Does packaging with a calendar feature improve adherence to self-administered medication for long-term use? A systematic review

Multidrug punch cards in primary care: a mixed methods study on patients' preferences and impact on adherence

Background: Multidrug punch cards are frame cards with 28 plastic cavities filled with a patient's oral solid medication. They are used in primary care to facilitate medication management and to enhance adherence. Main criticism concerned handling difficulties and fading knowledge about medication of patients using them. This study aimed at exploring daily use, preferences, and adherence of primary care patients using multidrug punch cards.

Methods: Community pharmacies in Switzerland recruited primary care patients using multidrug punch cards. A mixed methods approach was applied with quantitative interviews performed by telephone and qualitative interviews face-to-face.

Results: Of 149 eligible patients from 21 community pharmacies, 22 participated 2011 in the quantitative and 11 participated 2013/14 in the qualitative interview. Patients were very satisfied with the multidrug punch cards and stated increased medication safety. All considered adherence as very important. Self-reported adherence was 10 (median) on a visual analog scale (0 = no intake, 10 = perfect adherence). The absence of package inserts and predefined handling difficulties e.g., tablets spiking at removal were not perceived as problems.

Conclusions: Patients are satisfied with the multidrug punch cards, feel safe, mostly have no handling problems and adhere to their treatment. Trust in health-care professionals and patients' experiences emerged as key variables for initiating multidrug punch card use and for medication adherence. This mixed methods study invalidates previous concerns about disadvantages of multidrug punch cards. Health-care professionals should actively recommend them for primary care patients with polypharmacy and poor adherence.

Care transitions: a leverage point for safe and effective medication use in older adults--a mini-review

Older adults often face challenges as they transition out of the acute care hospital, especially with regard to adhering to their medications. In this narrative review, we discuss medication adherence in older adults across the continuum of care, describing reasons for nonadherence, methods to assess adherence and tools to improve adherence, with particular focus on emerging techniques and technologies. Taking steps at care transitions to assess medications and foster adherence to the medication regimen can increase the safety of older adults following hospitalization.

Non-adherence to cardiovascular medications

Despite evidence-based interventions, coronary heart disease (CHD) remains a leading cause of global mortality. As therapies advance, patient non-adherence to established treatments is well recognized. Non-adherence is a powerful confounder of evidence-based practice and can affect daily patient management, resulting in inappropriate therapeutic escalation with greater costs and potential for harm. Moreover, it increases risk for adverse cardiac events, including mortality. Yet, non-adherence is complex, remains difficult to define, and provider ability to identify its presence accurately remains limited. Improved screening tools are needed to detect at-risk patients, enabling appropriate targeting of interventions. Given the rapidly expanding global population with CHD and emerging clinical and cost-benefits of adherence, addressing non-adherence to prescribed therapies is a top priority.

The economics of medicines optimization: policy developments, remaining challenges and research priorities

BACKGROUND

This review scopes the evidence on the effectiveness and cost-effectiveness of interventions to improve suboptimal use of medicines in order to determine the evidence gaps and help inform research priorities.

SOURCES OF DATA

Systematic searches of the National Health Service (NHS) Economic Evaluation Database, the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects.

AREAS OF AGREEMENT

The majority of the studies evaluated interventions to improve adherence, inappropriate prescribing and prescribing errors.

AREAS OF CONTROVERSY

Interventions tend to be specific to a particular stage of the pathway and/or to a particular disease and have mostly been evaluated for their effect on intermediate or process outcomes.

GROWING POINTS

Medicines optimization offers an opportunity to improve health outcomes and efficiency of healthcare.

AREAS TIMELY FOR DEVELOPING RESEARCH

The available evidence is insufficient to assess the effectiveness and cost-effectiveness of interventions to address suboptimal medicine use in the UK NHS. Decision modelling, evidence synthesis and elicitation have the potential to address the evidence gaps and help prioritize research.

Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews

BACKGROUND

Many systematic reviews exist on interventions to improve safe and effective medicines use by consumers, but research is distributed across diseases, populations and settings. The scope and focus of such reviews also vary widely, creating challenges for decision-makers seeking to inform decisions by using the evidence on consumers' medicines use.This is an update of a 2011 overview of systematic reviews, which synthesises the evidence, irrespective of disease, medicine type, population or setting, on the effectiveness of interventions to improve consumers' medicines use.

OBJECTIVES

To assess the effects of interventions which target healthcare consumers to promote safe and effective medicines use, by synthesising review-level evidence.

METHODS

SEARCH METHODS

We included systematic reviews published on the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects. We identified relevant reviews by handsearching databases from their start dates to March 2012.

SELECTION CRITERIA

We screened and ranked reviews based on relevance to consumers' medicines use, using criteria developed for this overview.

DATA COLLECTION AND ANALYSIS

We used standardised forms to extract data, and assessed reviews for methodological quality using the AMSTAR tool. We used standardised language to summarise results within and across reviews; and gave bottom-line statements about intervention effectiveness. Two review authors screened and selected reviews, and extracted and analysed data. We used a taxonomy of interventions to categorise reviews and guide syntheses.

MAIN RESULTS

We included 75 systematic reviews of varied methodological quality. Reviews assessed interventions with diverse aims including support for behaviour change, risk minimisation and skills acquisition. No reviews aimed to promote systems-level consumer participation in medicines-related activities. Medicines adherence was the most frequently-reported outcome, but others such as knowledge, clinical and service-use outcomes were also reported. Adverse events were less commonly identified, while those associated with the interventions themselves, or costs, were rarely reported.Looking across reviews, for most outcomes, medicines self-monitoring and self-management programmes appear generally effective to improve medicines use, adherence, adverse events and clinical outcomes; and to reduce mortality in people self-managing antithrombotic therapy. However, some participants were unable to complete these interventions, suggesting they may not be suitable for everyone.Other promising interventions to improve adherence and other key medicines-use outcomes, which require further investigation to be more certain of their effects, include:· simplified dosing regimens: with positive effects on adherence;· interventions involving pharmacists in medicines management, such as medicines reviews (with positive effects on adherence and use, medicines problems and clinical outcomes) and pharmaceutical care services (consultation between pharmacist and patient to resolve medicines problems, develop a care plan and provide follow-up; with positive effects on adherence and knowledge).Several other strategies showed some positive effects, particularly relating to adherence, and other outcomes, but their effects were less consistent overall and so need further study. These included:· delayed antibiotic prescriptions: effective to decrease antibiotic use but with mixed effects on clinical outcomes, adverse effects and satisfaction;· practical strategies like reminders, cues and/or organisers, reminder packaging and material incentives: with positive, although somewhat mixed effects on adherence;· education delivered with self-management skills training, counselling, support, training or enhanced follow-up; information and counselling delivered together; or education/information as part of pharmacist-delivered packages of care: with positive effects on adherence, medicines use, clinical outcomes and knowledge, but with mixed effects in some studies;· financial incentives: with positive, but mixed, effects on adherence.Several strategies also showed promise in promoting immunisation uptake, but require further study to be more certain of their effects. These included organisational interventions; reminders and recall; financial incentives; home visits; free vaccination; lay health worker interventions; and facilitators working with physicians to promote immunisation uptake. Education and/or information strategies also showed some positive but even less consistent effects on immunisation uptake, and need further assessment of effectiveness and investigation of heterogeneity.There are many different potential pathways through which consumers' use of medicines could be targeted to improve outcomes, and simple interventions may be as effective as complex strategies. However, no single intervention assessed was effective to improve all medicines-use outcomes across all diseases, medicines, populations or settings.Even where interventions showed promise, the assembled evidence often only provided part of the picture: for example, simplified dosing regimens seem effective for improving adherence, but there is not yet sufficient information to identify an optimal regimen.In some instances interventions appear ineffective: for example, the evidence suggests that directly observed therapy may be generally ineffective for improving treatment completion, adherence or clinical outcomes.In other cases, interventions may have variable effects across outcomes. As an example, strategies providing information or education as single interventions appear ineffective to improve medicines adherence or clinical outcomes, but may be effective to improve knowledge; an important outcome for promoting consumers' informed medicines choices.Despite a doubling in the number of reviews included in this updated overview, uncertainty still exists about the effectiveness of many interventions, and the evidence on what works remains sparse for several populations, including children and young people, carers, and people with multimorbidity.

AUTHORS' CONCLUSIONS

This overview presents evidence from 75 reviews that have synthesised trials and other studies evaluating the effects of interventions to improve consumers' medicines use.Systematically assembling the evidence across reviews allows identification of effective or promising interventions to improve consumers' medicines use, as well as those for which the evidence indicates ineffectiveness or uncertainty.Decision makers faced with implementing interventions to improve consumers' medicines use can use this overview to inform decisions about which interventions may be most promising to improve particular outcomes. The intervention taxonomy may also assist people to consider the strategies available in relation to specific purposes, for example, gaining skills or being involved in decision making. Researchers and funders can use this overview to identify where more research is needed and assess its priority. The limitations of the available literature due to the lack of evidence for important outcomes and important populations, such as people with multimorbidity, should also be considered in practice and policy decisions.

Avoidable hospitalizations in youth with kidney failure after transfer to or with only adult care

OBJECTIVE

Hospital admissions for ambulatory care-sensitive conditions (also called avoidable hospitalizations) are a measure of quality and access to outpatient care. We determined if young patients with end-stage renal disease (ESRD) are at increased risk of avoidable hospitalizations.

METHODS

A national organ failure registry was used to identify patients with ESRD onset at <22 years of age between April 1, 2001, and March 31, 2010, who had received care in an adult care facility after age 15 years. The cohort was linked to the national hospitalizations database to identify avoidable hospitalizations relevant for young patients with ESRD. Patients were followed up until death, loss to follow-up, or study end. Two groups were studied: (1) patients transferred from pediatric to adult care; and (2) patients receiving ESRD care exclusively in adult centers. We determined the association between overall and avoidable hospitalization rates and both age and transfer status by using Poisson regression models.

RESULTS

Our cohort included 349 patients. Among the 92 (26.4%) patients transferred to adult care during the study period, avoidable hospitalization rates were highest during the period 3 to <4 years after transfer (rate ratio: 3.19 [95% confidence interval: 1.42-7.18]) compared with the last year in pediatric care. Among the 257 (73.6%) patients who received ESRD care exclusively in adult centers, avoidable hospitalization rates increased with age.

CONCLUSIONS

Among those who were transferred to adult care, avoidable hospitalization rates increased after transfer. Avoidable hospitalization rates increased with age in ESRD patients who received care in adult centers. Young patients with ESRD are at increased risk of avoidable hospitalizations.

Effect of drug reminder packaging on medication adherence: a systematic review revealing research gaps

BACKGROUND

This was a systematic review of the literature in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Evidence mapping was used to reveal the effect of drug reminder packaging on medication adherence, to identify research gaps and to make suggestions for future research.

METHODS

PubMed, Embase, CINAHL and PsycINFO were searched with an end date of September 2013 using the Medical Subject Headings (MeSH) term 'medication adherence' and 20 different search terms for 'drug reminder packaging', limited to the English and German languages. Additional references were identified through cross-referencing. All prospective controlled trials with an intervention using drug reminder packaging for patients taking at least one medication without the assistance of a health-care professional were included in the evidence mapping of the effect of drug reminder packaging on adherence and outcomes according to the Economic, Clinical and Humanistic Outcomes (ECHO) model.

RESULTS

A total of 30 studies met the inclusion criteria: 10 randomized controlled trials, 19 controlled clinical trials and 1 cohort study. Drug reminder packaging had a significant effect on at least one adherence parameter in 17 studies (57%). The methodological quality was strong in five studies. Two studies provided complete information. Clear research gaps emerged.

CONCLUSIONS

Overall, the studies showed a positive effect of drug reminder packaging on adherence and clinical outcomes. However, poor reporting and important gaps like missing humanistic and economic outcomes and neglected safety issues limit the drawing of firm conclusions. Suggestions are made for future research.

Individualization of drug therapy in older people

Older people are high consumers of prescription drugs and are at increasing risk of polypharmacy and adverse reactions. Pharmacokinetic and pharmacodynamic modifications due to age and co-morbidities are an important consideration, but pharmacological background evidence to guide safe and effective therapeutic approaches are often inadequate since the older population is under-represented in clinical trials. We review the pharmacokinetic and pharmacodynamic changes that are characteristic in old age and consider evidence regarding potentially safer prescription and monitoring of drugs commonly used in older patients. We also introduce the possible role of pharmacogenomics and therapeutic drug monitoring as tools to guide the individualization of drug therapy.

Smartphone medication adherence apps: potential benefits to patients and providers

OBJECTIVES

To provide an overview of medication adherence, discuss the potential for smartphone medication adherence applications (adherence apps) to improve medication nonadherence, evaluate features of adherence apps across operating systems (OSs), and identify future opportunities and barriers facing adherence apps.

PRACTICE DESCRIPTION

Medication nonadherence is a common, complex, and costly problem that contributes to poor treatment outcomes and consumes health care resources. Nonadherence is difficult to measure precisely, and interventions to mitigate it have been largely unsuccessful.

PRACTICE INNOVATION

Using smartphone adherence apps represents a novel approach to improving adherence. This readily available technology offers many features that can be designed to help patients and health care providers improve medication-taking behavior.

MAIN OUTCOME MEASURES

Currently available apps were identified from the three main smartphone OSs (Apple, Android, and Blackberry). In addition, desirable features for adherence apps were identified and ranked by perceived importance to user desirability using a three-point rating system: 1, modest; 2, moderate; or 3, high. The 10 highest-rated apps were installed and subjected to user testing to assess app attributes using a standard medication regimen. RESULTS 160 adherence apps were identified and ranked. These apps were most prevalent for the Android OS. Adherence apps with advanced functionality were more prevalent on the Apple iPhone OS. Among all apps, MyMedSchedule, MyMeds, and RxmindMe rated the highest because of their basic medication reminder features coupled with their enhanced levels of functionality.

CONCLUSION

Despite being untested, medication apps represent a possible strategy that pharmacists can recommend to nonadherent patients and incorporate into their practice.

Self-reported adherence to medications in a pediatric renal clinic: psychological aspects

Background

Chronically ill children and adolescents comprise a vulnerable population that requires specific considerations in order to positively impact their treatment outcome. Pediatric renal patients can be non-compliant and also forgetful in taking their medications.

Objective

The objectives of the study were to (a) assess medication adherence and (b) to identify emotionality and variables that influence non-adherence by use of “The Child & Adolescent Adherence to Medication Questionnaire” (CAAMQ), which was constructed at Texas Tech University Health Sciences Center.

Methods

Pediatric renal patients from 10 to 21 years-of-age, taking three or more medications, for longer than a three-month period, were eligible to complete the CAAMQ.

Results

Thirty-four patients participated in the study. Many of the respondents had problems remembering to take their medications on weekends (P = 0.021). The majority of the patients stated that they were not bothered about having to take their medications (70.6%); and that taking pills did not interfere with their daily activities (85.3%). Open-ended questions in the CAAMQ identified patients’ feelings of sadness, distress, and the importance of strong family support systems. The study participants reported that they preferred to take their medications at school, in the nurses’ office or in a place where privacy was assured. The results indicated that Prednisone was the most disliked of all of the medications. Female patients were more reactive and secretive than males regarding peers knowing about their disease and medication schedules (P<0.017).

Conclusions

Non-adherence in pediatric patients is a complex and serious problem, which ultimately affects the patients’ health. Privacy and daily routine were found to impact the patients’ adherence to medications. Creative and individualized reminders for teenagers need to be developed and validated. Further studies that take into consideration developmental and motivational factors may help researchers identify modifiable psychosocial predictors that will lead to improved medication adherence.

Patient adherence and persistence with Imatinib, Nilotinib, Dasatinib in clinical practice

Introduction

The aim of this study is to evaluate adherence and persistence of patients treated with Imatinib, Nilotinib or Dasatinib, also giving economic evaluations on therapy costs for Received Daily Dose (RDD).

Materials and Methods

In this retrospective study, we took into account 3 years from 1st Jan. 2009 to 31st March.2012. Treatment adherence was quantified utilizing ratio between RDD and PDD (Prescribed Daily Dose). Persistence is reckoned taking into account the actual therapy days, comparing posology with supplied dose, drawing the graph using Kaplan-Meir method.

Results

Adherence results in values between 0.8 and 1.0 for Nilotinib (Adh  = 0.93), Imatinib (Adh  = 0.83) and Dasatinib (0.85). Imatinib has better persistence, 90% of patients in treatment exceed one year of treatment versus 83.3% for Nilotinib and 80% for Dasatinib. The cost per single day of treatment (cost per RDD) was € 39.41 for Imatinib, € 113.60 for Nilotinib and € 94.84 for Dasatinib.

Conclusion

Patients with CML have a loose of adherence both in first line with Imatinib and in second line of therapy with Dasatinib and Nilotinib. Loss of adherence remains a big problem and could be minimized by a patient-oriented project invlolving physicians, nurses, pharmacists and caregiver.

A smartphone-based medication self-management system with realtime medication monitoring

BACKGROUND

Most patients cannot remember their entire medication regimen and occasionally forget to take their medication.

OBJECTIVES

The objective of the study was to design, develop, and demonstrate the feasibility of a new type of medication self-management system using smartphones with real-time medication monitoring.

METHODS

We designed and developed a smartphone-based medication self-management system (SMSS) based on interviews of 116 patients. The system offered patients two main functions by means of smartphones: (1) storage and provision of an accurate, portable medication history and medication-taking records of patients; and (2) provision of a reminder to take medication only when the patient has forgotten to take his/her medication. These functions were realized by two data input methods: (a) reading of prescription data represented in two-dimensional barcodes using the smartphone camera and getting the photographic images of the pills; and (b) real-time medication monitoring by novel user-friendly wireless pillboxes.

RESULTS

Interviews suggested that a pocket-sized pillbox was demanded to support patient's medication-taking outside the home and pillboxes for home use should be adaptable to the different means of pillbox storage. In accordance with the result, we designed and developed SMSS. Ten patients participated in the feasibility study. In 17 out of 47 cases (36.2%), patients took their medication upon being presented with reminders by the system. Correct medication-taking occurrence was improved using this system.

CONCLUSIONS

The SMSS is acceptable to patients and has the advantage of supporting ubiquitous medication self-management using a smartphone. We believe that the proposed system is feasible and provides an innovative solution to encourage medication self-management.

Definitions, variants, and causes of nonadherence with medication: a challenge for tailored interventions

BACKGROUND

Nonadherence with medication is a complex and multidimensional health care problem. The causes may be related to the patient, treatment, and/or health care provider. As a consequence, substantial numbers of patients do not benefit optimally from pharmacotherapy, resulting in increased morbidity and mortality as well as increased societal costs. Several interventions may contribute to improved adherence. However, most interventions have only a modest effect. Thus, despite the many efforts made, there has been little progress made as yet in tackling the problem of nonadherence.

METHODS

This paper summarizes the definitions and taxonomy of adherence with medication, as well as types and causes of nonadherence. In addition, interventions aimed at improvement of adherence are discussed.

CONCLUSION

There is not just one solution for the nonadherence problem that fits all patients. Most interventions to improve adherence are aimed at all patients regardless of whether they are adherent or not. Recently, a number of tailored interventions have been described in the literature. Modern techniques are useful. Electronic pill boxes combined with Short Message Service reminders are specifically designed to improve unintentional adherence and have resulted in an increase in refill adherence in diabetic patients with suboptimal adherence. Tailored Internet interventions are a possibility for influencing patient drug-taking behavior and show promising results. Tailored counseling interventions targeted at the underlying causes of nonadherence seem an attractive method for supporting patients with their use of drugs. However, despite the plausible theoretical framework, data on long-term health effects of the various interventions are not available. To improve adherence effectively, there is a need for a tailored approach based on the type and cause of nonadherence and the specific needs of the patient.

Persistence, adherence, and toxicity with oral CMF in older women with early-stage breast cancer (Adherence Companion Study 60104 for CALGB 49907)

BACKGROUND

Cyclophosphamide-methotrexate-5-fluorouracil (CMF) is often selected as adjuvant chemotherapy for older patients with early-stage breast cancer due to perceived superior tolerability. We sought to measure persistence with CMF, adherence to oral cyclophosphamide, and the association of these with toxic effects.

PATIENTS AND METHODS

CALGB 49907 was a randomized trial comparing standard chemotherapy (CMF or AC, provider/patient choice) with capecitabine in patients aged ≥65 with stage I-IIIB breast cancer. Those randomized to standard therapy and choosing CMF were prescribed oral cyclophosphamide 100 mg/m(2) for 14 consecutive days in six 28-day cycles. Persistence was defined as being prescribed six cycles of at least one of the three CMF drugs. Adherence was the number of cyclophosphamide doses that women reported they had taken divided by the number prescribed. Persistence and adherence were based on case report forms and medication calendars.

RESULTS

Of 317 randomized to standard chemotherapy, 133 received CMF. Median age was 73 (range 65-88). Seventy-one percent submitted at least one medication calendar; 65% persisted with CMF. Non-persistence was associated with node negativity (P = 0.019), febrile neutropenia (P = 0.002), and fatigue (P = 0.044). Average adherence was 97% during prescribed cycles.

CONCLUSIONS

Self-reported adherence to cyclophosphamide was high, but persistence was lower, which may be attributable to toxic effects.

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.

Real-world impact of reminder packaging on antihypertensive treatment adherence and persistence

BACKGROUND

Patient medication adherence is multidimensional and poses significant concerns to health care professionals. One aspect of adherence is a patient forgetting to take their prescribed medication, which may be improved with reminder packaging (RP). The objective of this analysis was to assess the impact of RP on patient adherence to antihypertensive therapy.

METHODS

This retrospective, propensity score-matched study evaluated patients switching to a single-pill combination of valsartan-hydrochlorothiazide in RP compared with patients remaining on the combination without reminder packaging (non-RP). Patients receiving combination therapy between April 1, 2009 and July 31, 2010 were eligible for inclusion. Patients were propensity score-matched on baseline adherence and background demographic variables, including comorbidities. Medication possession ratio, proportion of days covered, time to refill, and time to discontinuation were evaluated as primary measures of subsequent adherence and persistence.

RESULTS

In a total of 9266 matched patients (4633 participants in both cohorts), adherence was significantly higher in the RP cohort compared with patients in the non-RP cohort (medication possession ratio, RP 80% versus non-RP 73%; proportion of days covered, RP 76% versus non-RP 63%; both P < 0.001). Refill timing was 10 days for RP patients versus 16 days for non-RP patients (P < 0.001). Similar trends were observed with respect to time to discontinuation (RP 196 days, non-RP 174 days; P < 0.001). A higher proportion of RP patients remained on therapy compared with non-RP patients, with patients in the RP group being 17% less likely to discontinue therapy compared with patients in the non-RP group (hazards ratio 0.833; 95% confidence interval 0.793-0.875).

CONCLUSION

This real-world assessment of differences in adherence and persistence rates demonstrated that patients receiving RP were more adherent and persistent with their treatment regimens.

A pharmacoepidemiologic analysis of the impact of calendar packaging on adherence to self-administered medications for long-term use

BACKGROUND

Calendar blister packaging (CBP) that incorporates a day or date feature is a simple medication packaging technology that is designed to improve medication adherence and persistence.

OBJECTIVE

This study was conducted to assess the effect of a new calendar packaging technology on prescription refill adherence and persistence for daily, self-administered, long-term medication use.

METHODS

Anonymized pharmacy dispensing data from a large US mass merchandiser were analyzed. This retrospective cohort study included people aged 18 to 75 years who filled prescriptions for oral lisinopril or enalapril (control group) at a study pharmacy during 1 year before and after the switch of lisinopril packaging from vials to CBP. Cohorts were stratified into new and prevalent medication users. We used linear and logistic regression modeling and propensity score matching to assess the impact of CBP on refill adherence, using medication possession ratio (MPR) and proportion of days covered (PDC), and persistence using length of therapy (LOT).

RESULTS

Our sample comprised 76,321 new users and 249,040 prevalent users. Across all user, medication, and packaging groups, the mean unadjusted LOT decreased in the follow-up year, possibly due to economic recession. The LOT decline was attenuated in the CBP cohort. After adjustment for covariates, CBP use in new and prevalent medication users was associated with significantly higher LOT and PDC but not MPR. The odds of achieving PDC ≥80% were higher by 15% in new users (odds ratio [OR] = 1.15; 95% CI, 1.09-1.21) and 12% in prevalent users (OR = 1.12; 95% CI, 1.09-1.15) who switched to CBP, compared with continued vial use.

CONCLUSIONS

CBP of medication prescribed for daily, self-administered, long-term use was associated with modest improvement in prescription refill adherence and persistence. An adherence strategy of even small effect size that is broadly implemented on a population level could significantly leverage therapeutic effect and provide substantial cumulative public health benefit. Clinical benefit, or harm, associated with use of CBP should be investigated. Usability assessments of CBP in patient subgroups may provide insight about differential impact on adherence and persistence.

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.