Recommendations for Evaluating Compliance and Persistence With Hypertension Therapy Using Retrospective Data

Factors associated with medication adherence in patients living with cirrhosis

AIMS AND OBJECTIVES

Medication adherence in people with cirrhosis is largely unknown. This study aims to determine adherence patterns and factors associated with adherence in patients with cirrhosis.

BACKGROUND

Prescribed medications are a pivotal component in the clinical management of cirrhosis with potential to retard disease progression and reduce complication risks. Medication adherence is necessary to optimise health outcomes. Understanding why medications are missed may help to develop strategies and inform nursing practice.

DESIGN

Prospective cohort study.

METHODS

Participants (n = 29) diagnosed with cirrhosis attending a tertiary hospital consented to complete a self-reported survey. Demographic information, adherence to medications, patient knowledge and quality of life data were collected, collated, checked and analysed using SPSS version 21.

RESULTS

Less than half of the 28 patients who completed the adherence questionnaire (n = 13, 46%) reported that they had never missed medication. Being forgetful, being away from home and falling asleep contributed to nonadherence. Having less abdominal symptoms, less fatigue and increased emotional well-being were significantly associated with patients never missing medications.

CONCLUSIONS

To our knowledge this is the first published study to describe adherent behaviour and the reasons medications are missed in this population. The percentage of nonadherent participants is of concern considering the potential morbidity risk that is associated with missed medications and rebound symptoms of cirrhosis. Strategies to improve and sustain adherence levels are required including enhanced adherence counselling offered to patients who are deteriorating or experience periodic exacerbation of symptoms.

RELEVANCE TO CLINICAL PRACTICE

Study findings have the potential to change clinical practice especially the way nurses target motivational adherence counselling, key treatment messages, education and adherence monitoring. The results presented here provide a basis for developing adherence strategies and nursing management plans to improve adherence and health outcomes in people with cirrhosis.

Ramipril + amlodipine and ramipril + hydrochlorothiazide fixed-dose combinations in relation to patient adherence

Objective

To compare 1-year treatment adherence of ramipril + amlodipine and ramipril +hydroclorothiazide fixed-dose combination therapies in patients with hypertension.

Methods

Data were extracted from the database of the National Health Insurance Fund of Hungary. Treatment adherence was modelled using survival analysis.

Results

At 2 months after initiation of treatment, 42% of patients using ramipril +hydrochlorothiazide (n = 28,800) had discontinued treatment, compared with 0% of patients using ramipril + amlodipine (n = 10,295). At 1 year, treatment adherence was 29% in the ramipril + hydrochlorothiazide group and 54% in the ramipril + amlodipine group. The hazard ratio for discontinuing ramipril + hydrochlorothiazide vs ramipril + amlodipine was 2.318 (95% confidence intervals 2.246, 2.392).

Conclusion

Ramipril + amlodipine had significantly higher 1-year treatment adherence than ramipril + hydrochlorothiazide in patients with hypertension.

Cholinesterase Inhibitor Utilization: The Impact of Provincial Drug Policy on Discontinuation

BACKGROUND

In October 2007, British Columbia started to cover the cost of cholinesterase inhibitors (ChEIs)-donepezil, galantamine, and rivastigmine-for patients with mild to moderate dementia and prominent Alzheimer's disease.

OBJECTIVES

To examine the impact of this policy on persistence with ChEIs.

METHODS

A population-based cohort study was conducted using British Columbia administrative health data. We examined 45,537 new ChEI users aged 40 years and older between 2001 and 2012; 20,360 (45%) started the treatment after the coverage policy was launched. Patients were followed until treatment discontinuation, defined as a ChEI-free gap of 90 days, death, or December 2013. Persistence on ChEIs was estimated using survival analysis and competing risk approach. Hazards of discontinuation were compared using competing risk Cox regression with propensity adjustment.

RESULTS

Patients who started ChEI therapy after the introduction of the coverage policy had a significantly longer persistence. Median ChEI persistence until discontinuation or death was 9.37 months (95% confidence interval [CI] 9.0-39.7) and 17.6 months (95% CI 16.9-18.3) in patients who started therapy before and after the new policy, respectively. The propensity-adjusted hazard ratio for discontinuing therapy was 0.91 (95% CI 0.88-0.94). Similar patterns were observed for persistence with the first ChEI (propensity-adjusted hazard ratio of 0.94; 95% CI 0.91-0.98). In rivastigmine users, the hazard ratio was insignificant (0.98; 95% CI 0.92-1.02).

CONCLUSIONS

The British Columbia ChEI coverage policy was associated with significantly prolonged persistence with donepezil and galantamine, but not rivastigmine.

Medication adherence and persistence according to different antihypertensive drug classes: A retrospective cohort study of 255,500 patients

BACKGROUND

Suboptimal adherence to antihypertensives leads to adverse clinical outcomes. This study aims to determine and compare medication adherence and persistence to different first-line antihypertensive drug classes in a large cohort.

METHODS

A cohort study was performed using claims data for prescriptions in the German statutory health insurance scheme that insures approximately 90% of the population. A total of 255,500 patients with a first prescription of an antihypertensive were included and followed for 24months. Persistence was determined based on gaps in continuous dispensation. Adherence was analyzed by calculating the medication possession ratio (MPR).

RESULTS

Within a 2-year period, 79.3% of all incident users of antihypertensive monotherapy met the classification of non-persistence (gap >0.5 times the number of days supplied with medication) and 56.3% of non-adherence (MPR<0.8). Beta-blockers (42.5%) and angiotensin-converting enzyme inhibitors (31.9%) were the most widely prescribed drug classes. Non-persistence and non-adherence were highest for diuretics (85.4%, n=6149 and 66.3%, n=4774) and lowest for beta-blockers (77.6%, n=76,729 and 55.2%, n=54,559). The first gap of antihypertensive medication occurred in median 160-250days after initiation, and the average medication possession ratio for all drug classes was less than 0.8. Fixed combinations with diuretics showed a 19.8% lower chance for non-adherence (OR=0.802, 99.9% CI=[0.715-0.900], p<0.001) and an 8.4% lower hazard for non-persistence (HR 0.916, 99.9% CI=[0.863-0.973], p<0.001) compared with monotherapies.

CONCLUSIONS

This large cohort study reveals important differences in 2-year adherence and persistence between antihypertensives that were lowest for diuretics. Fixed-dose combinations with diuretics may facilitate adherence compared to single substance products. However, effective strategies to improve adherence to antihypertensives are needed regardless of drug class.

Improving Medication Adherence in Patients with Hypertension: A Randomized Trial

BACKGROUND AND PURPOSE

In patients with hypertension, medication adherence is often suboptimal, thereby increasing the risk of ischemic heart disease and stroke. In a randomized trial, we investigated the effectiveness of a multifaceted pharmacist intervention in a hospital setting to improve medication adherence in hypertensive patients. Motivational interviewing was a key element of the intervention.

METHODS

Patients (n = 532) were recruited from 3 hospital outpatient clinics and randomized to usual care or a 6-month pharmacist intervention comprising collaborative care, medication review, and tailored adherence counseling including motivational interviewing and telephone follow-ups. The primary outcome was composite medication possession ratio (MPR) to antihypertensive and lipid-lowering agents, at 1-year follow-up, assessed by analyzing pharmacy records. Secondary outcomes at 12 months included persistence to medications, blood pressure, hospital admission, and a combined clinical endpoint of cardiovascular death, stroke, or acute myocardial infarction.

RESULTS

At 12 months, 20.3% of the patients in the intervention group (n = 231) were nonadherent (MPR <0.80), compared with 30.2% in the control group (n = 285) (risk difference -9.8; 95% confidence interval [CI], -17.3, -2.4) and median MPR (interquartile range) was 0.93 (0.82-0.99) and 0.91 (0.76-0.98), respectively, P = .02. The combined clinical endpoint was reached by 1.3% in the intervention group and 3.1% in the control group (relative risk 0.41; 95% CI, 0.11-1.50). No significant differences were found for persistence, blood pressure, or hospital admission.

CONCLUSIONS

A multifaceted pharmacist intervention in a hospital setting led to a sustained improvement in medication adherence for patients with hypertension. The intervention had no significant impact on blood pressure and secondary clinical outcomes.

Adherence with antihypertensive drug therapy and the risk of heart failure in clinical practice

Randomized clinical trials have shown that antihypertensive treatment reduces the risk of heart failure (HF). Limited evidence exists, however, on whether and to what extent this benefit is translated into real-life practice. A nested case-control study was carried out by including the cohort of 76 017 patients from Lombardy (Italy), aged 40 to 80 years, who were newly treated with antihypertensive drugs during 2005. Cases were the 622 patients who experienced hospitalization for HF from initial prescription until 2012. Up to 5 controls were randomly selected for each case. Logistic regression was used to model the HF risk associated with adherence to antihypertensive drugs, which was measured by the proportion of days covered by treatment (PDC). Data were adjusted for several covariates. Sensitivity analyses were performed to account for possible sources of systematic uncertainty. Compared with patients with very low adherence (PDC, ≤25%), low, intermediate, and high adherences were associated with progressively lower risk of HF, reduction in the high-adherence group (>75%) being 34% (95% confidence interval, 17%-48%). Similar effects were observed in younger (40-70 years) and older (71-80 years) patients and between patients treated with angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and diuretics. There was no evidence that adherence with calcium-channel blockers reduced the HF risk. Antihypertensive treatment lowers the HF risk in real-life practice, but adherence to treatment is necessary for a substantial benefit to take place. This is the case with a variety of antihypertensive drugs.

Adherence and medication utilisation patterns of fixed-dose and free combination of angiotensin receptor blocker/thiazide diuretics among newly diagnosed hypertensive patients: a population-based cohort study

OBJECTIVE

The study aimed to compare the adherence and persistence among newly diagnosed hypertensive patients using fixed-dose (FDC) and free combinations (FC) of angiotensin receptor blocker (ARB)/thiazide diuretic using Taiwan's National Health Insurance Research Database.

METHODS

General linear regression and Kaplan-Meier analyses were used to estimate the impact of FDC on adherence [measured by medication possession ratio (MPR)] and persistence (time from day of initiation to treatment discontinuation) of ARB/thiazide diuretic.

RESULTS

The adjusted MPRs were all significantly higher among FDC group compared with FC group (6 months: 66.55% vs. 63.86%; 1 year: 52.58% vs. 46.73%, 1.5 year: 46.30% vs. 38.07%; 2 year: 42.06% vs. 32.45%, all p < 0.001). Patients received FDC therapy were less likely to discontinue their therapy [adjusted hazard ratio (HR) 0.79, 95% CI = 0.74-0.85].

CONCLUSIONS

Our findings suggest that use of FDC is associated with higher adherence and persistence rates than use of FC in newly diagnosed hypertensive patients.

Knowledge and Adherence to Medications among Palestinian Geriatrics Living with Chronic Diseases in the West Bank and East Jerusalem

Background

Adequate patient knowledge about medications is essential for appropriate drug taking behavior and patient adherence. This study aims to assess and quantify the level of knowledge and adherence to medications among Palestinian geriatrics living with chronic diseases and to investigate possible associated socio-demographic characteristics.

Methods and Findings

We conducted a cross-sectional study during June 2013 and January 2014 among Palestinian geriatrics ≥60 years old living with chronic disease in the West Bank and East Jerusalem. A stratified random sample was selected and a questionnaire-assisted interview was applied for data collection. T-test was applied for bivariate analyzing and one-way ANOVA test was applied for multivariate analyses.

Results

A total of 1192 Palestinian geriatrics were studied. The average age was 70.3 (SD=8.58) years and ranged from 60-110 years. The sample comprised 659 (55.3%) females and 533 (44.7%) males. The global knowledge and global adherence scores were (67.57%) and (89.29%), respectively. Adequate levels of knowledge were 71.4%, and of adherence 75%, which were recorded for 705 (59.1%) and 1088 (91.3%) participants, respectively. Significant higher levels of global knowledge and global adherence were recorded for males, and for participants who hold a Bachelor’s degree, those who live on their own, and did physical activity for more than 40 hours/week (p-value <0.05). Furthermore, workers, participants with a higher monthly income, and non-smokers have a higher knowledge level with (p-value <0.05). We found positive correlation between participants’ global adherence and global knowledge (r=0.487 and p-value <0.001). Negative correlation was found between participants’ global knowledge and adherence with age (r= -0.236, p-value <0.001 and r= -0.211 and p-value <0.001, respectively. Negative correlation between global knowledge and the number of drugs taken (r= -0.130, p-value <0.001) was predicted.

Conclusion

We concluded that patients with a higher level of knowledge are more adherent to their medications and that better understanding of socio-demographic factors has a clear influence on the level of knowledge and adherence to medications and thus contributes to the development of guidelines for treatment and may consequently lead to favourable clinical outcomes and savings of health care costs.

Correlation between the use of ‘over-the-counter’ medicines and adherence in elderly patients on multiple medications

BACKGROUND

Medication adherence is a multifaceted issue that is influenced by various factors. One factor may be the concurrent use of over-the-counter (OTC)medicines. The use of OTC medicine has been reported as common amongst elderly patients.

OBJECTIVE

To determine if a correlation exists between the use of OTC medicines and adherence to prescribed medications in elderly patients.

SETTING

Non-institutionalised elderly patients in Denmark.

METHODS

Elderly unassisted patients aged ≥65 prescribed five or more prescription drugs were included in the study. Information on the use of concurrent OTC medications (herbal medicines, dietary supplements, or non-prescribed drugs) was elicited during home visit interviews. Prescription drug adherence was determined by pill counts. A patient was categorised as non-adherent if the me an adherence rate for all drugs consumed was\80 %. Different sensitivity analyses were made where adherence was defined different.

MAIN OUTCOME MEASURE

Medication adherence based on pill-count.

RESULTS

A total of 253 participants included 72 % who used OTC medicines and 11 % who did not adhere to their prescriptions. Users of OTC medicines, however, were significantly more likely to be adherent than were non-users (odds ratio 0.41; 95 %confidence interval 0.18–0.91). Sensitivity analyses where adherence was defined different show no relationship between adherence and use of OTC medicine. Furthermore,separate analyses of herbal medicines, dietary supplements,or non-prescribed drugs did not correlate with adherence to prescriptions.

CONCLUSION

Amongst elderly patients on multiple medications a positive relationship was found between the overall use of OTC medicines and adherence to prescription drugs, in contrast to none when adherence were defined different or herbal medicines, dietary supplements, or non-prescribed drugs were analysed separately.

Multifaceted intervention including motivational interviewing to support medication adherence after stroke/transient ischemic attack: a randomized trial

Background and Purpose

Adherence to medication is often suboptimal after stroke and transient ischemic attack (TIA), which increases the risk of recurrent stroke and death. Complex interventions and motivational interviewing (MI) have been proven effective in other areas of medicine. The objective of this study was to investigate the effectiveness of a multifaceted intervention including MI in improving medication adherence for secondary stroke prevention.

Methods

In this randomized controlled trial, TIA and stroke patients receiving a pharmacist intervention in a hospital setting were compared with patients receiving usual care. The intervention consisted of a focused medication review, an MI-approached consultation and 3 follow-up telephone calls and lasted for 6 months. The primary outcome was a composite medication possession ratio (MPR) for antiplatelets, anticoagulants and statins in the year after hospitalization, assessed by analyzing pharmacy records and reported as both a continuous rate and a binary outcome. Secondary outcomes included composite MPRs at 3, 6 and 9 months as well as adherence and persistence to specific thrombopreventive medications at 12 months. Clinical outcomes included a combined end point of cardiovascular death, stroke or acute myocardial infarction. Patient satisfaction with the service was assessed for the intervention patients.

Results

The analyses included 102 intervention patients and 101 controls. At 12 months, the median MPRs (IQR) were 0.95 (0.77-1) in the intervention group and 0.91 (0.83-0.99) in the control group, and 28 and 21% of the patients, respectively, were nonadherent (MPR <0.80; risk difference: 7%; 95% CI: −5 to 19%). In both groups, the median MPR decreased over time. From 3 to 12 months, the MPR fell by 5% (p < 0.05) in the intervention group and by 9% (p < 0.05) in the control group, but between the groups, comparisons showed no statistically significant difference. No significant differences were found for adherence and persistence to specific thrombopreventive agents or for the clinical outcome. The intervention patients were satisfied with the service; about half of them reported increased knowledge about medication, and one third reported increased confidence with medication use. Pharmacists identified drug-related problems in one third of the patients.

Conclusions

A multifaceted pharmacist intervention including MI did not improve adherence or persistence to secondary stroke prevention therapy and had no impact on clinical outcomes. However, due to the high adherence rates, only little room for improvement existed. Future studies should focus on patients at high risk of nonadherence and include outcomes more sensitive to the impact of behavioral interventions.

Similarity between generic and brand-name antihypertensive drugs for primary prevention of cardiovascular disease: evidence from a large population-based study

BACKGROUND

Although generic and earlier brand-name counterparts are bioequivalent, their equivalence in preventing relevant clinical outcomes is of concern.

OBJECTIVE

To compare effectiveness of generic and brand-name antihypertensive drugs for preventing the onset of cardiovascular (CV) outcomes.

DESIGN AND SUBJECTS

A population-based, nested case-control study was carried out by including the cohort of 78 520 patients from Lombardy (Italy) aged 18 years or older who were newly treated with antihypertensive drugs during 2005. Cases were the 2206 patients who experienced a hospitalization for CV disease from initial prescription until 2011. One control for each case was randomly selected from the same cohort that generated cases. Logistic regression was used to model the CV risk associated with starting on and/or continuing with generic or brand-name agents.

RESULTS

There was no evidence that patients who started on generics experienced different CV risk than those on brand-name product (OR 0·86; 95% CI 0·63-1·17). Patients at whom generics were main dispensed had not significantly difference in CV outcomes than those mainly on brand-name agents (OR 1·19; 95% CI 0·86-1·63). Compared with patients who kept initial brand-name therapy, those who experienced brand-to-generic or generic-to-brand switches, and those always on generics, did not show differential CV risks, being the corresponding ORs (and 95% CIs), 1·18 (0·96-1·47), 0·87 (0·63-1·21) and 1·08 (0·80-1·46).

CONCLUSIONS

Our findings do not support the notion that brand-name antihypertensive agents are superior to generics for preventing CV outcomes in the real-world clinical practice.

Identification of Hypertension Management-related Errors in a Personal Digital Assistant-based Clinical Log for Nurses in Advanced Practice Nurse Training

PURPOSE

The purposes of this study were to develop a taxonomy for detection of errors related to hypertension management and to apply the taxonomy to retrospectively analyze the documentation of nurses in Advanced Practice Nurse (APN) training.

METHOD

We developed the Hypertension Diagnosis and Management Error Taxonomy and applied it in a sample of adult patient encounters (N = 15,862) that were documented in a personal digital assistant-based clinical log by registered nurses in APN training. We used Standard Query Language queries to retrieve hypertension-related data from the central database. The data were summarized using descriptive statistics.

RESULT

Blood pressure was documented in 77.5% (n = 12,297) of encounters; 21% had high blood pressure values. Missed diagnosis, incomplete diagnosis and misdiagnosis rates were 63.7%, 6.8% and 7.5% respectively. In terms of treatment, the omission rates were 17.9% for essential medications and 69.9% for essential patient teaching. Contraindicated anti-hypertensive medications were documented in 12% of encounters with co-occurring diagnoses of hypertension and asthma.

CONCLUSION

The Hypertension Diagnosis and Management Error Taxonomy was useful for identifying errors based on documentation in a clinical log. The results provide an initial understanding of the nature of errors associated with hypertension diagnosis and management of nurses in APN training. The information gained from this study can contribute to educational interventions that promote APN competencies in identification and management of hypertension as well as overall patient safety and informatics competencies.

The impact of medication adherence on health outcomes for chronic metabolic diseases: a retrospective cohort study

BACKGROUND

Hypertension, diabetes, and hyperlipidemia have a large influence on health outcomes due to their chronic nature and serious complications. Medication is a key factor in preventing disease advancement, and it is important to assess whether good medication adherence has any potential long-term impact on health outcomes and provides an international validation on the relationship.

OBJECTIVES

To evaluate the impact of good medication adherence on health outcomes of complications and hospitalizations for hypertension, hyperlipidemia, and diabetes.

METHODS

Patients who had had outpatient pharmacy claims for drugs for hypertension, diabetes, or hyperlipidemia were separately identified from the Korean National Health Insurance Claims Database in year 2009. A 10% random sample was respectively drawn from the three disease groups, and all claims from years 2008-2011 were extracted for the sampled subjects. Medication adherence was measured by the medication possession ratio (MPR) during the 12-month after the index date, the initial date from when medication was counted, with poor adherence as <80% of MPR. Health outcomes were measured both at 2 and 3 years after the index date as any occurrence of disease-related complications, disease-specific hospitalizations, and all-cause hospitalizations.

RESULTS

Poor medication adherence was associated with a higher occurrence of disease-specific hospitalizations for hypertension patients (+10.9%, only at 2 years). The likelihood of all-cause hospitalization was higher among patients who had poor medication adherence in hypertension (+32% and +29% at 2 and 3 years), hyperlipidemia (+16% and +14% at 2 and 3 years), and diabetes (+32% and +29% at 2 and 3 years). Poor medication adherence also increased the likelihood of complications for hypertension (+14% and +7% at 2 and 3 years) and hyperlipidemia patients (+8.1% at 2 years).

CONCLUSIONS

Targeting good medication adherence could be a valuable policy strategy to effectively manage chronic diseases to improve health outcomes.

Development and validation of a survey to assess patient-perceived medication knowledge and confidence in medication use

BACKGROUND AND PURPOSE

The primary objective of this study is to establish the validity and reliability of a perceived medication knowledge and confidence survey instrument (Okere-Renier Survey).

METHODS

Two-stage psychometric analyses were conducted to assess reliability (Cronbach's alpha > .70) of the associated knowledge scale. To evaluate the construct validity, exploratory and confirmatory factor analyses were performed.

RESULTS

Exploratory factor analysis (EFA) revealed three subscale measures and confirmatory factor analysis (CFA) indicated an acceptable fit to the data (goodness-of-fit index [GFI = 0.962], adjusted goodness-of-fit index [AGFI = 0.919], root mean square residual [RMR = 0.065], root mean square error of approximation [RMSEA] = 0.073). A high internal consistency with Cronbach's a of .833 and .744 were observed in study Stages 1 and 2, respectively.

CONCLUSIONS

The Okere-Renier Survey is a reliable instrument for predicting patient-perceived level of medication knowledge and confidence.

Real-world adherence and persistence associated with nebivolol or hydrochlorothiazide as add-on treatment for hypertension

OBJECTIVE

To compare adherence and persistence associated with nebivolol and hydrochlorothiazide (HCTZ) as add-on hypertension treatments.

RESEARCH DESIGN AND METHODS

Adults with ≥1 hypertension diagnosis (ICD-9-CM 401-405) who used nebivolol or HCTZ as their first add-on antihypertensive therapy between 1/1/2008 and 9/30/2010 were identified from a large claims database. Patients had continuous enrollment for ≥1 year preceding (baseline period) and following (study period) the first qualifying prescription fill, and did not use nebivolol or HCTZ during the baseline period. A random sample of HCTZ patients meeting selection criteria were selected in a 3:1 ratio to nebivolol patients.

MAIN OUTCOME MEASURES

The probability of receiving each drug, adjusted for baseline patient demographics, significantly different comorbidities, and costs was estimated using a logistic model. Inverse propensity score weights were used to balance confounding factors for between-cohort comparisons. Adherence (estimated using the medication possession ratio [MPR]) and persistence (estimated as days from initiation to the first >30 day gap in the index drug supply) at 6, 9, and 12 months were compared using weighted t tests.

RESULTS

Baseline characteristics of nebivolol (n = 722) and HCTZ (n = 2166) patients were well balanced after weighting. At 12 months, nebivolol patients had a significantly higher MPR than HCTZ patients (0.76 vs. 0.70, P < 0.001), and medication persistence was 28 days longer (273 vs. 245 days, P < 0.001). Between-group differences were also significant at 6 and 9 months.

CONCLUSIONS

When used as an add-on therapy for hypertension, nebivolol was associated with significantly higher rates of adherence and persistence compared with HCTZ, after adjusting for baseline differences between treatment groups. These results may be impacted by limitations inherent in insurance claims data, such as the lack of clinical information.

Maintaining persistence and adherence with subcutaneous growth-hormone therapy in children: comparing jet-delivery and needle-based devices

PURPOSE

Persistence and adherence with subcutaneous growth hormone (GH; somatropin) therapy in children is widely acknowledged to be suboptimal. This study aimed to investigate how the use of a jet-delivery device, ZomaJet(®), impacts on medication-taking behaviors compared to needle-based devices.

MATERIALS AND METHODS

A retrospective cohort study of children aged ≤18 years was conducted using a UK-based, nationwide database of GH home-delivery schedules. Data were evaluated for the period between January 2010 and December 2012 for 6,061 children receiving either Zomacton(®) (somatropin) via the ZomaJet jet-delivery device or one of six brands of GH all administered via needle-based devices. Persistence was analyzed for patients with appropriate data, measured as the time interval between first and last home deliveries. An analysis of adherence was conducted only for patients using ZomaJet who had appropriate data, measured by proportion of days covered. Brand switches were identified for all patients.

RESULTS

Persistence with GH therapy was significantly longer in patients using ZomaJet compared to needle-based devices (599 days versus 535 days, respectively, n=4,093; P<0.001); this association was observed in both sexes and across age subgroups (≤10 and 11-16 years). The majority (58%) of patients using ZomaJet were classed as adherent (n=728). Only 297 patients (5%) switched GH brand (n=6,061), and patients tended to use ZomaJet for longer than other devices before switching.

CONCLUSION

It appears important that the choice of a jet-delivery device is offered to children prescribed daily GH therapy. These devices may represent a much-needed effective strategy for maintaining persistence with subcutaneous GH administration in children, potentially offering better clinical outcomes and greater cost-efficiency.

Persistence of antihypertensive drug use in German primary care: a follow-up study based on pharmacy claims data

PURPOSE

To study drug persistence for antihypertensive treatment considering typical patient behaviour including extended drug holidays or irregular repeat prescriptions.

METHODS

We used prescription data from a German statutory health insurance to follow up patients for 4 years. Medication persistence was defined as the continued use of a specific drug class, therapy persistence as the continued use of any antihypertensive drug. We applied 2 different interval criteria within which a repeat prescription had to be issued: 180 and 360 days.

RESULTS

A total of 9,513 patients started an antihypertensive therapy between 2006 and 2008. Applying the 180-day (360-day) interval criterion, 28 % (66 %) of the patients starting therapy with a beta-blocker were still medication-persistent after 4 years. The rates were similar for angiotensin-II receptor blockers (ARBs; 30 % and 69 % respectively) or angiotensin-converting enzyme (ACE) inhibitors (28 % and 61 % respectively). Looking at therapy persistence, these rates were 44 % (79 %) when an ACE inhibitor was the initial drug, 46 % (82 %) for ARBs. On average, even of those who were defined as therapeutically persistent with the 360 days criterion, half received a repeat prescription within 96 days, three quarters within 131 days-with a median supply of 1.2 units per day and 1.25 defined daily doses.

CONCLUSION

By applying more patient-orientated criteria, we found that many patients were therapy-persistent and received a prescription at the appropriate time. Therapy persistence was nearly independent of the initial agent; thus, drug persistence may not be an argument in favour of choosing a certain drug as a first-line option.

Correlation between the use of 'over-the-counter' medicines and adherence in elderly patients on multiple medications

Background Medication adherence is a multifaceted issue that is influenced by various factors. One factor may be the concurrent use of over-the-counter (OTC) medicines. The use of OTC medicine has been reported as common amongst elderly patients. Objective To determine if a correlation exists between the use of OTC medicines and adherence to prescribed medications in elderly patients. Setting Non-institutionalised elderly patients in Denmark. Methods Elderly unassisted patients aged ≥65 prescribed five or more prescription drugs were included in the study. Information on the use of concurrent OTC medications (herbal medicines, dietary supplements, or non-prescribed drugs) was elicited during home visit interviews. Prescription drug adherence was determined by pill counts. A patient was categorised as non-adherent if the mean adherence rate for all drugs consumed was <80 %. Different sensitivity analyses were made where adherence was defined different. Main outcome measure Medication adherence based on pill-count. Results A total of 253 participants included 72 % who used OTC medicines and 11 % who did not adhere to their prescriptions. Users of OTC medicines, however, were significantly more likely to be adherent than were non-users (odds ratio 0.41; 95 % confidence interval 0.18-0.91). Sensitivity analyses where adherence was defined different show no relationship between adherence and use of OTC medicine. Furthermore, separate analyses of herbal medicines, dietary supplements, or non-prescribed drugs did not correlate with adherence to prescriptions. Conclusion Amongst elderly patients on multiple medications a positive relationship was found between the overall use of OTC medicines and adherence to prescription drugs, in contrast to none when adherence were defined different or herbal medicines, dietary supplements, or non-prescribed drugs were analysed separately.

Maintaining stable symptom control in inflammatory bowel disease: a retrospective analysis of adherence, medication switches and the risk of relapse

BACKGROUND

Maintenance therapy with 5-aminosalicylic acid (5-ASA) is a key strategy for preventing relapse in many patients with inflammatory bowel disease (IBD). Factors which disrupt 5-ASA delivery, such as non-adherence and 5-ASA switches, may destabilise symptom control.

AIM

To investigate the impact of non-adherence and medication switches on stable symptom control in UK patients with IBD.

METHODS

A retrospective cohort study was conducted using a UK dispensing database. Adherence was analysed in randomised matched samples for each of the six leading oral mesalazine formulations, measured by medication possession ratio (MPR); MPR ≥80% was classified as adherent. Relationships among adherence, switch and relapse were analysed over 18 months in patients receiving continuous mesalazine therapy throughout a 6-month baseline period (primary subgroup analysis). Relapses of active ulcerative colitis were identified using a doubling of MPR as a proxy.

RESULTS

Only 39% of patients in the matched samples (n = 1200) were classed as adherent. No significant differences in adherence were observed among mesalazine formulations. In the primary subgroup analysis (n = 568), non-adherent patients had a significantly greater risk of relapse than adherent patients (RR = 1.44, 95% CI = 1.08-1.94; P = 0.014). Among adherent patients (n = 276), those who switched had a 3.5-fold greater risk of relapse than those who did not switch (95% CI = 1.16-10.62; P = 0.008).

CONCLUSIONS

Both non-adherence and mesalazine switches in adherent patients were associated with significant increases in the risk of relapse, suggesting that disruption of mesalazine maintenance therapy may destabilise symptom control. These findings provide evidence to advocate caution when considering mesalazine switches for stable patients.

Effect of antihypertensive medication adherence on hospitalization for cardiovascular disease and mortality in hypertensive patients

Antihypertensive medication treatment is one effective management strategy to prevent cardiovascular disease (CVD) and mortality. However, little research has been conducted on the rates of antihypertensive medication adherence and the effect of antihypertensive medication adherence on health outcomes in South Korea. We searched the Korean National Health Insurance Claims Database for records from 2003 to 2007. Patients in this study were 18 years of age or older and they were diagnosed with hypertension and newly prescribed antihypertensive medication in 2003. Adherence to antihypertensive medication was estimated as the medication possession ratio (MPR). Multivariate Cox regression was used to evaluate the association between medication adherence and adverse health outcomes after adjusting for patient demographics and clinical characteristics. Our study population consisted of 40,408 patients with a mean age of 51 years. Among the patients, 50.3% were men, 4.0% had Medicaid health insurance, 17.8% had diabetes, 20.9% had dyslipidemia and 42.4% were adherent (MPR ≥ 80%). Nonadherent patients (MPR<80%) were younger and more likely to have Medicaid health insurance; they had lower rates of diabetes and dyslipidemia compared with adherent patients. In the Cox multivariate analysis, nonadherence increased the risk of all adverse health outcomes, including all-cause mortality and hospitalization for CVD (hazard ratio: 1.57, confidence interval: 1.40-1.76). In conclusion, our study indicates that medication adherence is important for reducing hospitalization due to CVD and mortality.

Achieving recommended low density lipoprotein cholesterol goals and the factors associated with target achievement of hypercholesterolemia patients with rosuvastatin in primary care

OBJECTIVE

Hypercholesterolemia is a major risk factor for cardiovascular disease and requires continuous management. The role of primary physicians in this regard is important, yet the factors associated with successful lipid lowering treatments in primary clinics have not been clearly identified. We aimed to evaluate the rate of successful hypercholesterolemia treatment in Korean primary care, and to identify the factors associated with achieving low density lipoprotein cholesterol (LDL-C) targets.

METHODS

We prospectively recruited and retrospectively assessed 1851 Korean patients with hypercholesterolemia who visited family physicians and were prescribed rosuvastatin for the first time. LDL-C lowering targets, defined according to NCEP ATP III guidelines, were evaluated at 6 months after the first prescription. The factors associated with achieving these targets were also assessed.

RESULTS

Overall, 87.6% of our participants attained their LDL-C goals. In multiple logistic regression analysis, good adherence to medication was strongly associated with the achievement of target LDL-C levels, whereas higher cardiovascular risk factors including diabetes (in both sexes), low high density lipoprotein, and current smoking status (in males), and hypertension (in females) were related to LDL-C target level failures.

CONCLUSION

Our observations of the short period for hypercholesterolemia in Korean primary care has revealed that the rate of achieving target LDL-C levels was high in these patients, whereas patients at higher risk for cardiovascular disease tended to have lower LDL-C achievement outcomes. Primary care physicians should pay more attention to patients showing higher cardiovascular risk and stress the need for good adherence and management regimens in these individuals.

Adherence to chronic disease medications among New York City Medicaid participants

Medication adherence is critical for cardiovascular disease prevention and control. Local health departments are well positioned to address adherence issues, however relevant baseline data and a mechanism for monitoring impact of interventions are lacking. We performed a retrospective analysis using New York State Medicaid claims from 2008 to 2009 to describe rates and predictors of adherence among New York City Medicaid participants with dyslipidemia, diabetes, or hypertension. Adherence was measured using the medication possession ratio, and multivariable logistic regression was used to assess factors related to adherence. Medication regimen adherence was 63%. Greater adherence was observed in those who were older, male, and taking medications from ≥3 drug classes. Compared with whites, blacks and Hispanics were less likely to be adherent (adjusted odds ratio [OR]=0.67, 95% confidence interval [CI]: 0.65-0.70 and adjusted OR=0.76, 95% CI: 0.73-0.78, respectively), while Asians were as likely. Medication adherence was inadequate and racial disparities were identified in NYC Medicaid participants on stable medication regimens for chronic disease. This study demonstrates a claims-based model that may be used by local health departments to monitor and evaluate efforts to improve adherence and reduce disparities.

Revisiting the medication possession ratio threshold for adherence in lipid management

OBJECTIVE

We sought to evaluate the relationship between different levels of medication possession ratio (MPR) attained and achievement of clinically meaningful reductions in lipid levels.

RESEARCH DESIGN AND METHODS

This was a retrospective cohort study of 4691 new statin users from the Department of Veteran Affairs (VA). Subjects were required to be eligible for VA medical and pharmacy services throughout the 1 year study period from index date and to have complete data for exposure, outcome, and adjustment variables. MPR was defined as number of days supplied with prescription medication divided by days of observation.

MAIN OUTCOME MEASURES

Achieving 25% or greater reduction from baseline in lipid levels for three lipid outcomes: non-high-density lipoprotein (non-HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, and total cholesterol (TC).

RESULTS

We observed a statistically significant trend of an increasing proportion of study subjects achieving a 25% reduction or more for all three lipid outcomes (p-values <0.001 for each of the three outcomes using the Cochran-Armitage trend test). Using multiple logistic regression, odds ratios (ORs) for each of the three outcomes were at a maximum for the 0.9-1.0 MPR category with ORs of 12.90 (95% confidence interval (CI), 9.60, 17.35) for the non-HDL cholesterol outcome; 11.29 (95% CI, 8.61, 14.80) for the LDL cholesterol outcome; and 9.11 (95% CI, 6.62, 12.53) for the TC outcome. Direct comparison of the 0.9-1.0 MPR category versus the 0.8-0.89 MPR category demonstrated an increase in odds of achieving 25% or more reduction for all three lipid outcomes.

CONCLUSIONS

We conclude that significant improvements in outcomes are achieved with higher MPR thresholds than commonly targeted. The authors propose consideration of an MPR-adherence threshold of 0.9 MPR. Limitations include the possible modification of study findings in non-VA settings. MPR is a secondary adherence measure based on refill frequency.

Incomplete medication adherence of chronically ill patients in German primary care

BACKGROUND

Incomplete medication adherence is a major problem in health care worldwide. Patients who adhere to medical treatment have a better prognosis and create fewer costs.

OBJECTIVE

To assess the degree of incomplete adherence of chronically ill routine primary care patients in a German setting and analyze the association between incomplete medication adherence, as well as clinical and sociodemographic patient characteristics.

METHODS

In a cross-sectional survey, chronically ill patients were asked to assess their adherence in primary care retrospectively using the Medication Adherence Report Scale (MARS-D) questionnaire. To investigate the association of incomplete adherence with sociodemographic and clinical data, univariate and multivariate analyses were conducted.

RESULTS

In total, 62.1% of 190 patients were categorized as incompletely adherent. The mean MARS-D score was 23.5 (standard deviation = 2.7). Analyses revealed no statistically significant associations at P < 0.05 between degree of adherence and patient characteristics. The total explained variance amounted to 11.8% (Nagelkerke's R(2) = 0.118) in the multivariate analysis.

CONCLUSION

Previously reported results regarding associations of sociodemographic and clinical data with incomplete medication adherence could not be confirmed for this sample of chronically ill patients. In order to be able to provide guidelines for the reduction of incomplete medication adherence in German primary care, further research is needed.

Warnings without guidance: patient responses to an FDA warning about ezetimibe

BACKGROUND

In January 2008, the Food and Drug Administration (FDA) communicated concerns about the efficacy of ezetimibe, but did not provide clear clinical guidance, and substantial media attention ensued. We investigated the proportion of patients who discontinued therapy and switched to a clinically appropriate alternative after the FDA communication.

METHODS

Using claims data from a national pharmacy benefits manager, we created a rolling cohort of new users of ezetimibe between January 2006 and August 2008 and created a supply diary for each patient in the year after cohort entry. A patient was identified as nonpersistent if a gap of 90 days was seen in the diary. Using segmented linear regression, we compared rates of nonpersistence before and after the FDA communication and assessed patient-level characteristics associated with discontinuation. Among nonpersistent patients, we determined whether a patient made a clinically appropriate switch in the subsequent 90 days by adding a new cholesterol-lowering medication or by increasing the dose of an existing one. We used a weighted t test to compare the rates of appropriate switching before and after the communication.

RESULTS

Among 867,027 new ezetimibe users, 407,006 (46.9%) were nonpersistent in the first year. After the FDA communication, the monthly level of ezetimibe nonpersistence increased by 5.7 percentage points (P<0.0001). Younger patients, those who lived in low-income zip codes, and female patients were less likely to discontinue therapy (P<0.0001 for all). Among nonpersistent patients, rates of clinically appropriate switching increased from 10.8% before to 16.5% after the FDA warning (P = 0.004).

CONCLUSIONS

A substantial increase in ezetimibe nonpersistence rates was seen after an FDA communication regarding its efficacy and following associated media attention, and a small proportion of patients made a clinically appropriate switch after discontinuation. Further consideration is needed to deliver messages that promote appropriate use of chronic therapy rather than simply reduce use.

[Relationship of polymedication in controlling blood pressure: compliance, persistence, costs and incidence of new cardiovascular events]

BACKGROUND AND OBJECTIVE

To determine the relationship of polypharmacy on blood pressure (BP) control, compliance, persistence, the cost and incidence of cardiovascular events (CVD) in patients with moderate/severe hypertension.

PATIENTS AND METHODS

An observational multicenter retrospective study. We evaluated patients > 30 years who started a third antihypertensive treatment during 2004-2006. Depending on the number of chronic medications, we established 3 groups: regular consumption of 3-6 drugs, including between 7-10 and ≥ 11. Top-measures: sociodemographic, comorbidity, BP, compliance and persistence. For each group we determined the incidence of new CVD totals and total costs.

RESULTS

We evaluated 1,906 patients, 765 between 3-6 drugs, 624 between 7-10 and 517 in ≥ 11 (P<.001). Overage age: 69.4 years and 55.5% women. The group of 3-6 drugs showed better BP control (51.8 vs. 47.0 and 41.1%, P<.001), compliance (71.4 vs. 69.9 and 67.1%, P=.017), persistence (50.1 vs. 45.5 and 46.2%, P=.044) and lower incidence of CVD (12.2 vs. 19.7 and 30.2%, P<.001), respectively. The average/unit total costs was 3,369.1 vs. 4,362.1 and € 4,902.3 (P<.001). The presence of CVD was associated with therapy noncompliance (odds ratio [OR] 1.9, 95% confidence interval [95%CI] 1.1 to 3.6) and controlled by the lower BP control (OR 1.4 (95%CI 1.1-2.0) (P < .05). The use of antihypertensive fixed dose has greater compliance (72.8 vs. 68.2%), persistence (64.4 vs. 39.3%) and degree of BP control (52.6 vs. 43, 8%) (p<.001).

CONCLUSIONS

Polypharmacy is associated with lower compliance and persistence to antihypertensive treatment, cardiovascular disease and increased health care costs.

Factors influencing antihypertensive medication compliance in Taiwan: a nationwide population-based study

BACKGROUND

Poor medication compliance with antihypertensive drugs may have a significant impact on clinical outcomes, hospitalisation and healthcare expenditure. This study aims to assess medication compliance and its underlying factors in patients receiving antihypertensive drugs in Taiwan.

METHODS

This retrospective population-based study was based on data from Taiwan's Longitudinal Health Insurance Database (LHID). All patients (n = 78,558) were aged 30 years or more and had received at least one antihypertensive prescription between January 2004 and December 2007. We used the medication possession ratio (MPR) as an index to measure the level of medication compliance.

RESULTS

Approximately 53% of the patients had high compliance with antihypertensive medication. Factors that were positively associated with medication compliance included patients being aged 30-44 years, higher comorbidity scores (odds ratio (OR): 1.18; 95% confidence interval (CI): 1.08-1.28), the same prescribing physician being visited and a single-drug therapy being prescribed. Female sex (OR: 0.92; 95% CI: 0.89-0.95) and higher socioeconomic status (OR: 0.91; 95% CI: 0.86-0.96) were negatively associated with drug compliance. In addition, high-compliance patients were less likely to be treated at medical centres, corporations (OR: 0.89; 95% CI: 0.84-0.93) or rural (OR: 0.88; 95% CI: 0.83-0.94) institutions.

CONCLUSION

Several patient- and institution-related factors may influence medication compliance. Therefore, for optimal outcomes, patients' awareness of the need for compliance with antihypertensive therapy must be enhanced, and effective intervention strategies should be developed.

Development and psychometric evaluation of the German version of the Medication Regimen Complexity Index (MRCI-D)

BACKGROUND

Several factors contribute to the complexity of pharmacotherapeutic regimens, like the total number of medications to be taken, the number of dosage units to take at a time, dosage frequency, as well as specific directions concerning the administration. The Medication Regimen Complexity Index (MRCI) is a validated instrument developed in English for the measurement of the complexity of a given pharmacotherapeutic regimen.

OBJECTIVES

Translation of the MRCI into German and evaluation of the translated instrument (MRCI-D) in order to make it more easily accessible for use in German practice and research.

METHODS

The process of validation included the translation of the English version to German, back-translation into English, comparison of the back-translated and the original versions, pre-tests, and pilot-testing of the German version by three raters using 20 medication regimens for inpatients. The subsequent psychometric evaluation included the calculation of inter-rater and test-retest reliability, as well as the assessment of convergent validity.

RESULTS

The number of medications correlated highly and statistically significantly with the MRCI-D score (0.91, P < 0.001), indicating sufficient convergent validity of the instrument. Both inter-rater and test-retest reliability were very high (intraclass correlation coefficients above 0.80 in all cases).

CONCLUSION

Our results demonstrate that the German version of the MRCI reflects the complexity of therapeutic regimens with similar validity and reliability as the established English version. Thus, it may be a valuable tool to analyse therapeutic regimens in both clinical practice and science.

A new taxonomy for describing and defining adherence to medications

Interest in patient adherence has increased in recent years, with a growing literature that shows the pervasiveness of poor adherence to appropriately prescribed medications. However, four decades of adherence research has not resulted in uniformity in the terminology used to describe deviations from prescribed therapies. The aim of this review was to propose a new taxonomy, in which adherence to medications is conceptualized, based on behavioural and pharmacological science, and which will support quantifiable parameters. A systematic literature review was performed using MEDLINE, EMBASE, CINAHL, the Cochrane Library and PsycINFO from database inception to 1 April 2009. The objective was to identify the different conceptual approaches to adherence research. Definitions were analyzed according to time and methodological perspectives. A taxonomic approach was subsequently derived, evaluated and discussed with international experts. More than 10 different terms describing medication-taking behaviour were identified through the literature review, often with differing meanings. The conceptual foundation for a new, transparent taxonomy relies on three elements, which make a clear distinction between processes that describe actions through established routines ('Adherence to medications', 'Management of adherence') and the discipline that studies those processes ('Adherence-related sciences'). 'Adherence to medications' is the process by which patients take their medication as prescribed, further divided into three quantifiable phases: 'Initiation', 'Implementation' and 'Discontinuation'. In response to the proliferation of ambiguous or unquantifiable terms in the literature on medication adherence, this research has resulted in a new conceptual foundation for a transparent taxonomy. The terms and definitions are focused on promoting consistency and quantification in terminology and methods to aid in the conduct, analysis and interpretation of scientific studies of medication adherence.

A new taxonomy for describing and defining adherence to medications

Interest in patient adherence has increased in recent years, with a growing literature that shows the pervasiveness of poor adherence to appropriately prescribed medications. However, four decades of adherence research has not resulted in uniformity in the terminology used to describe deviations from prescribed therapies. The aim of this review was to propose a new taxonomy, in which adherence to medications is conceptualized, based on behavioural and pharmacological science, and which will support quantifiable parameters. A systematic literature review was performed using MEDLINE, EMBASE, CINAHL, the Cochrane Library and PsycINFO from database inception to 1 April 2009. The objective was to identify the different conceptual approaches to adherence research. Definitions were analyzed according to time and methodological perspectives. A taxonomic approach was subsequently derived, evaluated and discussed with international experts. More than 10 different terms describing medication-taking behaviour were identified through the literature review, often with differing meanings. The conceptual foundation for a new, transparent taxonomy relies on three elements, which make a clear distinction between processes that describe actions through established routines ('Adherence to medications', 'Management of adherence') and the discipline that studies those processes ('Adherence-related sciences'). 'Adherence to medications' is the process by which patients take their medication as prescribed, further divided into three quantifiable phases: 'Initiation', 'Implementation' and 'Discontinuation'. In response to the proliferation of ambiguous or unquantifiable terms in the literature on medication adherence, this research has resulted in a new conceptual foundation for a transparent taxonomy. The terms and definitions are focused on promoting consistency and quantification in terminology and methods to aid in the conduct, analysis and interpretation of scientific studies of medication adherence.

Undertreatment of COPD: a retrospective analysis of US managed care and Medicare patients

Background

We investigated a large population of patients with chronic obstructive pulmonary disease (COPD) to determine their frequency of medication use and patterns of pharmacotherapy.

Methods

Medical and pharmacy claims data were retrospectively analyzed from 19 health plans (>7.79 million members) across the US. Eligible patients were aged ≥40 years, continuously enrolled during July 2004 to June 2005, and had at least one inpatient or at least two outpatient claims coded for COPD. As a surrogate for severity of illness, COPD patients were stratified by complexity of illness using predefined International Classification of Diseases, Ninth Revision, Clinical Modification, Current Procedural Terminology, Fourth Edition, and Healthcare Common Procedure Coding System codes.

Results

A total of 42,565 patients with commercial insurance and 8507 Medicare patients were identified. Their mean age was 54.7 years and 74.8 years, and 48.7% and 46.9% were male, respectively. In total, 66.3% of commercial patients (n = 28,206) were not prescribed any maintenance COPD pharmacotherapy (59.1% no medication; 7.2% inhaled short-acting β2-agonist only). In the Medicare population, 70.9% (n = 6031) were not prescribed any maintenance COPD pharmacotherapy (66.0% no medication; 4.9% short-acting β2-agonist only). A subset of patients classified as high-complexity were similarly undertreated, with 58.7% (5358/9121) of commercial and 68.8% (1616/2350) of Medicare patients not prescribed maintenance COPD pharmacotherapy. Only 18.0% and 9.8% of diagnosed smokers in the commercial and Medicare cohorts had a claim for a smoking cessation intervention and just 16.6% and 23.5%, respectively, had claims for an influenza vaccination.

Conclusion

This study highlights a high degree of undertreatment of COPD in both commercial and Medicare patients, with most patients receiving no maintenance pharmacotherapy or influenza vaccination.

Subjects at risk of discontinuation of lipid-lowering agents: a 6-month cohort study among 12,875 patients in a chinese population

BACKGROUND

Dyslipidemia is a significant health problem, and persistent use of lipid-lowering agents among dyslipidemic patients is clinically important. However, few studies have evaluated the profiles of medication discontinuation among ethnic Chinese patients.

OBJECTIVE

The objective of this study was to evaluate the level of medication adherence among Chinese patients who were prescribed a lipid-lowering drug and to investigate factors that could help physicians identify patients at risk for discontinuing their medication.

METHODS

All patients who attended any primary care clinic in 1 territory of Hong Kong and were prescribed at least 1 lipid-lowering agent from January 2004 to June 2007 were included. The incidences of drug discontinuation within 180 days after drug prescriptions were measured, and the factors associated with discontinuation using binary logistic regression analyzes were evaluated.

RESULTS

Of the 12,875 eligible patients, the majority were prescribed fibrates (54.4%) and statins (45.1%). Among the patients, 17.0% discontinued their medication. Older patients (adjusted odds ratio [aOR] = 0.72-0.79 for patients >50 years), male subjects (aOR = 0.87; 95% CI, 0.78-0.97; P = 0.009), fee payers (aOR = 0.88; 95% CI, 0.78-0.99; P = 0.029), attendees in family medicine specialist clinics (aOR = 0.82; 95% CI, 0.70-0.96; P = 0.013), residents in rural districts (aOR = 0.52; 95% CI, 0.44-0.60; P < 0.001), follow-up visitors (aOR = 0.60; 95% CI, 0.54-0.66; P < 0.001), patients with comorbidities (aOR = 0.39; 95% CI, 0.35-0.44; P < 0.001 for 1 comorbidity and aOR = 0.28; 95% CI, 0.25-0.33; P < 0.001 for at least 2 comorbidities), and persons who use fibrates (aOR = 0.56; 95% CI, 0.49-0.64; P < 0.001) were significantly less likely to discontinue their medication.

CONCLUSIONS

The findings of these associated factors were new for ethnic Chinese patients. These findings could help physicians identify patients who had been prescribed a lipid-lowering agent who were at higher risk of discontinuing their medication. Their medication-taking behavior should be monitored more closely, and future studies should evaluate the reasons of drug discontinuation.

Adherence to lipid-lowering agents among 11,042 patients in clinical practice

AIMS

Dyslipidaemia is a poorly-controlled condition in clinical practice largely because of poor adherence to medication regimens by patients. This study evaluated the levels of and factors associated with adherence to lipid-lowering agents in a large Chinese population.

METHODS

From a validated clinical database, we included all patients who attended any public, primary care clinics in one large Territory of Hong Kong for medication refill at least twice during the study period January 2004 to June 2007. The major outcome variable was Medication Possession Ratio (MPR), an internationally-recognised metric to measure drug adherence. The factors associated with optimal drug adherence (MPR ≥ 0.8) were evaluated by multivariate regression analysis.

RESULTS

From 11,042 eligible patients, 90% were adherent. After adjusting for patients' age, gender, socioeconomic status, service type, district of residence, visit type (new visits vs. follow-up visits), the number of comorbidities and the drug class (statin vs. fibrates), older patients [aged 50-59 years; adjusted odds ratio (AOR) 1.30, p = 0.009; 60-69 years; AOR 1.53, p < 0.001; ≥ 70 years; AOR 1.72, p < 0.001], attendance in family medicine specialist clinics (FMSC; AOR 1.56, p < 0.001), follow-up visits (AOR 2.93, p < 0.001) and the presence of comorbidities (one comorbidity; AOR 1.45, p < 0.001; ≥ 2 comorbidities; AOR 1.56, p < 0.001) were associated with optimal drug adherence.

DISCUSSION AND CONCLUSION

These findings carry an implication that younger subjects, new patients, visitors in clinics other than FMSC and those without comorbidities should receive more meticulous monitoring of their medication-taking behaviour. Future studies should evaluate the major reasons for non-adherence among them.

Better compliance to antihypertensive medications reduces cardiovascular risk

OBJECTIVE

The effect of compliance with antihypertensive medications on the risk of cardiovascular outcomes in a population without a known history of cardiovascular disease has been addressed by a large population-based prospective, cohort study carried out by linking Italian administrative databases.

METHODS

The cohort of 242 594 patients aged 18 years or older, residents in the Italian Lombardy Region, who were newly treated for hypertension during 2000-2001, was followed from index prescription until 2007. During this period patients who experienced a hospitalization for coronary or cerebrovascular disease were identified (outcome). Exposure to antihypertensive drugs from index prescription until the date of hospitalization or censoring was assessed. Proportional hazards models were fitted to assess the association between persistence on and adherence with antihypertensive drug therapy and outcome. Data were adjusted for several covariates.

RESULTS

During an average follow-up of 6 years, 12 016 members of the cohort experienced the outcome. Compared with patients who experienced at least one episode of treatment discontinuation, those who continued treatment had a 37% reduced risk of cardiovascular outcomes (95% confidence interval 34-40%). Compared with patients who had very low drug coverage (proportion of days covered ≤ 25%), those at intermediate (from 51 to 75%) and high coverage (>75%) had risk reductions of 20% (16-24%) and 25% (20-29%), respectively. Similar effects were observed when coronary and cerebrovascular events were considered separately.

CONCLUSIONS

In the real life setting, fulfillment compliance with antihypertensive medications is effective in the primary prevention of cardiovascular outcomes.