Primary medication non-adherence: analysis of 195,930 electronic prescriptions

The position of renal denervation in treatment of hypertension: an expert consensus statement

Hypertension is an important risk factor for cardiovascular disease. In the Netherlands, there are approximately 2.8 million people with hypertension. Despite treatment recommendations including lifestyle changes and antihypertensive drugs, most patients do not meet guideline-recommended blood pressure (BP) targets. In order to improve BP control and lower the risk of subsequent cardiovascular events, renal sympathetic denervation (RDN) has been introduced and studied as a non-pharmacological approach. While early data on the efficacy of RDN showed conflicting results, improvements in treatment protocols and study design resulted in robust new evidence supporting the potential of the technology to improve patient care in hypertensive subjects. Recently, 5 randomised sham-controlled trials demonstrated the safety and efficacy of the technology. Modelling studies have further shown that RDN is cost-effective in the Dutch healthcare setting. Given the undisputable disease burden along with the shortcomings of current therapeutic options, we postulate a new, clearly framed indication for RDN as an adjunct in the treatment of hypertension. The present consensus statement summarises current guideline-recommended BP targets, proposed workup and treatment for hypertension, and position of RDN for those patients with primary hypertension who do not meet guideline-recommended BP targets (see central illustration).

Using the national electronic prescription system to determine the primary non-adherence to medication in the Czech Republic

The primary medication non-adherence occurs when a patient does not collect his or her newly prescribed medication. Various studies give estimates that this occurs between 0.2 percent and 74 percent. Recently, this topic has been researched by analyzing data in national electronic prescription systems. The database of the Czech electronic prescription system was used to obtain the number of all prescriptions issued and collected in 2021 for fifty particular substances (associated with six medication groups). Additionally, a similar query was performed with an additional criterion that the same substance had not been prescribed within the last 365 days. The data were obtained separately in five age categories. The total number of prescriptions analyzed in this study was over 21 million, which represents almost 30 percent of all prescriptions issued in the Czech Republic in 2021. The primary medication non-adherence in the selected substances was 4.56 percent, which negatively correlates (rxy = 0.707) with the age of a patient. There is a higher primary non-adherence in the Psychoanaleptics and Lipid modifying medication groups than in the whole studied sample (p < 0.05). Lipid-modifying medication group and several other particular substances showed a larger difference between primary non-adherence and overall non-adherence, indicating issues in the initiation of these drugs. The results of our study are following earlier studies with similar methodologies from other countries. However, the difference between primary non-adherence and overall non-adherence had not been observed in other studies before. The electronic prescription system proved to be a valuable tool for conducting this type of research.

A Mobile Application to Improve Diabetes Self-Management Using Rapid Prototyping: Iterative Co-Design Approach in Asian Settings

BACKGROUND

Diabetes is a global public health issue, causing burden on healthcare system and increasing risk of mortality. Mobile applications (apps) can be a promising approach to facilitate diabetes self-management. An increasingly utilized approach to facilitate engagement with mobile health (mHealth) technology is to involve potential users in the creation of the technology.

OBJECTIVE

The aim of this study was to use co-design for type 2 diabetes mellitus (T2DM) self-management mHealth development.

METHODS

Three rounds of iterative rapid prototyping panel sessions were conducted with a total of 9 T2DM participants in an Asian setting between Oct 2020 and April 2021. The participants were recruited through convenience sampling. For each round, feedback was gathered through qualitative interviews, and the feedback was used as a reference by the development team to develop and test a more refined version of the app in the next round. Transcribed semi-structured interview data was analyzed thematically using an inductive approach.

RESULTS

Participants' ages ranged from 40 to 69 years. Data saturation was reached, with no new themes emerging from the data. During the sessions, the participants expressed a variety of concerns and feedback on T2DM self-management using EMPOWER app and raised suggestions on the features of ideal T2DM self-management app. Important features include 1) reminders and notifications for medications, 2) Bluetooth integration with glucometers and blood pressure machines to minimize manual entry, 3) enlarged local food database including information on sugar content and recommendations for healthier options, 4) one touch for logging of routine medications and favorite foods, 5) export function for data sharing with physicians. Overall inputs concerned aspects such as user-friendliness of the app, customization possibilities, and educational content for the features in the mobile app.

CONCLUSION

In this study, we explored users' opinions on a T2DM self-management mobile app using co-design approach. This study adds to the growing body of literature on co-designing behavioral mHealth interventions and can potentially guide researchers in mobile app design for other chronic conditions.

Medication regimen complexity and its impact on medication adherence and asthma control among patients with asthma in Ethiopian referral hospitals

BACKGROUND

Various studies have found that medication adherence is generally low among patients with asthma, and that the complexity of the regimen may be a potential factor. However, there is no information on the complexity of the regimen and its relationship to adherence and asthma outcomes in Ethiopian asthma patients. Therefore, this study assessed how complex medication regimens affected medication adherence and asthma control in patients with asthma.

METHOD

From February 1 to May 30, 2022, a multicenter cross-sectional study was conducted in three public referral hospitals in northwestern Ethiopia. The Medication Complexity Index (MRCI), a 65-item validated instrument, was used to represent the complexity of medication regimens The Medication Adherence Rating Scale for Asthma (MARS-A) was used to assess medication adherence, and the ACT was used to measure the level of asthma control. The association between predictor and outcome variables was determined using multivariable logistic regression analysis. P-values of < 0.05 were declared as a significant association.

RESULT

Patients with asthma (n = 396) who met the inclusion criteria were included in the final analysis. About 21.2% and 24.5% of the participants had high asthma-specific MRCI and patient-level MRCI, respectively. The majority (84.4%) of the participants did not adhere to their medication, and 71% of the participants were classified as having uncontrolled asthma. According to the result of the multivariable analysis, moving from a high asthma-specific MRCI to a moderate asthma MRCI enhances the likelihood of medication adherence by 2.51 times (AOR = 2.51, 95%CI: (1.27, 7.71). Likewise, patients who have low asthma MRCI were four times more likely to adhere to the medication compared with high asthma MRCI (AOR = 3.80, 95%CI: (2.0, 11.1). Similarly, patients having low patient-level MRCI were eight times more likely their asthma level had been controlled (AOR = 7.84, 95%CI: 1.46 to 21.3) and patients who had moderate patient-level MRCI were three times (AOR = 2.83, 95%CI: 1.05 to 8.25) more controlled asthma compared with patients who had high patient level MRCI.

CONCLUSION

The majority of asthma patients had low and moderate complexity of MRCI. Patients with low and moderate regimen complexity demonstrated high adherence and had well-controlled asthma. Therefore, future researchers should consider MRCI as one factor for adherence and asthma control levels.

Digital health technologies to support medication adherence in chronic kidney disease

Non-adherence to medications is a critical challenge in the management of people with chronic kidney disease (CKD). This review explores the complexities of adherence in this population, the unique barriers and enablers of good adherence behaviours, and the role of emerging digital health technologies in bridging the gap between evidence-based treatment plans and the real-world standard of care. We present the current evidence supporting the use of digital health interventions among CKD populations, identifying the key research questions that remain unanswered, and providing practical strategies for clinicians to support medication adherence in a digital age.

Incidence and Predictors of Primary Nonadherence to Sodium Glucose Co-transporter 2 Inhibitors and Glucagon-Like Peptide 1 Agonists in a Large Integrated Healthcare System

BACKGROUND

Newer glucose-lowering drugs, including sodium glucose co-transporter 2 inhibitors (SGLT2i) and GLP-1 agonists, have a key role in the pharmacologic management of type 2 diabetes. No studies have measured primary nonadherence for these two drug classes, defined as when a medication is prescribed for a patient but ultimately not dispensed to them.

OBJECTIVE

To describe the incidence and predictors of primary nonadherence to SGLT2i (canagliflozin, empagliflozin) or GLP-1 agonists (dulaglutide, liraglutide, semaglutide) using a dataset that links electronic prescribing with health insurance claims.

DESIGN AND PARTICIPANTS

A retrospective cohort design using data of adult patients from a large health system who had at least one prescription order for a SGLT2i or GLP-1 agonist between 2012 and 2019. We used mixed-effects multivariable logistic regression to determine associations between sociodemographic, clinical, and provider variables and primary nonadherence.

MAIN MEASURES

Primary medication nonadherence, defined as no dispensed claim within 30 days of an electronic prescription order for any drug within each medication class.

KEY RESULTS

The cohort included 5146 patients newly prescribed a SGLT2i or GLP-1 agonist. The overall incidence of 30-day primary medication nonadherence was 31.8% (1637/5146). This incidence rate was 29.8% (n = 726) and 33.6% (n = 911) among those initiating a GLP-1 agonist and SGLT2i, respectively. Age ≥ 65 (aOR 1.37 (95% CI 1.09 to 1.72)), Black race vs White (aOR 1.29 (95% CI 1.02 to 1.62)), diabetic nephropathy (aOR 1.31 (95% CI 1.02 to 1.68)), and hyperlipidemia (aOR 1.18 (95% CI 1.01 to 1.39)) were associated with a higher odds of primary nonadherence. Female sex (aOR 0.86 (95% CI 0.75 to 0.99)), peripheral artery disease (aOR 0.73 (95% CI 0.56 to 0.94)), and having the index prescription ordered by an endocrinologist vs a primary care provider (aOR 0.76 (95% CI 0.61 to 0.95)) were associated with lower odds of primary nonadherence.

CONCLUSIONS

One third of patients prescribed SGLT2i or GLP-1 agonists in this sample did not fill their prescription within 30 days. Black race, male sex, older age, having greater baseline comorbidities, and having a primary care provider vs endocrinologist prescribe the index drug were associated with higher odds of primary nonadherence. Interventions targeting medication adherence for these newer drugs must consider primary nonadherence as a barrier to optimal clinical care.

Novel formulations of oral bisphosphonates in the treatment of osteoporosis

Oral bisphosphonates are a key intervention in the treatment of osteoporosis and in reducing the risk of fragility fractures. Their use is supported by over 3 decades of evidence; however, patient adherence to oral bisphosphonates remains poor in part due to complex dosing instructions and adverse events, including upper gastrointestinal symptoms. This problem has led to the development of novel oral bisphosphonate formulations. Buffered, effervescent alendronate is dissolved in water and so seeks to reduce upper gastro-intestinal adverse events, and gastro-resistant risedronate aims to reduce the complexity of dosing procedure (e.g. fasting prior to consumption) whilst still maintaining the efficacy of fracture risk reduction. Clinical trials and real-world data have been employed to demonstrate some benefits in terms of reduced upper gastro-intestinal adverse events, adherence, persistence and health economic outcomes. This report describes the result of an ESCEO (European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis) expert working group, which explores where oral bisphosphonates sit in current clinical practice guidelines, review their risk-benefit profile and the consequences of poor adherence before exploring novel oral bisphosphonate formulations and their potential clinical and health economic impact. Further research is required but there are signs that these novel, oral bisphosphonate formulations may lead to improved tolerance of oral bisphosphonates and thus, improved adherence and fracture outcomes.

Nondifferential Treatment Misclassification Biases Toward the Null? Not a Safe Bet for Active Comparator Studies

Active comparator studies are increasingly common, particularly in pharmacoepidemiology. In such studies, the parameter of interest is a contrast (difference or ratio) in the outcome risks between the treatment of interest and the selected active comparator. While it may appear treatment is dichotomous, treatment is actually polytomous as there are at least 3 levels: no treatment, the treatment of interest, and the active comparator. Because misclassification may occur between any of these groups, independent nondifferential treatment misclassification may not be toward the null (as expected with a dichotomous treatment). In this work, we describe bias from independent nondifferential treatment misclassification in active comparator studies with a focus on misclassification that occurs between each active treatment and no treatment. We derive equations for bias in the estimated outcome risks, risk difference, and risk ratio, and we provide bias correction equations that produce unbiased estimates, in expectation. Using data obtained from US insurance claims data, we present a hypothetical comparative safety study of antibiotic treatment to illustrate factors that influence bias and provide an example probabilistic bias analysis using our derived bias correction equations.

Linkage between electronic prescribing data and pharmacy claims records to determine primary adherence: the case of antihypertensive therapy in the Lisbon and Tagus Valley Region, Portugal

BACKGROUND

Hypertension (HT) is highly prevalent and a major risk factor for cardiovascular disease. Over 42% of Portuguese adults have HT. Even though the benefits of antihypertensive (AHT) drugs have been demonstrated, HT control remains inadequate. One major reason is that patients often fail to take their medications as prescribed. This paper aims to determine primary adherence to AHT therapy in newly diagnosed and treated hypertensive patients in Primary Health Care (PHC) units of Lisbon and Tagus Valley Health Region.

METHODS

This study reports data from a population-based, retrospective, cohort study from patients diagnosed with HT in PHC units of Lisbon and Tagus Valley Region from 1 January to 31 March 2011, with no prior use of AHT drugs. Primary adherence rate was expressed as number of claims records/total number of prescriptions records. Data were collected from SIARS for each patient during a 2-year period.

RESULTS

Overall primary adherence rate was 58.5%, increasing with age. Rates were higher for men, living in the Lisbon Metropolitan Area and diagnosed with uncomplicated HT. Drugs acting on the renin-angiotensin system had the highest rates, increasing for fixed-dose combinations and diminishing with the increase of cost for the patient.

CONCLUSIONS

Overall, almost 1 out of 2 prescribed AHT drugs were not dispensed. Until this study, little was known in Portugal about primary adherence. Our findings imply that the potential benefits of AHT therapy cannot be fully realized in this population.

Medication adherence and its impact on glycemic control in type 2 diabetes mellitus patients with comorbidity: A multicenter cross-sectional study in Northwest Ethiopia

BACKGROUND

Medication nonadherence in patients with chronic diseases, particularly in type 2 diabetes mellitus (T2DM) with comorbidity, has continued to be the cause of treatment failure. The current study assessed medication adherence and its impact on glycemic control in T2DM patients with comorbidity.

METHODS

An institutional-based multicenter cross-sectional study was conducted among T2DM patients with comorbidity at the selected hospitals in Northwest Ethiopia. Medication adherence was measured using a structured questionnaire of the General Medication Adherence Scale (GMAS). A logistic regression model was used to identify predictors of the level of medication adherence and glycemic control. P < 0.05 at 95% confidence interval (CI) was statistically significant.

RESULTS

A total of 403 samples were included in the final study. This study showed that more than three-fourths (76.9%) of the participants were under a low level of medication adherence. Source of medication cost coverage [AOR = 10.593, 95% CI (2.628-41.835; P = 0.003], monthly income (P < 0.00), self-monitoring of blood glucose (SMBG) practice [AOR = 0.266, 95% CI (0.117-0.604); P = 0.002], number of medications [AOR = 0.068, 95% CI (0.004-0.813); P = 0.014] and medical conditions [AOR = 0.307, 95% CI (0.026-0.437); P = 0.018] were found to be significant predictors of medication adherence. Significantly, majority (74.7%) of participants had poor levels of glycemic control. Patients who had a high level of medication adherence [AOR = 0.003, 95% CI (0.000-0.113); P = 0.002] were found less likely to have poor glycemic control compared with patients who were low adherent to their medications.

CONCLUSION

The current study concluded that medication adherence was low and significantly associated with poor glycemic control. Number of medical conditions and medications were found to be associated with medication adherence. Management interventions of T2DM patients with comorbidity should focus on the improvement of medication adherence.

Non-adherence to medication and associated factors among type 2 diabetes patients at Clinique Medicale Fraternite, Rwanda: a cross-sectional study

BACKGROUND

Type 2 Diabetes Miletus (T2DM) is a public health burdens that alarmingly increases and leads to morbidity and mortality over the last decades globally. Its management is multifaceted and adherence to diabetic medications plays great roles in life of T2DM patients. But epidemiology on adherence and its associated factors remain unknown in Rwanda. Therefore, this study determined the extent of non-adherence and its predictors among T2DM patients seeking healthcare services at the Clinique Medicale la Fraternite.

METHODS

A cross-sectional study among 200 adults' patients with T2DM receiving care in the Medicale la Fraternite clinic was investigated. Bivariate and multivariate logistic regression models were performed based on odds ratio employed to examine associated predictors of non-adherence. The cut-off value for all statistical significances tests were considered at p < 0.05 with 95% for the confidence intervals.

RESULTS

Overall, more than a half of T2DM patients (53.5%) had poor medication adherence. Being females [OR = 2.1, 95%CI(1.13-3.71), p = 0.002], consuming anti-diabetic drugs for 4-10 years [OR = 2.18, 95%CI(1.09-4.34), p = 0.027], experiencing poor communication with healthcare providers [OR = 2.4; 95%CI (1.36-4.25), p = 0.003] and being perceived as burden of the family [OR = 5.8; 95%CI(1.3-25.7), p < 0.021] had higher odds of non-adherence to anti-diabetic medications. Those with poor HbA1C [OR = 4.26; 95%CI(1.7-10.67), p = 0.002] had 4.26 times higher odds to be non-adherent compared to those with good HbA1C. Respondents with primary [OR = 3.56; 95%CI (1.12-11.28), p = 0.031] and secondary education [OR = 2.96; 95%CI (1.11-7.87), p = 0.03] were more likely to be non-adherent than those with informal education respectively. Those with normal BMI [OR = 5.17; 95%CI(1.63-16.37), p = 0.005] and those with overweight or obese [OR = 3.6; 95%CI (1.04-9.1), p < 0.02] had higher odds of being non-adherent than those with underweight.

CONCLUSION

Sex, glycaemia, communication with healthcare providers, education and gycosylated hemoglobin were the major predictors of non-adherence. Interventions for tackling this problem through bringing together efforts to stem this epidemic and controlling predictors of non-adherence are urgently recommended.

Considerations for observational study design: Comparing the evidence of opioid use between electronic health records and insurance claims

PURPOSE

Pharmacoepidemiology studies often use insurance claims and/or electronic health records (EHR) to capture information about medication exposure. The choice between these data sources has important implications.

METHODS

We linked EHR from a large academic health system (2015-2017) to Medicare insurance claims for patients undergoing surgery. Drug utilization was characterized based on medication order dates in the EHR, and prescription fill dates in Medicare claims. We compared opioid use documented in EHR orders to prescription claims in four time periods: 1) Baseline (182 days before surgery); 2) Perioperative period; 3) Discharge date; 4) Follow-up (90 days after surgery).

RESULTS

We identified 11 128 patients undergoing surgery. During baseline, 34.4% (EHR) versus 44.1% (claims) had evidence of opioid use, and 56.9% of all baseline use was reflected only in one data source. During the perioperative period, 78.8% (EHR) versus 47.6% (claims) had evidence of use. On the day of discharge, 59.6% (EHR) versus 45.5% (claims) had evidence of use, and 51.8% of all discharge use was reflected only in one data source. During follow-up, 4.3% (EHR) versus 10.4% (claims) were identified with prolonged opioid use following surgery with 81.4% of all prolonged use reflected only in one data source.

CONCLUSIONS

When characterizing opioid exposure, we found substantial discrepancies between EHR medication orders and prescription claims data. In all time periods assessed, most patients' use was reflected only in the EHR, or only in the claims, not both. The potential for misclassification of drug utilization must be evaluated carefully, and choice of data source may have large impacts on key study design elements.

Effectiveness of interventions to improve medication adherence in adults with depressive disorders: a meta-analysis

BACKGROUND

Non-adherence to medication is a major obstacle in the treatment of depressive disorders. We systematically reviewed the literature to evaluate the effectiveness of interventions aimed at improving adherence to medication among adults with depressive disorders with emphasis on initiation and implementation phase.

METHODS

We searched Medline, EMBASE, The Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, Social Science Citation Index and Science Citation Index for randomized or non-randomized controlled trials up to January 2022. Risk of bias was assessed using the criteria of the Cochrane Collaboration. Meta-analyses, cumulative and meta-regression analyses for adherence were conducted.

RESULTS

Forty-six trials (n = 24,324) were included. Pooled estimate indicates an increase in the probability of adherence to antidepressants at 6 months with the different types of interventions (OR 1.33; 95% CI: 1.09 to 1.62). The improvement in adherence is obtained from 3 months (OR 1.62, 95% CI: 1.25 to 2.10) but it is attenuated at 12 months (OR 1.25, 95% CI: 1.02 to 1.53). Selected articles show methodological differences, mainly the diversity of both the severity of the depressive disorder and intervention procedures. In the samples of these studies, patients with depression and anxiety seem to benefit most from intervention (OR 2.77, 95% CI: 1.74 to 4.42) and collaborative care is the most effective intervention to improve adherence (OR 1.88, 95% CI: 1.40 to 2.54).

CONCLUSIONS

Our findings indicate that interventions aimed at improving adherence to medication among adults with depressive disorders are effective up to six months. However, the evidence on the effectiveness of long-term adherence is insufficient and supports the need for further research efforts.

TRIAL REGISTRATION

International Prospective Register for Systematic Reviews (PROSPERO) number: CRD42017065723 .

Identifying and Managing Treatment Nonadherence

Nonadherence to medical treatment is exceptionally common and associated with poor clinical outcomes, a negative impact on quality of life, and a large financial burden on health care systems. This article first addresses key contributors to nonadherence from patient-specific, treatment-specific, and health care system-specific factors. Second, it outlines tools for the practicing clinician to identify, evaluate, and manage nonadherence across the spectrum of chronic disease in partnership with patients.

Assessment of a Naloxone Coprescribing Alert for Patients at Risk of Opioid Overdose: A Quality Improvement Project

BACKGROUND

Patients taking high doses of opioids, or taking opioids in combination with other central nervous system depressants, are at increased risk of opioid overdose. Coprescribing the opioid-reversal agent naloxone is an essential safety measure, recommended by the surgeon general, but the rate of naloxone coprescribing is low. Therefore, we set out to determine whether a targeted clinical decision support alert could increase the rate of naloxone coprescribing.

METHODS

We conducted a before-after study from January 2019 to April 2021 at a large academic health system in the Southeast. We developed a targeted point of care decision support notification in the electronic health record to suggest ordering naloxone for patients who have a high risk of opioid overdose based on a high morphine equivalent daily dose (MEDD) ≥90 mg, concomitant benzodiazepine prescription, or a history of opioid use disorder or opioid overdose. We measured the rate of outpatient naloxone prescribing as our primary measure. A multivariable logistic regression model with robust variance to adjust for prescriptions within the same prescriber was implemented to estimate the association between alerts and naloxone coprescribing.

RESULTS

The baseline naloxone coprescribing rate in 2019 was 0.28 (95% confidence interval [CI], 0.24-0.31) naloxone prescriptions per 100 opioid prescriptions. After alert implementation, the naloxone coprescribing rate increased to 4.51 (95% CI, 4.33-4.68) naloxone prescriptions per 100 opioid prescriptions (P < .001). The adjusted odds of naloxone coprescribing after alert implementation were approximately 28 times those during the baseline period (95% CI, 15-52).

CONCLUSIONS

A targeted decision support alert for patients at risk for opioid overdose significantly increased the rate of naloxone coprescribing and was relatively easy to build.

Estimating Medication Adherence from Electronic Health Records Using Rolling Averages of Single Refill-based Estimates

Medication adherence is usually defined as the manner in which a patient takes their medication, in relation to the regimen agreed to with their healthcare provider. Electronic Health Records (EHRs) can be used to estimate adherence in a cost-effective and non-invasive manner across large-scale populations, although there is no universally agreed optimal approach to doing so. We sought to explore patterns of asthma ICS prescription refills in a large EHR dataset, and to evaluate the use of rolling-average based measures towards short-term adherence estimation. Over 1.6 million asthma controllers were prescribed for our cohort of 91,332 individuals, between January 2009 and March 2017. The Continuous Single interval measures of medication Availability (CSA) and Gaps (CSG) were calculated for individual prescriptions, as well as rolling-average adherence measures of the CSA over 3, 5, or 10 past prescription intervals. 16.7% of the study population had only a single prescription during their follow-up (a median duration of 7.1 years). 51% of prescriptions were refilled before (or on the day that) supply was exhausted, and for 19% of prescription refills, the amount of medication dispensed should have lasted at least twice as long as the duration before the next refill was filled. The rolling average measures had statistically strong associations (Spearman |R|>0.7) with the estimate for the subsequent prescription refill. Rolling averages of multiple individual refill-level adherence estimates provide a novel and simple way to crudely smoothen estimates from individual prescription refills, which are strongly influenced by common (and adherent) real-world behaviors, for more meaningful and effective trend detection. Clinical Relevance- This demonstrates a novel methodology for estimating medication adherence which can detect recent changes in trends.

Improving the Management of Hypertension by Tackling Awareness, Adherence, and Clinical Inertia: A Symposium Report

Hypertension remains the leading cause of global mortality, with elevated systolic blood pressure (BP) leading to 10.8 million deaths each year. Despite this, only around 50% of individuals with hypertension are aware of their condition. Alongside low awareness rates, lack of patient adherence to medication and therapeutic inertia have been identified as factors contributing to the lack of hypertension control worldwide. This report summarizes presentations from the “one of a kind” Servier-sponsored symposium, Improving the Management of Hypertension: Acting on Key Factors, which was conducted as part of the European Society of Hypertension (ESH)-International Society of Hypertension (ISH) 2021 ON-AIR meeting. The symposium focused on how low awareness, therapeutic inertia, and nonadherence can be addressed by combining the experience of a patient with the expertise of physicians. May Measurement Month, the ongoing global BP measurement program, is raising awareness of hypertension in over 90 countries, and the 2018 European Society of Cardiology/ESH guidelines and the 2020 ISH guidelines now include recommendations that specifically address low adherence and therapeutic inertia, including involving patients in a shared decision-making process and the use of single-pill combination therapy. Understanding the role of emotion in decision making and addressing the different psychological states and attitudes in the patient’s “cycle of change” are key to effective shared decision making and improving adherence.

Raised blood pressure (hypertension) is involved in the death of around 10.8 million people throughout the world each year. However, only about half of the people with hypertension are aware of their condition. In addition, many patients who are prescribed blood pressure-lowering medications do not take their pills regularly (intentional or nonintentional low adherence). Many doctors are not as strict as they should be in ensuring blood pressure control of their hypertensive patients (therapeutic inertia). This report presents ideas and data from a “first of its kind” symposium sponsored by Servier as part of the European Society of Hypertension (ESH)-International Society of Hypertension (ISH) 2021 ON-AIR meeting involving both patient and physicians. The report summarizes the ways in which low awareness, therapeutic inertia, and lack of adherence can be addressed and includes insights into patients’ perspectives. An ongoing global blood pressure screening program called May Measurement Month was discussed, which has detected almost a million people with untreated or inadequately treated hypertension worldwide since 2017. Recent ESH and ISH guidelines for managing hypertension now include recommendations on how to address low adherence and therapeutic inertia. Crucially, doctors should involve their patients with hypertension in decisions about their own treatment, which will help improve adherence to medication and ultimately reduce hypertension-related serious adverse events (e.g. heart attacks, strokes and deaths).

Linking the Paul Coverdell National Acute Stroke Program to commercial claims to establish a framework for real-world longitudinal stroke research

BACKGROUND

Non-interventional large-scale research on real-world patients who had a stroke requires the use of multiple data sources ensuring access to longitudinal data from large populations with clinically-detailed information. We sought to establish a framework for longitudinal research on patients hospitalised with stroke by linking information-rich, deidentified inpatient data from the Paul Coverdell National Acute Stroke Program (PCNASP) to commercial and Medicare Advantage longitudinal claims data.

METHODS

All stroke admissions in PCNASP between 2008 and 2015 were evaluated for linkage to longitudinal claims from a commercial insurer using an algorithm based on six available common data fields (patient age, gender, admission date, discharge date, discharge diagnosis and state) and a hospital match. We evaluated the linkage quality (via the percentage of unique records in the linked dataset) and the representativeness of the linked population. We also described medical history, stroke severity and patterns of medication use among the PCNASP-claims linked cohort.

RESULTS

The linkage produced uniqueness equal to 99.1%. We identified 5644 linked and 98 896 unlinked patients who had an ischaemic stroke hospitalisation in claims data. Linked patients were younger than unlinked (69.7 vs 72.5 years), but otherwise similar by medical history, prestroke medication use or lab values. Stroke severity was mild and most patients were discharged home. Prestroke and discharge use of antihypertensive and statins in the PCNASP were greater than their use as measured by filled prescriptions in claims.

CONCLUSIONS

High-quality linkage between the PCNASP and commercial claims data is feasible. This linkage identified differences between reported or recommended versus actual out-of-hospital medication utilisation, highlighting the importance of longitudinal data availability for research aimed to improve the care of patients who had a stroke.

Adherence to Therapy in Patients with Multiple Sclerosis-Review

Multiple sclerosis (MS) is a chronic, autoimmune, demyelinating disease of the central nervous system (CNS). MS is an incurable disease. The goal of disease-modifying therapies (DMT) is to slow the progression of the disease, prevent relapses and increase the patient’s overall quality of life. According to the World Health Organisation definition, adherence means the extent to which a person’s medication-taking behaviour corresponds with the agreed upon treatment recommendations from a healthcare provider. Accurate adherence is necessary for efficient treatment. Non-adherence is related to unsuccessful treatments, the risk of relapses and increased healthcare costs. The aim of this study is to present the main factors relating to non-adherence in MS patients.

Adherence and persistence rates of major antidiabetic medications: a review

The objective of this paper was to review the adherence and persistence rates of major antidiabetic medication classes (i.e., metformin, sulfonylureas, sodium glucose cotransporter-2 inhibitors, dipeptidyl peptidase-4 inhibitors, insulin, glucagon-like peptide-1 receptor agonists, and thiazolidinediones) by summarizing the major findings of the studies published since 2017. In addition, we reported the potential causes for low adherence and persistence of antidiabetic medications. Based on the literature, the highest rate of adherence and persistence was consistently observed in metformin users. Second to metformin were sodium glucose cotransporter-2 inhibitors. Injectable therapies such as insulin and glucagon-like peptide-1 receptor agonists trailed low on the adherence and persistence rates. To the best of our knowledge, no studies published since the year 2017 analyzed the adherence and persistence of thiazolidinediones independently. The most frequently cited cause for low adherence and persistence was the severity of adverse events. Baseline characteristics (e.g., baseline HbA1c level), demographic information (e.g., age, gender, or ethnicity), and comorbidity profiles also had significant impacts on adherence and persistence in patients with type 2 diabetes mellitus.

Pediatric Medication Noninitiation in Spain

OBJECTIVES

To estimate medication noninitiation prevalence in the pediatric population and identify the explanatory factors underlying this behavior.

METHODS

Observational study of patients (<18 years old) receiving at least 1 new prescription (28 pharmaceutical subgroups; July 2017 to June 2018) in Catalonia, Spain. A prescription was considered new when there was no prescription for the same pharmaceutical subgroup in the previous 6 months. Noninitiation occurred when a prescription was not filled within 1 month or 6 months (sensitivity analysis). Prevalence was estimated as the proportion of total prescriptions not initiated. To identify explanatory factors, a multivariable multilevel logistic regression model was used, and adjusted odds ratios were reported.

RESULTS

Overall, 1 539 003 new prescriptions were issued to 715 895 children. The overall prevalence of 1-month noninitiation was 9.0% (ranging from 2.6% [oral antibiotics] to 21.5% [proton pump inhibitors]), and the prevalence of 6-month noninitiation was 8.5%. Noninitiation was higher in the youngest and oldest population groups, in children from families with a 0% copayment rate (vulnerable populations) and those with conditions from external causes. Out-of-pocket costs of drugs increased the odds of noninitiation. The odds of noninitiation were lower when the prescription was issued by a pediatrician (compared with a primary or secondary care clinician).

CONCLUSIONS

The prevalence of noninitiation of medical treatments in pediatrics is high and varies according to patients' ages and medical groups. Results suggest that there are inequities in access to pharmacologic treatments in this population that must be taken into account by health care planners and providers.

Initial non-adherence to antihypertensive medications in the United States: a systematic literature review

An important component of hypertension management is the initiation and continuation of antihypertensive medications. Non-adherence during the long-term use of antihypertensive medications is well studied. However, there is a paucity of research about the frequency and clinical consequences of failing to take the first dose of an antihypertensive, a treatment challenge known as initial medication non-adherence (IMN). This systematic literature review summarizes the published evidence from 2010 to 2019 on the prevalence, associated factors, consequences, and solutions for IMN to antihypertensive medications in the United States. Of the fifteen studies identified, nine studies reported the prevalence of IMN, two studies examined patient-reported reasons for IMN, and four studies evaluated interventions aimed to lower IMN. It is estimated that 5-34% of patients do not obtain their new antihypertensive medications. Factors and reasons cited include patient demographics, patient beliefs or perceptions about medications, cost or financial barriers, and clinical characteristics, such as a new hypertension diagnosis or higher co-morbid disease burden. The clinical, economic, and patient-reported outcomes of IMN are not well researched. In addition, interventions to address IMN have yielded inconsistent results. Significant opportunities exist for further research into this dimension of patient behavior to better understand and address IMN to new antihypertensive medications.

Impact of Personal, Cultural and Religious Beliefs on Medication Adherence among Patients with Chronic Diseases at University Hospital in Northwest Ethiopia

BACKGROUND

Subjective beliefs about chronic disease conditions and their drug management are among factors determining adherence to medications that are amenable to interventions. Patient-level factors such as personal, cultural, and religious beliefs about diseases, and medication use may have a significant impact on medication adherence. The purpose of this study was to assess the impact of personal, cultural and religious beliefs on medication adherence behavior among patients with chronic follow-up.

PATIENTS AND METHODS

An institutional-based cross-sectional study design was conducted among chronic ambulatory patients from July to August 2021. The data was collected through an interviewer administered questionnaire. Initially stratified sampling technique was used to include proportional participants from different disease conditions, and systematic random sampling was employed to enroll eligible patients from each subgroup. Descriptive statistics such as frequencies and percentages were computed for categorical variables and mean with (standard deviation ±SD) used for continuous variables. Logistic regression model was employed to determine variable with poor adherence. A 95% confidence interval with P-value ≤0.05 was used to declare statically significance.

RESULTS

Among the 404 participants, more than half (51%) were males. The mean (±SD) age of the patients was 47.8 ± 14.8 years. Patients with strong belief in the harm of medications were found 4 times more likely to have poor medication adherence than those with weak belief in the harm of medications (AOR = 4.027, 95% CI:1.232-13.161, P = 0.021). In contrast, having strong personal belief regarding the necessity of medications were found to be less likely to have poor medication adherence (AOR = 0.368, 95% CI: 0.220-0.615, P < 0.001).

CONCLUSION

This study generalized that most of the patients were poor adherent to their medications. Personal beliefs were found to influence medication adherence of the patients. Future studies could be needed to explore and identify how these factors affect patients' medication adherence.

Congruence of opioid prescriptions and dispensing using electronic records and claims data

OBJECTIVE

To quantify discrepancies between opioid prescribing and dispensing via the percentage of patients with Electronic Medical Record (EMR) prescriptions who subsequently filled the prescription within 90 days, defined as congruence, and compared opioid congruence with related medications.

DATA SOURCES

Deidentified data from the IBM MarketScan Explorys Claims-EMR Dataset.

STUDY DESIGN

In this retrospective, observational study, we examined congruence for commonly prescribed controlled substances-opioids, stimulants, and benzodiazepines. Congruence was stratified by age group and sex.

DATA COLLECTION/EXTRACTION METHODS

Continuously enrolled adults aged 18-64 years with an EMR encounter (excluding inpatient settings) and ≥ 1 prescription for selected classes between 1/1/2016 and 10/2/2017.

PRINCIPAL FINDINGS

During the study period, 1,353,478 adults had ≥1 EMR encounter. Patients with stimulants prescriptions had the highest congruence (83%) corresponding to 7151 claims for 8,635 EMR prescriptions, followed by opioids (66%; 62,766/95,690) and benzodiazepines (64%; 30,181/47,408). Chi-square testing showed congruence differed by age group within opioids (P < .0001) and benzodiazepines (P < .0001) and was higher among females within benzodiazepines (P < .0001).

CONCLUSIONS

These findings demonstrate that relying on claims data alone for opioid prescribing measures might underestimate actual prescribing magnitude by as much as one-third in these data. Combined EMR and claims data can help future research better understand characteristics associated with congruence or incongruence between prescribing and dispensing.

Digital medicines for adherence support: A conceptual framework and qualitative study of adherence among chronically ill patients

Digital medicine programs (DMPs) are emerging technologies that use sensor-enabled medicine to detect when patients have taken their medication and then provide feedback about adherence. We use qualitative methods to understand how patients change their behavioral patterns while participating in a DMP intervention. An influence diagram outlining the factors hypothesized to affect adherence in DMPs constructed from prior scientific research and expert input was created. Subsequently, we conducted semi-structured interviews with 10 patients to see if their experience supported the relationships outlined in the model. We identified three pathways by which DMPs are likely to change behavior around medication adherence: (1) providing patients and providers with accurate, personalized information about adherence; (2) improving patient-provider interactions by structuring them around this information; and (3) facilitating routines and habits for medication use. Chronically ill patients often fail to adhere to drug regimens. Patients in a DMP intervention used the DMP-provided information to better understand drug efficacy and collaborated with their physician to develop adherence strategies. DMPs can promote medication adherence among patients who are willing to use them and may be most effective if physicians are active partners in the DMP.

Analysis of naloxone access and primary medication nonadherence in a community pharmacy setting

BACKGROUND

Access to naloxone is a primary public health strategy to prevent opioid overdose death. Factors associated with primary medication nonadherence (PMN) to naloxone are underreported in the literature.

OBJECTIVE

The objective of this study was to evaluate naloxone dispensing trends and PMN in a community pharmacy setting.

METHODS

This retrospective analysis included patients of a community pharmacy chain in Maine and New Hampshire (57 and 29 pharmacy locations, respectively) for whom a claim for a naloxone prescription was billed between January 1, 2019, and July 31, 2020.

RESULTS

A total of 2152 patients associated with 2606 naloxone claims were identified for analysis. A majority of the subjects were women (52.7%) and the mean age of all the subjects was 46.4 ± 16.0 years. Of the 2606 naloxone claims, 565 prescriptions were returned to stock and never dispensed to the patient for a PMN rate of 21.7%. Gender and age were not associated with naloxone PMN. Factors associated with naloxone PMN were urban location [x²(1) = 12.49, P = 0.0004], concomitant opioid analgesic [x²(1) = 4.56, P = 0.0328], and payment method [x²(4) = 251.07, P < 0.0001]. Regarding payment method, nonadherence was higher among cash (138 of 386, 35.8%) and private insurance (191 of 455, 42.0%) transactions whereas lower among Medicare (132 of 681, 19.4%) and Medicaid (89 of 899, 9.9%) transactions. Concomitant buprenorphine [x²(1) = 44.57, P < 0.0001] and the use of a naloxone standing order [x²(1) = 4.79, P = 0.0162] were associated with primary adherence to take-home naloxone.

CONCLUSION

A notable portion of naloxone prescribed and filled in the community pharmacy setting was never obtained by the patient. Factors associated with PMN in this study included geographic location, use of a standing order, concomitant prescriptions for buprenorphine or opioid analgesic medications, and payment method. Underlying causes of PMN must be addressed (e.g., removing financial barriers and optimizing the use of standing orders) to increase naloxone access for persons at risk of opioid overdose.

Simultaneous Benzodiazepine and SSRI Initiation in Young People With Anxiety Disorders

Objective: There are potential risks and benefits of combining benzodiazepine (BZD) and selective serotonin reuptake inhibitor (SSRI) therapy at anxiety disorder treatment onset. We investigated how often adolescents and young adults with anxiety disorders simultaneously initiate BZD treatment with SSRI treatment and examined whether SSRI treatment duration varies by simultaneous BZD initiation.

Methods: In a United States commercial claims database (January 2008-December 2016), we identified adolescents (10-17 years) and young adults (18-24 years) with ICD-9-CM/ICD-10-CM anxiety disorder diagnoses initiating SSRI treatment, without past-year SSRI and BZD treatment. We defined simultaneous initiation as filling a new BZD prescription on the date of SSRI initiation. We estimated time to SSRI treatment discontinuation and used stabilized inverse probability of treatment weighting for adjusted estimates.

Results: The study included 94,399 adolescents and 130,971 young adults initiating SSRI treatment with an anxiety disorder. Four percent of adolescents and 17% of young adults simultaneously initiated BZD treatment, varying by age, anxiety disorder, comorbidities, health care utilization, and provider type. Simultaneous BZD initiation among SSRI initiators declined from 2008 to 2016. SSRI treatment duration was similar in initiators of simultaneous therapy vs SSRI monotherapy: ≥ 6 months in adolescents (55% vs 56%, respectively) and in young adults (39% vs 40%). Nine percent of simultaneous initiators continued BZDs for ≥ 6 months.

Conclusions: Simultaneous initiation of BZD and SSRI treatment is relatively common in young adults with anxiety disorders and was not associated with longer SSRI persistence. Given risks of BZD treatment, potential benefits and risks of adding a BZD at SSRI treatment initiation must be carefully weighed.

Factors associated with primary nonadherence to newly initiated direct oral anticoagulants in patients with nonvalvular atrial fibrillation

BACKGROUND: Direct oral anticoagulants (DOACs) are widely used for the prevention of stroke in nonvalvular atrial fibrillation (NVAF); however, real-world primary nonadherence (failing to collect the first prescription) has been measured in very few studies. OBJECTIVE: To report primary nonadherence in NVAF patients who are newly prescribed DOACs and identify associated factors. METHODS: This observational retrospective cohort study used a large primary care database in Catalonia. Patients with NVAF who were newly prescribed a DOAC between January 2009 and December 2015 were identified, and primary nonadherence was measured by comparing prescribing records to pharmacy claims data. Multivariable logistic regression was used to determine associated factors. RESULTS: A total of 12,257 patients met the inclusion and exclusion criteria; of these, 1,276 (10.4%) were primary nonadherent. Primary nonadherence was found to be 12.8% for apixaban, 8.6% for dabigatran, and 10.8% for rivaroxaban. Multivariable logistic regression indicated higher odds of primary nonadherence with apixaban and rivaroxaban compared to dabigatran (apixaban: OR = 1.61, 95% CI = 1.39-1.87; rivaroxaban: OR = 1.28, 95% CI = 1.11-1.47). Patients aged at least 80 years showed lower odds of primary nonadherence compared to those aged less than 65 years (OR = 0.78, 95% CI = 0.66-0.93). A diagnosis of chronic kidney disease was associated with primary nonadherence (OR = 1.27, 95% CI = 1.08-1.50). Whereas, diabetes (OR = 0.85, 95% CI = 0.74-0.97), hypertension (OR = 0.79, 95% CI = 0.70-0.91), and stroke/transient ischemic attack (OR = 0.70, 95% C I =0.59-0.82) were inversely associated with primary nonadherence. CONCLUSIONS: Overall, 10.4% of patients prescribed DOACs were primary nonadherent, failing to collect the first prescription. The percentage could have serious implications for patient outcomes and the real-world cost-effectiveness of prescribing DOACs in NVAF. Rates of primary nonadherence and associated factors may provide useful information for the design and evaluation of adherence interventions. DISCLOSURES: No outside funding was received for this study. The data for this study came from the European Medicines Agency PE-PV project (Grant/Award Number EMA/2015/27/PH). The authors have nothing to disclose. A preliminary version of this work was presented at the European Drug Utilisation Research Group (EuroDURG) Conference, Szeged, Hungary, March 5, 2020.

Hypertension healthcare professional beliefs and behaviour regarding patient medication adherence: a survey conducted among European Society of Hypertension Centres of Excellence

PURPOSE

Little is known on the beliefs, perceptions and practices of hypertension specialists in addressing non-adherence to therapy. Therefore, a survey was undertaken amongst healthcare professionals (HCPs) managing hypertension in the European Society of Hypertension (ESH) Centres of Excellence.

MATERIALS AND METHODS

Cross-sectional data were obtained between December 2020 and April 2021 using an online anonymous structured questionnaire including 26 questions/136 items, that was sent to all ESH Excellence centres.

RESULTS

Overall 67 from 187 centres (37.3%) responded and 200 HCPs from 30 countries answered the questionnaire. Participants (60% men) were mainly physicians (91%) and nurses (8%) from University hospitals (77%). Among physicians, 83% had >10 years professional experience. Average time dedicated to discuss medications was 1-5 min in 48% and 6-10 min in 29% of cases. Interviews with patients about adherence were the most frequently used assessment method. Chemical detection of medications in urine was available in 36% of centres. One third of physicians involved their patients regularly in treatment decisions. The most frequent methods to improve adherence included simplification of medication therapy, more frequent visits, and home blood pressure monitoring.

CONCLUSIONS

The level of implementation of tools to detect and improve adherence in hypertension management by HCPs in ESH excellence centres is low. Structured educational activities focussing on adherence management and access to the newest objective measures to detect non-adherence might improve these deficits.

Effect of Electronic Prescribing Compared to Paper-Based (Handwritten) Prescribing on Primary Medication Adherence in an Outpatient Setting: A Systematic Review

BACKGROUND

Electronic prescriptions are often created and delivered electronically to the pharmacy while paper-based/handwritten prescriptions may be delivered to the pharmacy by the patients. These differences in the mode of creation and transmission of the two types of prescription could influence the rate at which outpatients fill new prescriptions of previously untried medications.

OBJECTIVES

This study aimed to evaluate literatures to determine the impact of electronic prescribing compared with paper-based/handwritten prescribing on primary medication adherence in an outpatient setting.

METHODS

The keywords and phrases "outpatients," "e-prescriptions," "paper-based prescriptions," and "primary medication adherence" were combined with their relevant synonyms and medical subject headings. A comprehensive literature search was conducted on EMBASE, CINAHL, and MEDLINE databases, and Google Scholar. The results of the search were screened and selected using predefined inclusion and exclusion criteria. The Critical Appraisal Skills Program (CASP) was used for quality appraisal of included studies. Data relevant to the objective of the review were extracted and analyzed through narrative synthesis.

RESULTS

A total of 10 original studies were included in the final review, including 1 prospective randomized study and 9 observational studies. Nine of the 10 studies were performed in the United States. Four of the studies indicated that electronic prescribing significantly increases initial medication adherence, while four of the studies suggested the opposite. The remaining two studies found no significant difference in primary medication adherence between the two methods of prescribing. The variations in the studies did not allow the homogeneity required for meta-analysis to be achieved.

CONCLUSION

The conflicting findings relating to the efficacy of primary medication adherence across both systems demonstrate the need for a standardized measure of medication adherence. This would help further determine the respective benefits of both approaches. Future research should also be conducted in different countries to give a more accurate representation of adherence.

Impact of implementing electronic prior authorization on medication filling in an electronic health record system in a large healthcare system

OBJECTIVE

Medications frequently require prior authorization from payers before filling is authorized. Obtaining prior authorization can create delays in filling prescriptions and ultimately reduce patient adherence to medication. Electronic prior authorization (ePA), embedded in the electronic health record (EHR), could remove some barriers but has not been rigorously evaluated. We sought to evaluate the impact of implementing an ePA system on prescription filling.

MATERIALS AND METHODS

ePA was implemented in 2 phases in September and November 2018 in a large US healthcare system. This staggered implementation enabled the later-implementing sites to be controls. Using EHR data from all prescriptions written and linked information on whether prescriptions were filled at pharmacies, we 1:1 matched ePA prescriptions with non-ePA prescriptions for the same insurance plan, medication, and site, before and after ePA implementation, to evaluate primary adherence, or the proportion of prescriptions filled within 30 days, using generalized estimating equations. We also conducted concurrent analyses across sites during the peri-implementation period (Sept-Oct 2018).

RESULTS

Of 74 546 eligible ePA prescriptions, 38 851 were matched with preimplementation controls. In total, 24 930 (64.2%) ePA prescriptions were filled compared with 26 731 (68.8%) control prescriptions (Adjusted Relative Risk [aRR]: 0.92, 95%CI: 0.91-0.93). Concurrent analyses revealed similar findings (64.7% for ePA vs 62.3% control prescriptions, aRR: 1.03, 95%CI: 0.98-1.09).

DISCUSSION

Challenges with implementation, such as misfiring and insurance fragmentation, could have undermined its effectiveness, providing implications for other health informatics interventions deployed in outpatient care.

CONCLUSION

Despite increasing interest in implementing ePA to improve prescription filling, adoption did not change medication adherence.

Impact of pharmacist-led interventions in improving adherence to glaucoma medications in the geriatric population

OBJECTIVES

Geriatric patients can be non-adherent to ophthalmic glaucoma medications because of complex eye drops instillation techniques and forgetfulness, so pharmacists can play their part in improving the clinical outcomes of patients by acting as care providers. The purpose of the current study was to implement various pharmacist-led interventions to improve adherence to glaucoma medications and to evaluate the outcomes of interventions in the geriatric population.

METHODS

The Morisky Green Levine (MGL) adherence scale was used for analysis because it measures the extent of non-adherence and analyses the reasons for it. The interview-based sessions were conducted with control and interventional groups followed by educational interventions, including techniques for eye drop instillation, graphical images, precautionary measures, and individual patient counselling for the interventional group. Patients were asked to complete the adherence scale after the conclusion of every follow-up session for a duration of 6 months.

RESULTS

After 6 months of pharmacist-led interventions, a significant shift was found in the interventional group from low to high adherence according to MGL scale evaluation. Moreover, the number of patients in the interventional group whose intraocular pressure was in the safe range significantly increased and follow-up sessions significantly improved the patient's knowledge about glaucoma.

CONCLUSION

The results of this pharmacist-led educational interventional study showed it was effective in improving adherence to glaucoma medications in the geriatric patients, who showed better adherence scores and improved intraocular pressure.

The clinical impact of adherence to therapy in airways disease

For a physician, the final step of a consultation consists of developing a treatment plan and prescription. For the patient, this is the start of a process. First, their role in the treatment plan must be clarified, then they may have to obtain an alternative prescription from their general practitioner. Next, they must have the prescription filled and dispensed from the pharmacy and, finally, they must take the treatment on time and for the required duration. For people with chronic conditions, this requires repeatedly returning to the pharmacy for the prescription to be renewed and dispensed. Given that many patients are on multiple treatment regimens and may have poor health literacy, this becomes a complex process and it is not surprising that this can, and frequently does, go wrong.

Research shows that when a patient does not adhere to standard asthma or COPD treatment, they report poor control and overuse of rescue β-agonists, experience frequent exacerbations and are often prescribed add-on treatments such as biological agents. In short, poor treatment adherence can manifest in the same way as a refractory condition.

These clinical features should prompt a clinician to investigate poor adherence as they might investigate a new blood or radiological finding. Examining a patient's prescription refill records or a digitally enabled inhaler can demonstrate a number of patterns of inhaler use. A small minority regularly use their treatment as prescribed but many appear to be “cluster users”: a group of patients who use their treatment correctly when they are unwell, but once some level of personal control is attained, they cease or reduce their use. Others may cease using their treatment because they are not perceiving a benefit or because an alternative condition accounts for their symptoms. In other words, clinicians can consider that treatment adherence is like a clinical sign: something to be investigated so that they may understand the patient's condition better.

Suspected poor treatment adherence should be treated as a clinical sign. It should be suspected among patients with asthma and COPD who have excessive reliever use or recurrent exacerbations. It can be detected using pharmacy data or electronic devices.https://bit.ly/3oqwS5L

Treatment Adherence in Integrative Medicine-Part One: Review of Literature

Treatment adherence is a topic that is well studied but not well understood. Low treatment adherence is a significant issue that limits the effective management and treatment of chronic conditions, creating significant health care burden, costs, and poor patient outcomes. This report provides a review of the factors that facilitate or create barriers to treatment adherence, as well as strategies recommended to overcome adherence barriers. A total of 25 interviews were conducted with practitioners demonstrating both high (n = 16) and low (n = 9) treatment adherence rates. A total of 185 survey responses were received from high-treatment adherence rate practitioners (n = 21), low-treatment adherence rate practitioners (n = 83), and practitioners that were neither in the high- or low-treatment adherence rate range (n = 81). Practitioner prescribing behaviors and adherence statistics were determined and stratified by high-treatment adherence rate and low-treatment adherence rate practitioners. From the interviews, 78% of low-rate practitioners mentioned that establishing trust is a primary best practice for optimizing adherence, and for high-rate practitioners, 69% thought that facilitating trust was important to optimizing adherence. Both low- and high-adherence rate practitioners prioritized using a staged approach as a strategy to overcome barriers to adherence. From the total survey sample it was found that key strategies to improving adherence included the practice of booking follow-up appointments, using lab results to explain treatment plans, and using a staged approach for treatment plans. Our research sought to elicit strategies and skills that can help improve treatment adherence in integrative medicine and our findings have identified several common practices that can help to improve adherence. Research taking advantage of mobile devices and the internet for adherence has started to expand within the last 10 to 15 years. Technology has the potential to lead the development and establishment of a centralized database that acquires adherence information and provides solutions to its practitioners and patients. Further work to advance the field of integrative medicine through additional research and interventions that support treatment adherence would be valuable to the effective treatment and management of integrative medicine patients.

Primary nonadherence to statin medications: Survey of patient perspectives

Statin medications reduce cardiovascular events, but many patients never start taking their prescribed statin (primary nonadherence). Limited knowledge exists about the attitudes and beliefs of those with primary nonadherence. In this study, patients with primary nonadherence to statin medications (n = 173) completed a self-administered cross-sectional survey that assessed their attitudes and beliefs related to primary nonadherence and to potential motivators for statin use. Patients were recruited in 2019 from two academic health systems and nationwide internet advertisements. Only 49 of 173 (28.3%) patients with primary nonadherence reported having cardiovascular disease (CVD). Ninety-nine patients (57.2%) never filled their prescription, and 74 (42.8%) filled but never took any statin. Over half failed to initially inform their prescriber they might not take the statin. Patients strongly or somewhat agreed that they desired alternate treatment plans such as diet and/or exercise (n = 134; 77.4%) or natural remedies/dietary supplements (n = 125; 72.3%). Ninety-eight (56.6%) stronglyor somewhat worried about the possibility of statin dependence or addiction. Twenty-seven (15.6%) patients noted that they would not take a statin based solely on CVD risk estimates; 50 (28.9%) selected a CVD risk threshold of >20%; and 23 (13.3%) a threshold of >50% as motivating factors to take statins. Patients with primary nonadherence have attitudes about taking statins based on CVD risk that differ from scientific recommendations, may not tell providers about their hesitation to take statins, and likely prefer alternative initial approaches to cholesterol lowering. Early shared decision-making and assessment of patient attitudes about statins could potentially better align initial approaches for CVD risk reduction.

The Prevalence of Opioid Analgesic Use in People with Chronic Noncancer Pain: Systematic Review and Meta-Analysis of Observational Studies

OBJECTIVE

To review studies examining the proportion of people with chronic noncancer pain who report consuming opioids and characteristics associated with their use.

DESIGN

Systematic review.

METHODS

We searched databases from inception to February 8, 2020, and conducted citation tracking. We included observational studies reporting the proportion of adults with chronic noncancer pain who used opioid analgesics. Opioids were categorized as weak (e.g., codeine) or strong (e.g., oxycodone). Study risk of bias was assessed, and Grading of Recommendations Assessment, Development and Evaluations provided a summary of the overall quality. Results were pooled using a random-effects model. Meta-regression determined factors associated with opioid use.

RESULTS

Sixty studies (N=3,961,739) reported data on opioid use in people with chronic noncancer pain from 1990 to 2017. Of these 46, 77% had moderate risk of bias. Opioid use was reported by 26.8% (95% confidence interval [CI], 23.1-30.8; moderate-quality evidence) of people with chronic noncancer pain. The use of weak opioids (17.3%; 95% CI 11.9-24.4; moderate-quality evidence) was more common than the use of strong opioids (9.8%; 95% CI, 6.8-14.0; low-quality evidence). Meta-regression determined that opioid use was associated with geographic region (P=0.02; lower in Europe than North America), but not sampling year (P=0.77), setting (P=0.06), diagnosis (P=0.34), or disclosure of funding (P=0.77).

CONCLUSIONS

Our review summarized data from over 3.9 million people with chronic noncancer pain reporting their opioid use. Between 1990 and 2017, one-quarter of people with chronic noncancer pain reported taking opioids, and this proportion did not change over time.

Assessment of Anti-Hypertensive Drug Adherence by Serial Aldosterone-To-Renin Ratio Measurement

Reduced or absent compliance to anti-hypertensive treatment is a major obstacle to the achievement of blood pressure target in patients with arterial hypertension. Current available methods for therapeutic adherence assessment display low accuracy, limited applicability in clinical practice and/or high costs. We designed a prospective study to evaluate the accuracy of serial measurement of ARR to assess the therapeutic compliance to RAAS inhibitors. We prospectively enrolled 80 subjects: 40 patients with arterial hypertension and 40 normotensive controls. The ARR was evaluated at baseline and 2 and 8 week after initiation of a RAAS inhibitor in patients with hypertension, and at baseline and 2 weeks for the control group. Adherence to the prescribed therapy was confirmed by therapeutic drug monitoring. We observed a significant increase of renin levels and reduction of aldosterone levels after RAAS inhibitors initiation, with consequent reduction of ARR. Delta ARR (ΔARR), defined as relative change in ARR before and after treatment initiation, provided high accuracy for determination of therapeutic compliance, with an AUC of 0.900 at 2 weeks and 0.886 at 8 weeks. A cut-off of −48% of ΔARR provided 90% sensitivity and 75% specificity, at 2 and 8 weeks. In conclusion, the measurement of ΔARR is a powerful test, cheap and widely available to accurately identify the non-adherence to RAAS inhibitors treatment. Herein we propose the implementation of ΔARR in clinical practice through a multi-step flow-chart for the management of patients with uncontrolled blood pressure, with identification of those suspected of non-adherence, reserving therapeutic drug monitoring for non-adherence confirmation.

Long-Acting Formulations: A Promising Approach for the Treatment of Chronic Diseases

Medication and patient adherence are the two main aspects of any successful treatment of chronic disease. Even though diseases and its treatment existed for several hundred years, the treatment optimization for a given patient is still a researcher question for scientists. There are differences in treatment duration, prognostic signs and symptoms between patient to patient. Hence, designing ideal formulation to suit individual patient is a challenging task. The conventional formulations like oral solids and liquids gives a partial or incomplete treatment because the patient needs to follow the daily pills for a longer time. In such cases, the long-acting formulations will have better patient compliances as drug will be released for a longer duration. Many such approaches are under the clinical investigation. The favorable pharmacokinetic and pharmacodynamic relationships, will be promising option for the treatment of chronic diseases. In this review, we have highlighted the importance of long-acting formulations in the treatment of chronic diseases and the advent of newer formulation technologies.

Medication adherence in hypertension

: Suboptimal adherence to antihypertensive medication is a major contributor to poor blood pressure control. Several methods, direct or indirect, are available for measuring adherence, including the recently developed biochemical screening, although there is no gold-standard method routinely used in clinical practice to accurately assess the different facets of adherence. Adherence to treatment is a complex phenomenon and several of the barriers to adherence will need to be addressed at the healthcare system level; however, when looking at adherence from a more practical side and from the practitioner's perspective, the patient-practitioner relationship is a key element both in detecting adherence and in attempting to choose interventions tailored to the patient's profile. The use of single-pill combinations enabling simplification of treatment regimen, the implementation of a collaborative team-based approach and the development of electronic health tools also hold promise for improving adherence, and thus impacting cardiovascular outcomes and healthcare costs.

The impact of medication synchronization programs on medication adherence: A meta-analysis

BACKGROUND

Medication nonadherence is associated with more than $100 billion in preventable medical costs each year in the United States. Medication synchronization (med sync) programs have emerged as a potential solution to addressing nonadherence.

OBJECTIVES

To assess the impact of med sync programs on adherence in adults on chronic medications through a meta-analysis.

METHODS

A comprehensive literature search was conducted for studies of med sync and adherence in adults published in English from database inception to May 2020. Studies were included if they provided a description of the med sync program, reported a quantitative measure of medication adherence using the proportion of days covered metric, and were conducted in the United States. The search terms included "medication synchronization," "med sync," "adherence," and "PDC." Pooled odds ratios (ORs) and 95% CIs using random-effects models were calculated to assess overall impact and subgroup analyses. The risk of bias of individual studies was assessed using the Downs and Black checklist.

RESULTS

Nine studies reporting 30 effect sizes were included in the meta-analysis. On the basis of the Downs and Black checklist, the methodological quality of the studies was fair (mean [SD] 17.6 [1.7]). Med sync was associated with greater odds of adherence (pooled OR 2.29 [95% CI 1.99-2.64], I² = 93.3%, τ² = 1.11). In addition, the type of med sync program influenced the variation in effect sizes (Cochran Q statistic [Q_between] = 45.4, P < 0.001), with appointment-based med sync programs having the largest impact on adherence (3.14 [95% CI 2.72-3.63]).

CONCLUSION

In this meta-analysis of the impact of med sync on adherence, med sync was associated with statistically significant improvement in adherence. Policy makers and payers should consider reimbursement to pharmacies to support med sync programs in efforts to combat medication nonadherence and improve health outcomes.

A Pharmacist and Health Coach-Delivered Mobile Health Intervention for Type 2 Diabetes: Protocol for a Randomized Controlled Crossover Study

BACKGROUND

Aggressive management of blood glucose, blood pressure, and cholesterol through medication and lifestyle adherence is necessary to minimize the adverse health outcomes of type 2 diabetes. However, numerous psychosocial and environmental barriers to adherence prevent low-income, urban, and ethnic minority populations from achieving their management goals, resulting in diabetes complications. Health coaches working with clinical pharmacists represent a promising strategy for addressing common diabetes management barriers. Mobile health (mHealth) tools may further enhance their ability to support vulnerable minority populations in diabetes management.

OBJECTIVE

The aim of this study is to evaluate the impact of an mHealth clinical pharmacist and health coach-delivered intervention on hemoglobin A1c (HbA1c, primary outcome), blood pressure, and low-density lipoprotein (secondary outcomes) in African-Americans and Latinos with poorly controlled type 2 diabetes.

METHODS

A 2-year, randomized controlled crossover study will evaluate the effectiveness of an mHealth diabetes intervention delivered by a health coach and clinical pharmacist team compared with usual care. All patients will receive 1 year of team intervention, including lifestyle and medication support delivered in the home with videoconferencing and text messages. All patients will also receive 1 year of usual care without team intervention and no home visits. The order of the conditions received will be randomized. Our recruitment goal is 220 urban African-American or Latino adults with uncontrolled type 2 diabetes (HbA1c ≥8%) receiving care from a largely minority-serving, urban academic medical center. The intervention includes the following: health coaches supporting patients through home visits, phone calls, and text messaging and clinical pharmacists supporting patients through videoconferences facilitated by health coaches. Data collection includes physiologic (HbA1c, blood pressure, weight, and lipid profile) and survey measures (medication adherence, diabetes-related behaviors, and quality of life). Data collection during the second year of study will determine the maintenance of any physiological improvement among participants receiving the intervention during the first year.

RESULTS

Participant enrollment began in March 2017. We have recruited 221 patients. Intervention delivery and data collection will continue until November 2021. The results are expected to be published by May 2022.

CONCLUSIONS

This is among the first trials to incorporate health coaches, clinical pharmacists, and mHealth technologies to increase access to diabetes support among urban African-Americans and Latinos to achieve therapeutic goals.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/17170.

Implementation of a care manager organisation and its association with antidepressant medication patterns: a register-based study of primary care centres in Sweden

OBJECTIVE

To evaluate the implementation of a care manager organisation for common mental disorders and its association with antidepressant medication patterns on primary care centre (PCC) level, compared with PCCs without this organisation. Moreover, to determine whether a care manager organisation is associated with antidepressant medication patterns that is more in accordance with treatment guidelines.

DESIGN

Register-based study on PCC level.

SETTING

Primary care in Region Västra Götaland, Sweden.

PARTICIPANTS

All PCCs in the region. PCCs were analysed in three subgroups: PCCs with a care manager organisation during 2015 and 2016 (n=68), PCCs without the organisation (n=92) and PCCs that shifted to a care manager organisation during 2016 (n=42).

OUTCOME MEASURES

Proportion of inadequate medication users, defined as number of patients >18 years with a common mental disorder diagnosis receiving care at a PCC in the region during the study period and dispensed 1-179 defined daily doses (DDD) of antidepressants of total patients with at least 1 DDD. The outcome was analysed through generalised linear regression and a linear mixed-effects model.

RESULTS

Overall, all PCCs had about 30%-34% of inadequate medication users. PCCs with a care manager organisation had significantly lower proportion of inadequate medication users in 2016 compared with PCCs without (-6.4%, p=0.02). These differences were explained by higher proportions in privately run PCCs. PCCs that shifted to a care manager organisation had a significant decrease in inadequate medication users over time (p=0.01).

CONCLUSIONS

Public PCCs had a more consistent antidepressant medication pattern compared with private PCCs that gained more by introducing a care manager organisation. It was possible to document a significant decrease in inadequate medication users, notwithstanding that PCCs in the region followed the guidelines to a comparatively high extent regardless of present care manager organisation.

Early Insights From a Digitally Enhanced Diabetes Self-Management Education and Support Program: Single-Arm Nonrandomized Trial

BACKGROUND

Translation of diabetes self-management education and support (DSMES) into a digital format can improve access, but few digital programs have demonstrated outcomes using rigorous evaluation metrics.

OBJECTIVE

The aim of this study was to evaluate the impact of a digital DSMES program on hemoglobin A_1c (HbA_1c) for people with type 2 diabetes.

METHODS

A single-arm, nonrandomized trial was performed to evaluate a digital DSMES program that includes remote monitoring and lifestyle change, in addition to comprehensive diabetes education staffed by a diabetes specialist. A sample of 195 participants were recruited using an online research platform (Achievement Studies, Evidation Health Inc). The primary outcome was change in laboratory-tested HbA_1c from baseline to 4 months, and secondary outcomes included change in lipids, diabetes distress, and medication adherence.

RESULTS

At baseline, participants had a mean HbA_1c of 8.9% (SD 1.9) and mean BMI of 37.5 kg/m² (SD 8.3). The average age was 45.1 years (SD 8.9), 70% were women, and 67% were White. At 4-month follow up, the HbA_1c decreased by 0.8% (P<.001, 95% CI -1.1 to -0.5) for the total population and decreased by 1.4% (P<.001, 95% CI -1.8 to -0.9) for those with an HbA_1c of >9.0% at baseline. Diabetes distress and medication adherence were also significantly improved between baseline and follow up.

CONCLUSIONS

This study provides early evidence that a digitally enhanced DSMES program improves HbA_1c and disease self-management outcomes.

Adherence to Oral Nutritional Supplements After Being Discharged from the Hospital is Low but Improves Outcome in Patients with Advanced Chronic Liver Disease

PURPOSE

Patients with advanced chronic liver disease (ACLD) often have a poor nutritional status. In the management, current guidelines recommend dietary counseling and oral nutritional supplements (ONS). Nutritional goals and adherence to ONS are difficult to achieve while studies addressing adherence are scarce. We aimed to evaluate adherence to ONS, the associated factors, and its impact on outcome among ALCD patients who are discharged from the hospital.

PATIENTS AND METHODS

We identified consecutive hospitalized patients with ACLD from the cirrhosis registry and ONS prescription at discharge. Baseline demographics, anthropometrics, hand-grip strength (HGS), nutritional, and laboratory parameters were recorded. Adherence was assessed at 30, 90, and 180 days, but not in patients who did not survive or in those who underwent liver transplantation (LT) before the time-point.

RESULTS

From the registry containing 1004 patients, we included 450 cases, the median age was 56.3 (IQR 47-62), 60% were males, 63.8% had alcoholic etiology, and the median model for end-stage liver disease score (MELD) was 16 (11-21). During follow-up, 13.6%, 23.6%, and 31.1% of patients have died within 30, 90, and 180 days, respectively, and 21 underwent LT. Adherence to ONS in surviving patients was observed in 46%, 26.1%, and 16.9% within 30, 90, and 180 days, respectively. Baseline refractory ascites (HR=0.43, 0.24-0.76), HGS (HR=1.03, 1.01-1.06), and mid-arm circumference (HR=0.93, 0.88-0.99) were independently associated with 30-day adherence. Among patients who survived beyond 30 days, adherents for >30 days had improved synthetic liver function, HGS, a higher probability of LT (HR=1.7, 1.03-2.8) and lower risk of death (HR=0.65, 0.45-0.89), particularly those with MELD>16 (OR=0.55, 0.36-0.85) and low HGS (OR=0.61, 0.39-0.93).

CONCLUSION

In ACLD patients after discharge, adherence to ONS steeply declined and was associated with baseline refractory ascites and low muscle strength. Adherence to ONS also improved liver function, muscle strength, and survival.

Community Medication Education, Data, & Safety (C-MEDS): Findings from a Pilot Project

OBJECTIVES

Medication-related problems remain one of the largest health risks for older adults, yet there are few resources available to effectively reduce medication-related problems for community dwelling older adults. The aim of this pilot program was to determine the effectiveness of a multifaceted medication intervention on medication adherence and self-efficacy in medication use.

DESIGN

A single sample, pre-post-test design.

SETTING

This pilot study was conducted at Independence at Home, a Senior Care Action Network (SCAN) community service in Southern California.

PARTICIPANTS

One hundred and eighty community-dwelling, diverse older adults with potential medication-related problems and their caregivers.

INTERVENTION

The Community Medication Education, Data, & Safety (C-MEDS) Program identified community-dwelling older adults with potential medication-related problems and provided in-depth personalized medication safety, management and support, based on an in-home assessment and interventions delivered by trained geriatrics experts including pharmacists, nurses, a community health worker, and a pharmacy technician.

MEASUREMENTS

The primary outcomes included medication use self-efficacy, measured by the MUSE, and select medication adherence measures. Adherence was measured via pill count and via the MedAdhIR tool, a scale that measures risk for medication non-adherence.

RESULTS

Following participation in the C-MEDS program, community-dwelling older adult C-MEDS graduates (n = 105) had higher self-efficacy in managing medications (P < .001). Additionally, C-MEDS graduates also exhibited increased adherence to three types of medications (statins, diabetes-related, and certain hypertension drugs; P < .001). Moreover, risk of non-adherence declined significantly following C-MEDS graduation (P < .001).

CONCLUSION

C-MEDS holds promise as an effective intervention among community-dwelling older adults in improving medication self-efficacy, medication adherence among select medications, and reducing risk for non-adherence. Additional studies are needed to assess replicability and impact on clinical outcomes.