However, the influence of adherence promoters on intervention outcomes has not been reported. This study examined the moderating effect of adherence-promoting strategies in a survey and meta-analysis of randomized clinical trials of cognitive behavioral treatments, interpersonal therapy, and psycho-education for children and adolescents with mental health problems (k = 33). Results indicated the type and intensity of adherence promoters' moderated study effect sizes according to client characteristics (age, gender, diagnosis). Preliminary findings suggest that males had higher effect sizes when more intensive adherence-promoting efforts were employed. Adherence-promoting efforts were associated with lower effect sizes for youths who were diagnosed with externalizing disorders. Results of this study suggest directions for future research to clarify clinical guidelines to maximize retention in evidence-based psychotherapy.

GRAND: the German retrospective cohort analysis on compliance and persistence and the associated risk of fractures in osteoporotic women treated with oral bisphosphonates

This database analysis of over 4,000 German women prescribed oral bisphosphonates between December 2004 and November 2007 showed that compliance and persistence with oral bisphosphonates in German women with osteoporosis were inadequate.

INTRODUCTION

GRAND is a database analysis designed to investigate persistence and compliance with oral bisphosphonate regimens, and their association with fracture incidence, in women with osteoporosis.

METHODS

Diagnostic, treatment and fracture data were obtained from the IMS Disease Analyzer patient database in Germany. Women with osteoporosis prescribed one of six specified oral bisphosphonates between December 2004 and November 2007 with no similar prescription for at least 1 year beforehand were eligible for analysis. Those treated with intravenous bisphosphonates were excluded. Persistence (prescription refill gap of ≤ 30 days or change of treatment frequency) and compliance (medication possession ratio) were measured for 2 years from therapy start.

RESULTS

Data from 4,147 women were evaluable, with a median oral bisphosphonate treatment duration of 145.5 days. Persistence rates after 1 and 2 years were 27.9% and 12.9%, respectively, and 66.3% of women were compliant. As expected, persistence rates were higher when the refill gap was increased to 60 or 90 days. No significant differences in 1-year persistence between patients on weekly or monthly treatment regimens were observed (28.6% and 29.4%, respectively), although 1-year persistence with daily treatment was only 7.2%. After 24 months of therapy, compliant women had fewer fractures than non-compliant women (88.1% and 85.0% fracture-free, respectively; p = 0.0147). In multivariate Cox regression analysis, treatment compliance was the only factor that significantly decreased fracture risk (p = 0.0034).

CONCLUSIONS

Compliance and persistence with oral bisphosphonates in German women with osteoporosis were inadequate. Better compliance and persistence can prevent fractures in these women.

Adherence with drug therapy in pregnancy

Available information suggests that nonadherence with medication is a common problem in pregnant women. Not taking prescribed drugs may have potentially negative consequences as patients may not achieve their therapeutic goal. In addition to the many factors that may influence medication-taking behaviour in the general population, unique challenges are encountered in pregnant women as both maternal health and fetal well-being must be considered. On the one hand, pregnant women may be motivated to keep their underlying disease under control, while, on the other hand, fear and anxiety regarding the potential harmful effects of their medication on their unborn child may result in poor adherence with needed medication. Providing evidence-based information, ideally preconceptually, regarding the effects of their medication during pregnancy may be important in avoiding misperceptions that lead to nonadherence.

The landscape of knowledge translation interventions in cancer control: what do we know and where to next? A review of systematic reviews

Background

Effective implementation strategies are needed to optimize advancements in the fields of cancer diagnosis, treatment, survivorship, and end-of-life care. We conducted a review of systematic reviews to better understand the evidentiary base of implementation strategies in cancer control.

Methods

Using three databases, we conducted a search and identified English-language systematic reviews published between 2005 and 2010 that targeted consumer, professional, organizational, regulatory, or financial interventions, tested exclusively or partially in a cancer context (primary focus); generic or non-cancer-specific reviews were also considered. Data were extracted, appraised, and analyzed by members of the research team, and research ideas to advance the field were proposed.

Results

Thirty-four systematic reviews providing 41 summaries of evidence on 19 unique interventions comprised the evidence base. AMSTAR quality ratings ranged between 2 and 10. Team members rated most of the interventions as promising and in need of further research, and 64 research ideas were identified.

Conclusions

While many interventions show promise of effectiveness in the cancer-control context, few reviews were able to conclude definitively in favor of or against a specific intervention. We discuss the complexity of implementation research and offer suggestions to advance the science in this area.

Interventions to improve adherence to antiretroviral therapy in children with HIV infection

BACKGROUND

Achieving and maintaining high levels of medication adherence are required to achieve the full benefits of antiretroviral therapy (ART), yet suboptimal adherence among children is common in both developed and developing countries.

OBJECTIVES

To conduct a systematic review of the literature of evaluations of interventions for improving paediatric ART adherence.

SEARCH METHODS

We created a comprehensive search strategy in order to identify all studies relevant to this topic. In July 2010, we searched the following electronic databases: EMBASE, MEDLINE, PsycINFO, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, LILACS, Web of Science, Web of Social Science, NLM Gateway (supplemented by a manual search of the most recent abstracts not included in the Gateway database). We searched abstracts from the International AIDS Conference from 2002 to 2010, the International AIDS Society Conference on Pathogenesis, Treatment and Prevention from 2003 to 2009, and from the Conference on Retroviruses and Opportunistic Infections from 1997 to 2010. We used search strategies determined by the Cochrane Review Group on HIV/AIDS. We also contacted researchers who work in this field and checked reference lists of related systematic reviews and of all included studies.

SELECTION CRITERIA

Randomised and non-randomised controlled trials of interventions to improve adherence to ART among children and adolescents (age ≤18 years) were included. Studies had to report adherence to ART as an outcome.

DATA COLLECTION AND ANALYSIS

After one author performed an initial screening to exclude citations that did not meet the inclusion criteria, two authors did a second screening of those citations that likely met the criteria. For all articles that passed the second screening, full articles were pulled in order to make a final determination. Two authors then extracted data and graded methodological quality independently. Differences were resolved through discussion.

MAIN RESULTS

Four studies met the inclusion criteria. No single intervention was evaluated by more than one trial. Two studies were conducted in low-income countries. Two studies were randomised controlled trials (RCT), and two were non-randomised trials. An RCT of a home-based nursing programme showed a positive effect of the intervention on knowledge and medication refills (p=.002), but no effect on CD4 count and viral load. A second RCT of caregiver medication diaries showed that the intervention group had fewer participants reporting no missed doses compared to the control group (85% vs. 92%, respectively), although this difference was not statistically significant (p=.08). The intervention had no effect on CD4 percentage or viral load. A non-randomised trial of peer support group therapy for adolescents demonstrated no change in self-reported adherence, yet the percentage of participants with suppressed viral load increased from 30% to 80% (p=.06). The second non-randomised trial found that the percentage of children achieving >80% adherence was no different between children on a lopinavir-ritonavir (LPV/r) regimen compared to children on a non-nucleoside reverse transcriptase regimen (p=.781). However, the proportion of children achieving virological suppression was significantly greater for children on the LPV/r regimen than for children on the NNRTI-containing regimen (p=.002).

AUTHORS' CONCLUSIONS

A home-based nursing intervention has the potential to improve ART adherence, but more evidence is needed. Medication diaries do not appear to have an effect on adherence or disease outcomes. Two interventions, an LPV/r-containing regimen and peer support therapy for adolescents, did not demonstrate improvements in adherence, yet demonstrated greater viral load suppression compared to control groups, suggesting a different mechanism for improved health outcomes. Well-designed evaluations of interventions to improve paediatric adherence to ART are needed.

Self-management skills in adolescents with chronic rheumatic disease: A cross-sectional survey

BACKGROUND

For adolescents with a diagnosis of lifelong chronic illness, mastery of self-management skills is a critical component of the transition to adult care. This study aims to examine self-reported medication adherence and self-care skills among adolescents with chronic rheumatic disease.

METHODS

Cross-sectional survey of 52 adolescent patients in the Pediatric Rheumatology Clinic at UCSF. Outcome measures were self-reported medication adherence, medication regimen knowledge and independence in health care tasks. Predictors of self-management included age, disease perception, self-care agency, demographics and self-reported health status. Bivariate associations were assessed using the Student's t-test, Wilcoxon rank sum test and Fisher exact test as appropriate. Independence in self-management tasks were compared between subjects age 13-16 and 17-20 using the chi-squared test.

RESULTS

Subjects were age 13-20 years (mean 15.9); 79% were female. Diagnoses included juvenile idiopathic arthritis (44%), lupus (35%), and other rheumatic conditions (21%). Mean disease duration was 5.3 years (SD 4.0). Fifty four percent reported perfect adherence to medications, 40% reported 1-2 missed doses per week, and 6% reported missing 3 or more doses. The most common reason for missing medications was forgetfulness. Among health care tasks, there was an age-related increase in ability to fill prescriptions, schedule appointments, arrange transportation, ask questions of doctors, manage insurance, and recognize symptoms of illness. Ability to take medications as directed, keep a calendar of appointments, and maintain a personal medical file did not improve with age.

CONCLUSIONS

This study suggests that adolescents with chronic rheumatic disease may need additional support to achieve independence in self-management.

A randomized trial of an intervention to improve use and adherence to effective coronary heart disease prevention strategies

Background

Efficacious strategies for the primary prevention of coronary heart disease (CHD) are underused, and, when used, have low adherence. Existing efforts to improve use and adherence to these efficacious strategies have been so intensive that they are impractical for clinical practice.

Methods

We conducted a randomized trial of a CHD prevention intervention (including a computerized decision aid and automated tailored adherence messages) at one university general internal medicine practice. After obtaining informed consent and collecting baseline data, we randomized patients (men and women age 40-79 with no prior history of cardiovascular disease) to either the intervention or usual care. We then saw them for two additional study visits over 3 months. For intervention participants, we administered the decision aid at the primary study visit (1 week after baseline visit) and then mailed 3 tailored adherence reminders at 2, 4, and 6 weeks. We assessed our outcomes (including the predicted likelihood of angina, myocardial infarction, and CHD death over 10 years (CHD risk) and self-reported adherence) between groups at 3 month follow-up. Data collection occurred from June 2007 through December 2009. All study procedures were IRB approved.

Results

We randomized 160 eligible patients (81 intervention; 79 control) and followed 96% to study conclusion. Mean predicted CHD risk at baseline was 11.3%. The intervention increased self-reported adherence to chosen risk reducing strategies by 25 percentage points (95% CI 8% to 42%), with the biggest effect for aspirin. It also changed predicted CHD risk by -1.1% (95% CI -0.16% to -2%), with a larger effect in a pre-specified subgroup of high risk patients.

Conclusion

A computerized intervention that involves patients in CHD decision making and supports adherence to effective prevention strategies can improve adherence and reduce predicted CHD risk.

Clinical trials registration number

ClinicalTrials.gov: NCT00494052

[Compliance enhancement in drug therapy : opportunities and limitations]

In the execution of their pharmacotherapy, many patients deviate from the prescribed treatment regimen. Reasons for noncompliance can be diverse and range from forgetfulness of the patient to attributes of the health care system. Besides increased health care costs, poor compliance causes both an endangerment to the patient and poor health outcomes. Therefore, it is crucial that compliance enhancement receives high priority. In the beginning of this process, noncompliance must be detected in daily practice. Moreover, various methods can provide valuable information about medication-taking behavior, time patterns, and reasons for noncompliance. Based on this assessment, appropriate measures to enhance compliance can be taken. In this article, the opportunities and limitations of compliance enhancement are discussed.

Understanding minority patients' beliefs about hypertension to reduce gaps in communication between patients and clinicians

The authors' objective was to gain a better understanding of minority patients' beliefs about hypertension and to use this understanding to develop a model to explain gaps in communication between patients and clinicians. Eighty-eight hypertensive black and Latino adults from 4 inner-city primary care clinics participated in focus groups to elucidate views on hypertension. Participants believed that hypertension was a serious illness in need of treatment. Participants' diverged from the medical model in their beliefs about the time-course of hypertension (believed hypertension was intermittent); causes of hypertension (believed stress, racism, pollution, and poverty were the important causes); symptoms of hypertension (believed hypertension was primarily present when symptomatic); and treatments for hypertension (preferred alternative treatments that reduced stress over prescription medications). Participants distrusted clinicians who prioritized medications that did not directly address their understanding of the causes or symptoms of hypertension. Patients' models of understanding chronic asymptomatic illnesses such as hypertension challenge the legitimacy of lifelong, pill-centered treatment. Listening to patients' beliefs about hypertension may increase trust, improve communication, and encourage better self-management of hypertension.

Individualised patient care as an adjunct to standard care for promoting adherence to ocular hypotensive therapy: an exploratory randomised controlled trial

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 according to need. The primary outcome was refill adherence, measured by collating prescription and dispensing data for 12 months. Secondary outcomes included self-reported 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. Self-report 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.

CONCLUSION

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.

Implementation of patient education at first and second dispensing of statins in Dutch community pharmacies: the sequel of a cluster randomized trial

Background

As a result of the previous part of this trial, many patients with cardiovascular disease were expected to receive a statin for the first time. In order to provide these patients with comprehensive information on statins, as recommended by professional guidance, education at first and second dispensing of statins had to be implemented. This study was designed to assess the effectiveness of an intensive implementation program targeted at pharmacy project assistants on the frequency of providing education at first dispensing (EAFD) and education at second dispensing (EASD) of statins in community pharmacies.

Methods

The participating community pharmacies were clustered on the basis of local collaboration, were numbered by a research assistant and subsequently an independent statistician performed a block randomization, in which the cluster size (number of pharmacies in each cluster) was balanced. The pharmacies in the control group received a written manual on the implementation of EAFD and EASD; the pharmacies in the intervention group received intensive support for the implementation. The impact of the intensive implementation program on the implementation process and on the primary outcomes was examined in a random coefficient logistic regression model, which took into account that patients were grouped within pharmacy clusters.

Results

Of the 37 pharmacies in the intervention group, 17 pharmacies (50%) provided EAFD and 12 pharmacies (35.3%) provided EASD compared to 14 pharmacies (45.2%, P = 0.715) and 12 pharmacies (38.7%, P = 0.899), respectively, of the 34 pharmacies in the control group. In the intervention group a total of 72 of 469 new statin users (15.4%) received education and 49 of 393 patients with a second statin prescription (12.5%) compared to 78 of 402 new users (19.4%, P = 0.944) and 35 of 342 patients with a second prescription (10.2%, P = 0.579) in the control group.

Conclusion

The intensive implementation program did not increase the frequency of providing EAFD and EASD of statins in community pharmacies.

Trial Registration

clinicaltrials.gov NCT00509717

Medication adherence: emerging use of technology

PURPOSE OF REVIEW

Adherence to proven, effective medications remains low, resulting in high rates of clinical complications, hospital readmissions, and death. The use of technology to identify patients at risk and to target interventions for poor adherence has increased. This review focuses on research that tests these emerging technologies and evaluates the effect of technology-based adherence interventions on cardiovascular outcomes.

RECENT FINDINGS

Recent studies have evaluated technology-based interventions to improve medication adherence by using pharmaceutical databases, tailoring educational information to individual patient needs, delivering technology-driven reminders to patients and providers, and integrating in-person interventions with electronic alerts. Cellular phone reminders and in-home electronic technology used to communicate reminder messages have shown mixed results. Only one study has shown improvement in both adherence and clinical outcome. Current trials suggest that increasing automated reminders will complement but not replace the benefits seen with in-person communication for medication taking.

SUMMARY

Integration of in-person contacts with technology-driven medication adherence reminders, electronic medication reconciliation, and pharmaceutical databases may improve medication adherence and have a positive effect on cardiovascular clinical outcomes. Opportunities for providers to monitor the quality of care based on new adherence research are evolving and may be useful as standards for quality improvement emerge.

How do the attitudes and beliefs of older people and healthcare professionals impact on the use of multi-compartment compliance aids?: a qualitative study using grounded theory

BACKGROUND

Low adherence of older people to multiple medicine regimens is of widespread concern, and multi-compartment compliance aids are frequently supplied to older people in an attempt to improve their ability to take all their medicines at home. However, the evidence base for the use of such aids is very limited, and there is some evidence that they are used inappropriately.

OBJECTIVE

We aimed to determine how the attitudes and beliefs of older people and healthcare professionals impacted on the use of multi-compartment compliance aids by older people living at home.

METHOD

This was a qualitative study using grounded theory. Semi-structured interviews were conducted with 15 older people (mean age 82 [range 72-92] years) living independently in the community and receiving primary healthcare from two health service organizations in a large northern UK city. We then interviewed 17 healthcare professionals working in primary, secondary or intermediate care and involved in the provision of multi-compartment compliance aids.

RESULTS

Maintaining independence and remaining in control was important for all the older people interviewed, and professionals supported the view that this influenced patients' attitudes towards using their aid. Some patients saw the aids as helping to maintain independence, others as casting doubt on their independence. The aids were often issued without discussion with the patient. The patients largely agreed that the aids did not help with memory problems and that the decision to issue an aid could be seen as paternalistic. A minority of patients had difficulties using the aids.

CONCLUSIONS

Careful multi-disciplinary assessment of older people is required before a compliance aid is provided. The views of the older person must be considered and respected. Further research is required to produce an evidence base for the use of such aids in this group of people.

Management of patient adherence to medications: protocol for an online survey of doctors, pharmacists and nurses in Europe

Introduction It is widely recognised that many patients do not take prescribed medicines as advised. Research in this field has commonly focused on the role of the patient in non-adherence; however, healthcare professionals can also have a major influence on patient behaviour in taking medicines. This study examines the perceptions, beliefs and behaviours of healthcare professionals-doctors, pharmacists and nurses-about patient medication adherence. Methods and analysis This paper describes the study protocol and online questionnaire used in a cross-sectional survey of healthcare professionals in Europe. The participating countries include Austria, Belgium, France, Greece, The Netherlands, Germany, Poland, Portugal, Switzerland, Hungary, Italy and England. The study population comprises primary care and community-based doctors, pharmacists and nurses involved in the care of adult patients taking prescribed medicines for chronic and acute illnesses. Discussion Knowledge of the nature, extent and variability of the practices of healthcare professionals to support medication adherence could inform future service design, healthcare professional education, policy and research.

Suitability of measures of self-reported medication adherence for routine clinical use: a systematic review

BACKGROUND

There is a recognised need to build primary care medication adherence services which are tailored to patients' needs. Continuous quality improvement of such services requires a regular working method of measuring adherence in order to monitor effectiveness. Self report has been considered the method of choice for clinical use; it is cheap, relatively unobtrusive and able to distinguish between intentional and unintentional non-adherence, which have different underlying causes and therefore require different interventions. A self report adherence measure used in routine clinical practice would ideally be brief, acceptable to patients, valid, reliable, have the ability to distinguish between different types of non-adherence and be able to be completed by or in conjunction with carers where necessary.

METHODS

We systematically reviewed the literature in order to identify self report adherence measures currently available which are suitable for primary care and evaluate the extent to which they met the criteria described above. We searched the databases Medline, Embase, International Pharmaceutical Abstracts, Pharmline, CINAHL, PsycINFO and HaPI to identify studies reporting the development, validation or reliability of generic adherence measures. One reviewer screened all abstracts and assessed all relevant full text articles obtained and a second reviewer screened/assessed 10% to check reliability.

RESULTS

Fifty eight measures were identified. While validation data were presented in support of the vast majority of self reported measures (54/58), data for a relatively small number of measures was presented for reliability (16/58) and time to complete (3/58). Few were designed to have the ability to be completed by or in conjunction with carers and few were able to distinguish between different types of non-adherence, which limited their ability be used effectively in the continuous improvement of targeted adherence enhancing interventions. The data available suggested that patients find it easier to estimate general adherence than to report a specific number of doses missed. Visual analogue scales can be easier for patients than other types of scale but are not suitable for telephone administration.

CONCLUSIONS

There is a need for a measure which can be used in the routine continual quality monitoring of adherence services.

Development of a taxonomy of interventions to organise the evidence on consumers' medicines use

OBJECTIVE

Safe, effective (quality) medicines use remains problematic worldwide, yet consumers' medicines use research is not well organised. This creates difficulties for decision makers in identifying evidence or research gaps and in understanding how or why interventions work. Developing a conceptual framework for this evidence helps to organise the evidence for application and raise awareness of the range of possible interventions.

METHODS

To scope the aims of interventions to improve consumers' medicines use we searched for and iteratively analysed policy documents, systematic reviews, and an existing consumer-oriented communication intervention taxonomy.

RESULTS

We identified eight recurrent themes associated with the purpose of the interventions: to inform and educate; to support behaviour change; to teach skills; to facilitate communication and/or decision making; to support; to minimise risk and harms; to involve consumers at the system level; and to improve health care quality.

CONCLUSION

The taxonomy accommodates the complexity and diversity of interventions in this field, by focussing on the purposes of interventions, rather than the intervention type.

PRACTICE IMPLICATIONS

Currently used to organise the evidence on consumers' medicines use, the taxonomy provides a conceptual and practical map of the evidence which will aid decision making and future research investment in the area.

Impact of recipients' socio-economic status on patient and graft survival after liver transplantation: the IsMeTT experience

AIM

We aimed to determine whether education level and socioeconomic status in a cohort of liver transplant recipients in the south of Italy were potential predictors of graft and patient survival.

METHODS

This retrospective study included 221 liver transplant recipients at Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione between January 2006 and September 2009. Donor gender and age, cold ischaemic time, extended criteria donors, recipient age, gender, body mass index, primary aetiology, Model for End-Stage Liver Disease score, co-morbidities, patient health score assessed on the basis of clinical follow-up, highest level of education achieved, and socioeconomic status were collected and analysed.

RESULTS

Kaplan-Meier analysis of survival measured by education level and socioeconomic status showed a higher survival rate in patients with higher education level (p=0.04) and socioeconomic status (p=0.01). After adjusting for all covariables, results of the multivariate Cox regression analyses showed that only socioeconomic status remained an independent and significant predictor of overall survival (Hazard Ratio=0.16, p=0.03).

CONCLUSION

Patient survival after liver transplantation was influenced by low income, low educational level, and lack of access to quality health care. Prospective clinical studies are necessary to fully identify the impact of socioeconomic status on long-term health outcomes, and to propose an evidence-based guide to clinical intervention.

A systematic review of adherence-enhancing interventions in adolescents taking long-term medicines

PURPOSE

To assess the effectiveness of adherence-enhancing interventions (AEIs) aimed at adolescents (10-19-year-olds).

METHODS

An extensive search of seven bibliographic databases was conducted at the end of 2009 to identify comparative studies evaluating AEIs targeting adolescents. Data describing study characteristics and intervention effects on adherence to medicines or health outcomes were extracted and summarized using qualitative and quantitative methods.

RESULTS

A total of 17 AEIs were identified: 12 studies (70%) were conducted in the United States, 10 (59%) included adolescents with type 1 diabetes mellitus, and 14 (82%) considered the developmental tasks of adolescence. In all, 12 AEIs successfully improved outcome measures. Features of successful interventions included targeting AEIs to a narrow age range, including family in type 1 diabetes mellitus management, and improving access to care. Poor quality and underpowered studies limit the inferences drawn from this review.

CONCLUSIONS

More diverse and robust studies are needed to identify strategies to help adolescents manage medicines.

Depression and medication adherence in the treatment of chronic diseases in the United States: a meta-analysis

OBJECTIVE

To conduct a meta-analysis of the association between depression and medication adherence among patients with chronic diseases. Poor medication adherence may result in worse outcomes and higher costs than if patients fully adhere to their medication regimens.

DATA SOURCES

We searched the PubMed and PsycINFO databases, conducted forward searches for articles that cited major review articles, and examined the reference lists of relevant articles.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

We included studies on adults in the United States that reported bivariate relationships between depression and medication adherence. We excluded studies on special populations (e.g., substance abusers) that were not representative of the general adult population with chronic diseases, studies on certain diseases (e.g., HIV) that required special adherence protocols, and studies on interventions for medication adherence.

STUDY APPRAISAL AND SYNTHESIS METHODS

Data abstracted included the study population, the protocol, measures of depression and adherence, and the quantitative association between depression and medication adherence. Synthesis of the data followed established statistical procedures for meta-analysis.

RESULTS

The estimated odds of a depressed patient being non-adherent are 1.76 times the odds of a non-depressed patient, across 31 studies and 18,245 participants. The association was similar across disease types but was not as strong among studies that used pharmacy records compared to self-report and electronic cap measures.

LIMITATIONS

The meta-analysis results are correlations limiting causal inferences, and there is some heterogeneity among the studies in participant characteristics, diseases studied, and methods used.

CONCLUSIONS

This analysis provides evidence that depression is associated with poor adherence to medication across a range of chronic diseases, and we find a new potential effect of adherence measurement type on this relationship. Although this study cannot assess causality, it supports the importance that must be placed on depression in studies that assess adherence and attempt to improve it.

Use of secondary prevention drugs for cardiovascular disease in the community in high-income, middle-income, and low-income countries (the PURE Study): a prospective epidemiological survey

BACKGROUND

Although most cardiovascular disease occurs in low-income and middle-income countries, little is known about the use of effective secondary prevention medications in these communities. We aimed to assess use of proven effective secondary preventive drugs (antiplatelet drugs, β blockers, angiotensin-converting-enzyme [ACE] inhibitors or angiotensin-receptor blockers [ARBs], and statins) in individuals with a history of coronary heart disease or stroke.

METHODS

In the Prospective Urban Rural Epidemiological (PURE) study, we recruited individuals aged 35-70 years from rural and urban communities in countries at various stages of economic development. We assessed rates of previous cardiovascular disease (coronary heart disease or stroke) and use of proven effective secondary preventive drugs and blood-pressure-lowering drugs with standardised questionnaires, which were completed by telephone interviews, household visits, or on patient's presentation to clinics. We report estimates of drug use at national, community, and individual levels.

FINDINGS

We enrolled 153,996 adults from 628 urban and rural communities in countries with incomes classified as high (three countries), upper-middle (seven), lower-middle (three), or low (four) between January, 2003, and December, 2009. 5650 participants had a self-reported coronary heart disease event (median 5·0 years previously [IQR 2·0-10·0]) and 2292 had stroke (4·0 years previously [2·0-8·0]). Overall, few individuals with cardiovascular disease took antiplatelet drugs (25·3%), β blockers (17·4%), ACE inhibitors or ARBs (19·5%), or statins (14·6%). Use was highest in high-income countries (antiplatelet drugs 62·0%, β blockers 40·0%, ACE inhibitors or ARBs 49·8%, and statins 66·5%), lowest in low-income countries (8·8%, 9·7%, 5·2%, and 3·3%, respectively), and decreased in line with reduction of country economic status (p(trend)<0·0001 for every drug type). Fewest patients received no drugs in high-income countries (11·2%), compared with 45·1% in upper middle-income countries, 69·3% in lower middle-income countries, and 80·2% in low-income countries. Drug use was higher in urban than rural areas (antiplatelet drugs 28·7% urban vs 21·3% rural, β blockers 23·5%vs 15·6%, ACE inhibitors or ARBs 22·8%vs 15·5%, and statins 19·9%vs 11·6%; all p<0·0001), with greatest variation in poorest countries (p(interaction)<0·0001 for urban vs rural differences by country economic status). Country-level factors (eg, economic status) affected rates of drug use more than did individual-level factors (eg, age, sex, education, smoking status, body-mass index, and hypertension and diabetes statuses).

INTERPRETATION

Because use of secondary prevention medications is low worldwide-especially in low-income countries and rural areas-systematic approaches are needed to improve the long-term use of basic, inexpensive, and effective drugs.

FUNDING

Full funding sources listed at end of paper (see Acknowledgments).

Reminder packaging for improving adherence to self-administered long-term medications

BACKGROUND

Current methods of improving medication adherence for health problems are mostly complex, labour-intensive, and not reliably effective. Medication 'reminder packaging', which incorporates a date or time for a medication to be taken in the packaging, can act as a reminder to improve adherence. This review of reminder packaging is an update of our 2006 Cochrane review.

OBJECTIVES

The objective of this review was to determine the effects of reminder packaging aids for self-administered medication/s taken for at least one month, on adherence and other outcomes.

SEARCH STRATEGY

We updated searches of the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library Issue 9, 2010), MEDLINE, EMBASE, CINAHL and PsycINFO from the database start dates to September 2010. We searched Current Controlled Trials to identify trials in progress. We performed a cited reference search on the Science Citation Index to identify papers that had cited the original systematic review.We also searched the Internet, contacted packaging manufacturers, and checked abstracts from the Pharm-line database and reference lists from relevant articles. We did not apply any language restrictions.

SELECTION CRITERIA

We selected randomised controlled trials with at least 80% follow up. We intended to do a sensitivity analysis of those studies that analysed their data on an intention-to-treat basis. Included studies compared a reminder packaging device with no device, for participants taking self-administered medications for at least one month.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed studies for inclusion, assessed quality, and extracted data from included studies. Where considered appropriate, data were combined for meta-analysis, or were reported and discussed in a narrative.

MAIN RESULTS

We included twelve studies containing data on 2196 participants; four of these studies were newly included in this 2011 update of our 2006 Cochrane review.Six intervention groups in four trials provided data on the percentage of pills taken. Reminder packaging increased the percentage of pills taken (mean difference (MD) 11% (95% confidence interval (CI) 6% to 17%)). Notable heterogeneity occurred among these trials (I(2) = 96.3%). Two trials provided data for the proportion of self-reported adherent patients, reporting a reduction in the intervention group which was not statistically significant (odds ratio = 0.89 (95% CI 0.56 to 1.40)). We conducted meta-analysis on data from two trials assessing the effect of reminder packaging on blood pressure measurements. We found that reminder packaging significantly decreased diastolic blood pressure (MD = -5.89 mmHg (95% CI -6.70 to -5.09; P < 0.00001; I(2) = 0%). No effect was seen on systolic blood pressure (mean change -1.01, 95% CI -2.22 to 0.20; P = 0.1, I(2) = 0%). We also conducted meta-analysis on extracted data from two trials that looked at change in glycated haemoglobin. We found that reminder packaging significantly reduced glycated haemoglobin levels (MD -0.72; 95% CI -0.83 to -0.60; P < 0.00001; I(2) = 92%), although there was considerable heterogeneity.No appropriate data were available for meta-analysis of remaining clinical outcomes, which included serum vitamin C and E levels, and self-reported psychological symptoms (one trial each). We reported remaining data narratively. In one study the presence of a reminder packaging aid was found to be preferred by patients with low literacy levels.

AUTHORS' CONCLUSIONS

Reminder packing may represent a simple method for improving adherence for patients with selected conditions. Further research is warranted to improve the design and targeting of these devices.

Adherence to Treatment in a Behavioral Intervention Curriculum for Parents of Children With Autism Spectrum Disorder

Parents ( N = 21) of children with autism spectrum disorders responded to a survey on adherence to skills instruction and problem behavior management strategies they had previously been observed to master in a standardized training curriculum based on the principles of applied behavior analysis. Survey items were guided by existing models of and research in treatment adherence. Parents reported adherence below observed mastery criteria in five of six skill areas. Three independent variables indexing caregiver perception were significantly correlated with reported adherence: perceived effectiveness as a behavior change agent, confidence in the intervention to produce meaningful change, and acceptance of child in family and community. Perceived confidence significantly predicted adherence in a regression model ( p < .05). Implications of caregiver perception in explanatory frameworks for adherence are discussed, and next steps in the measurement and study of treatment adherence in behavior analysis are proposed.

Medication adherence: a call for action

Poor adherence to efficacious cardiovascular-related medications has led to considerable morbidity, mortality, and avoidable health care costs. This article provides results of a recent think-tank meeting in which various stakeholder groups representing key experts from consumers, community health providers, the academic community, decision-making government officials (Food and Drug Administration, National Institutes of Health, etc), and industry scientists met to evaluate the current status of medication adherence and provide recommendations for improving outcomes. Below, we review the magnitude of the problem of medication adherence, prevalence, impact, and cost. We then summarize proven effective approaches and conclude with a discussion of recommendations to address this growing and significant public health issue of medication nonadherence.

The counseling African Americans to Control Hypertension (CAATCH) Trial: baseline demographic, clinical, psychosocial, and behavioral characteristics

Background

Effectiveness of combined physician and patient-level interventions for blood pressure (BP) control in low-income, hypertensive African Americans with multiple co-morbid conditions remains largely untested in community-based primary care practices. Demographic, clinical, psychosocial, and behavioral characteristics of participants in the Counseling African American to Control Hypertension (CAATCH) Trial are described. CAATCH evaluates the effectiveness of a multi-level, multi-component, evidence-based intervention compared with usual care (UC) in improving BP control among poorly controlled hypertensive African Americans who receive primary care in Community Health Centers (CHCs).

Methods

Participants included 1,039 hypertensive African Americans receiving care in 30 CHCs in the New York Metropolitan area. Baseline data on participant demographic, clinical (e.g., BP, anti-hypertensive medications), psychosocial (e.g., depression, medication adherence, self-efficacy), and behavioral (e.g., exercise, diet) characteristics were gathered through direct observation, chart review, and interview.

Results

The sample was primarily female (71.6%), middle-aged (mean age = 56.9 ± 12.1 years), high school educated (62.4%), low-income (72.4% reporting less than $20,000/year income), and received Medicaid (35.9%) or Medicare (12.6%). Mean systolic and diastolic BP were 150.7 ± 16.7 mm Hg and 91.0 ± 10.6 mm Hg, respectively. Participants were prescribed an average of 2.5 ± 1.9 antihypertensive medications; 54.8% were on a diuretic; 33.8% were on a beta blocker; 41.9% were on calcium channel blockers; 64.8% were on angiotensin converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs). One-quarter (25.6%) of the sample had resistant hypertension; one-half (55.7%) reported medication non-adherence. Most (79.7%) reported one or more co-morbid medical conditions. The majority of the patients had a Charlson Co-morbidity score ≥ 2. Diabetes mellitus was common (35.8%), and moderate/severe depression was present in 16% of participants. Participants were sedentary (835.3 ± 1,644.2 Kcal burned per week), obese (59.7%), and had poor global physical health, poor eating habits, high health literacy, and good overall mental health.

Conclusions

A majority of patients in the CAATCH trial exhibited adverse lifestyle behaviors, and had significant medical and psychosocial barriers to adequate BP control. Trial outcomes will shed light on the effectiveness of evidence-based interventions for BP control when implemented in real-world medical settings that serve high numbers of low-income hypertensive African-Americans with multiple co-morbidity and significant barriers to behavior change.

Using qualitative synthesis to explore heterogeneity of complex interventions

BACKGROUND

Including qualitative evidence on patients' perspectives in systematic reviews of complex interventions may reveal reasons for variation in trial findings. This is particularly the case when the intervention is for a long-term disease, as management may rely heavily on the efforts of the patient. Inclusion though seldom happens, possibly because of methodological challenges, and when it does occur the different forms of evidence are often kept separate. To explore heterogeneity in trial findings, we tested a novel approach to integrate qualitative review evidence on patients' perspectives with evidence from a Cochrane systematic review.

METHODS

We used, as a framework for a matrix, evidence from a qualitative review on patients' perspectives on helping them manage their disease. We then logged in the matrix whether the interventions identified in a Cochrane review corresponded with the patient perspectives on how to help them. We then explored correspondence.The Cochrane review we used included 19 trials of interventions to improve adherence to therapy in HIV/AIDS patients. The qualitative review we used included 23 studies on HIV/AIDS patients' perspectives on adherence; it translated the themes identified across the studies into recommendations in how to help patients adhere.Both reviews assessed quality. In the qualitative review they found no difference in findings between the better quality studies and the weaker ones. In the Cochrane review they were unable to explore the impact of quality in subgroup analysis because so few studies were of good quality.

RESULTS

Matrix tabulation of interventions and patients' perspectives identified a range of priorities raised by people infected with HIV-1 that were not addressed in evaluated interventions. Tabulation of the more robust trials revealed that interventions that significantly improved adherence contained more components considered important by patients than interventions where no statistically significant effect was found.

CONCLUSIONS

This simple approach breaks new ground in cross tabulating qualitative evidence with the characteristics of trialled interventions. In doing so it tests the assumption that patients are more likely to adhere to interventions that match more closely with their concerns. The potential of this approach in exploring varying content and rates of success in trialled complex interventions deserves further evaluation.

Comparative effectiveness of asthma interventions within a practice based research network

BACKGROUND

Asthma is a chronic lung disease that affects more than 23 million people in the United States, including 7 million children. Asthma is a difficult to manage chronic condition associated with disparities in health outcomes, poor medical compliance, and high healthcare costs. The research network coordinating this project includes hospitals, urgent care centers, and outpatient clinics within Carolinas Healthcare System that share a common electronic medical record and billing system allowing for rapid collection of clinical and demographic data. This study investigates the impact of three interventions on clinical outcomes for patients with asthma. Interventions are: an integrated approach to care that incorporates asthma management based on the chronic care model; a shared decision making intervention for asthma patients in underserved or disadvantaged populations; and a school based care approach that examines the efficacy of school-based programs to impact asthma outcomes including effectiveness of linkages between schools and the healthcare providers.

METHODS/DESIGN

This study will include 95 Practices, 171 schools, and over 30,000 asthmatic patients. Five groups (A-E) will be evaluated to determine the effectiveness of three interventions. Group A is the usual care control group without electronic medical record (EMR). Group B practices are a second control group that has an EMR with decision support, asthma action plans, and population reports at baseline. A time delay design during year one converts practices in Group B to group C after receiving the integrated approach to care intervention. Four practices within Group C will receive the shared decision making intervention (and become group D). Group E will receive a school based care intervention through case management within the schools. A centralized database will be created with the goal of facilitating comparative effectiveness research on asthma outcomes specifically for this study. Patient and community level analysis will include results from patient surveys, focus groups, and asthma patient density mapping. Community variables such as income and housing density will be mapped for comparison. Outcomes to be measured are reduced hospitalizations and emergency department visits; improved adherence to medication; improved quality of life; reduced school absenteeism; improved self-efficacy and improved school performance.

DISCUSSION

Identifying new mechanisms that improve the delivery of asthma care is an important step towards advancing patient outcomes, avoiding preventable Emergency Department visits and hospitalizations, while simultaneously reducing overall healthcare costs.