ESPACOMP Medication Adherence Reporting Guideline (EMERGE)

Half a Century of Fragmented Research on Deviations from Advised Therapies: Is This a Good Time to Call for Multidisciplinary Medication Adherence Research Centres of Excellence?

Medication adherence is a key precondition of the effectiveness of evidence-based therapies. However, in real-life settings, non-adherence to medication is still very common. This leads to profound health and economic consequences at both individual and public health levels. The problem of non-adherence has been extensively studied in the last 50 years. Unfortunately, with more than 130,000 scientific papers published on that subject so far, we are still far from finding an ultimate solution. This is, at least partly, due to fragmented and poor-quality research that has been conducted in this field sometimes. To overcome this deadlock, there is a need to stimulate the adoption of best practices in medication adherence-related research in a systematic way. Therefore, herein we propose the establishment of dedicated medication adherence research Centres of Excellence (CoEs). These Centres could not only conduct research but could also create a profound societal impact, directly serving the needs of patients, healthcare providers, systems and economies. Additionally, they could play a role as local advocates for good practices and education. In this paper, we propose some practical steps that might be taken in order to establish such CoEs. We describe two success stories, i.e., Dutch and Polish Medication Adherence Research CoEs. The COST Action “European Network to Advance Best practices & technoLogy on medication adherencE” (ENABLE) aims to develop a detailed definition of the Medication Adherence Research CoE in the form of a list of minimal requirements regarding their objectives, structure and activities. We hope that it will help to create a critical mass and catalyse the setup of regional and national Medication Adherence Research CoEs in the near future. This, in turn, may not only increase the quality of the research but also raise the awareness of non-adherence and promote the adoption of the best medication adherence-enhancing interventions.

Italian Translation and Validation of the Original ABC Taxonomy for Medication Adherence

Medication adherence represents a complex and multifaceted process. Standardized terminology is essential to enable a reproducible process in various languages. The study's aim was to translate and adapt the original Ascertaining Barriers for Compliance (ABC) Taxonomy on medication adherence, first proposed in 2012, into Italian language. The study was carried out according to the Preferred Methods for Translation of the ABC Taxonomy for Medication Adherence adopted by the ESPACOMP. Key steps included: (1) a systematic literature review using PubMed and Embase according to the PRISMA Guidelines to identify published Italian terms and definitions, and Italian adherence experts; (2) a forward translation of terms and definitions; (3) panelists' selection; (4) a three-round Delphi survey. From the systematic review, 19 studies allowed detection of 4 terms, 4 definitions and 767 Italian experts. To these, Italian ESPACOMP members and experts though snowball sampling were added. The identified Italian adherence experts received the Delphi questionnaire. The Italian ABC Taxonomy was achieved after three rounds of Delphi survey by reaching at least a moderate consensus on unambiguous naming and definition of medication adherence-related terms. The Taxonomy is intended to be used in research, academic, and professional fields in order to harmonize adherence terminology and avoid confusion in comparing research findings.

Differences in medication adherence by sex and organ type among adolescent and young adult solid organ transplant recipients

BACKGROUND

Identification of differences in medication adherence by sex or organ type may help in planning interventions to optimize outcomes. We compared immunosuppressive medication adherence between males and females, and between kidney, liver and heart transplant recipients.

METHODS

This multicenter study of prevalent kidney, liver and heart transplant recipients 14-25 years assessed adherence 3 times (0, 3, 6 months post-enrollment) with the BAASIS self-report tool. At each visit, participants were classified as adherent if they missed no doses in the prior 4 weeks and non-adherent otherwise. Adherence was also assessed using the coefficient of variation (CV) of tacrolimus trough levels; CV < 30% was classified as adherent. We used multivariable mixed effects logistic regression models adjusted for potential confounders to compare adherence by sex and by organ.

RESULTS

Across all visits, males (n = 150, median age 20.4 years, IQR 17.2-23.3) had lower odds of self-reported adherence than females (n = 120, median age 19.8 years, IQR 17.1-22.7) (OR 0.41, 95% CI 0.21-0.80) but higher odds of adherence by tacrolimus CV (OR 2.50, 95% CI 1.30-4.82). No significant differences in adherence (by self-report or tacrolimus CV) were noted between the 184 kidney, 58 liver, and 28 heart recipients.

CONCLUSION

Females show better self-reported adherence than males but greater variability in tacrolimus levels. Social desirability bias, more common in females than males, may contribute to better self-reported adherence among females. Higher tacrolimus variability among females may reflect biologic differences in tacrolimus metabolism between males and females rather than sex differences in adherence. There were no significant differences in adherence by organ type.

The effect of combining therapeutic drug monitoring of antihypertensive drugs with personalised feedback on adherence and resistant hypertension: the (RHYME-RCT) trial protocol of a multi-centre randomised controlled trial

BACKGROUND

Adherence to antihypertensive drugs (AHDs) is important for adequate blood pressure control. Not taking these drugs as prescribed is one of the main underlying causes for resistant hypertension (RH), which in turn leads to an increased risk of cardiovascular events, stroke and kidney damage. Therefore, correct identification of patients that are non-adherent to AHDs is crucial to improve clinical outcome. For this goal, therapeutic drug monitoring is the most reliable method. The primary objective of this trial is to investigate whether monitoring of drug concentrations with a dried blood spot (DBS) sampling method combined with personalised feedback leads to a decrease in prevalence of RH after 12 months due to an increase in adherence. Secondary objectives include the difference over time in the number of required AHDs as well as the defined daily dose (DDD). Lastly, the cost-utility of SoC versus the intervention in RH is determined.

METHODS

This is a multi-centre single-blinded randomised controlled trial (RHYME-RCT). First, at an eligibility visit, DBS sampling, to monitor drug concentrations in blood, and a 24-h ambulatory blood pressure measurement (24-h ABPM) are performed simultaneously. Patients with a daytime systolic blood pressure (SBP) > 135 and/or diastolic blood pressure (DBP) > 85 mmHg are randomised to SoC or intervention + SoC. The intervention is performed by the treating physician and includes information on drug concentrations and a comprehensive personalised feedback conversation with the use of a communication tool. The follow-up period is one year with visits at 3, 6 and 12 months randomisation and includes 24-h ABPM and DBS sampling.

DISCUSSION

This will be the first trial that focusses specifically on patients with RH without taking into account suspicion of non-adherence and it combines monitoring of AHD concentrations to identify non-adherence to AHDs with a comprehensive feedback to improve non-adherence. Furthermore, if this trial shows positive outcomes for the intervention it can be directly implemented in clinical practice, which would be a great improvement in the treatment of RH.

TRIAL REGISTRATION

RHYME-RCT is registered in the Dutch Trial Register on 27/12/2017 (NTR6914) and can be found in the International Clinical Trials Registry Platform.

Reinitiation and Subsequent Discontinuation of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers among New and Prevalent Users Aged 65 Years or More with Peripheral Arterial Disease

Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin-receptor blockers (ARBs) are recommended in the treatment of arterial hypertension in patients with peripheral arterial disease (PAD). The aims of our study were: (a) to analyse the extent of reinitiation and subsequent discontinuation in older hypertensive PAD patients non-persistent with ACEIs/ARBs; (b) to determine patient and medication factors associated with reinitiation and subsequent discontinuation; and (c) to compare these factors between prevalent and new users. The analysis of reinitiation was performed on a sample of 1642 non-persistent patients aged ≥65 years with PAD newly diagnosed in 2012. Patients reinitiating ACEIs/ARBs were used for the analysis of subsequent discontinuation identified according to the treatment gap period of at least 6 months without any prescription of ACEI/ARB. In the group of non-persistent patients, 875 (53.3%) patients reinitiated ACEIs/ARBs during a follow-up (24.8 months on average). Within this group, subsequent discontinuation was identified in 414 (47.3%) patients. Being a new user was associated with subsequent discontinuation, but not with reinitiation. Myocardial infarction during non-persistence and after reinitiation was associated with reinitiation and lower likelihood of subsequent discontinuation, respectively. Being a prevalent or a new user is associated with the use of medication also after initial discontinuation.

Adherence to the CDK 4/6 Inhibitor Palbociclib and Omission of Dose Management Supported by Pharmacometric Modelling as Part of the OpTAT Study

The cyclin-dependent kinase 4/6 inhibitor (CDK4/6i) palbociclib is administered orally and cyclically, causing medication adherence challenges. We evaluated components of adherence to palbociclib, its relationship with pharmacokinetics (PK), and drug-induced neutropenia. Patients with metastatic breast cancer (MBC) receiving palbociclib, delivered in electronic monitors (EM), were randomized 1:1 to an intervention and a control group. The intervention was a 12-month interprofessional medication adherence program (IMAP) along with monthly motivational interviews by a pharmacist. Implementation adherence was compared between groups using generalized estimating equation models, in which covariates were included. Model-based palbociclib PK and neutrophil profiles were simulated under real-life implementation scenarios: (1) optimal, (2) 2 doses omitted and caught up at cycle end. At 6 months, implementation was slightly higher and more stable in the intervention (n = 19) than in the control (n = 19) group, 99.2% and 97.3% (Δ1.95%, 95% CI 1.1−2.9%), respectively. The impact of the intervention was larger in patients diagnosed with MBC for >2 years (Δ3.6%, 95% CI 2.1−5.4%), patients who received >4 cycles before inclusion (Δ3.1%, 95% CI 1.7−4.8%) and patients >65 (Δ2.3%, 95% CI 0.8−3.6%). Simulations showed that 25% of patients had neutropenia grade ≥3 during the next cycle in scenario 1 versus 30% in scenario 2. Education and monitoring of patient CDK4/6i cycle management and adherence along with therapeutic drug monitoring can help clinicians improve prescription and decrease toxicity.

A scoping review of non-professional medication practices and medication safety outcomes during public health emergencies

OBJECTIVES

Public health emergencies (PHE) can disrupt personal medication practices and increase the risk of medication-related harm and other negative medication-related outcomes. Our aim was to examine the extent and nature of published research on this topic to guide future research and practice.

STUDY DESIGN

Scoping review.

METHODS

Standard electronic databases were searched. PRISMA-ScR guidelines were followed. Extracted data were organised in response to review questions and narrative accounts developed.

RESULTS

A total of 129 studies were included, conducted across 32 countries, mostly in the USA (n = 42). Sixty-eight (53%) reported on infectious events, 49 (39%) climatological or ecological events and the remainder a mixture of terrorism, war or other disasters. The studies described several medication safety outcomes (medication-related harm, adherence, supply) and adaptive medication practices (self-altering prescribed medications, sharing medications and changing healthcare providers). Challenges to maintaining routine medication practices during a PHE included transport, finance, quarantine and knowledge-related issues. Twenty-eight studies (22%) examined health inequalities pertaining to adverse medication-related outcomes, with findings suggesting that gender, age, ethnicity, educational and socio-economic status may be related to inequalities. Research gaps identified included carers', children's and minority communities' experiences and intervention studies.

CONCLUSIONS

There is considerable evidence of disruptions to routine personal medication practices during PHEs and of medication-related harm and other negative outcomes. Maintaining medication supply for the management of chronic conditions is a universal problem across all emergency types. Research is needed to address these disruptions, particularly amongst people who experience health inequalities who may need additional support.

Self-reported adherence to direct oral anticoagulants versus warfarin therapy in a specialized thrombosis service-a cross-sectional study of patients in a Canadian Health Region

PURPOSE

Direct oral anticoagulants (DOACs) have a better safety and efficacy profile than warfarin and are currently recommended for stroke prevention in non-valvular atrial fibrillation (AF) and treatment of venous thromboembolism (VTE). Given that DOACs do not require regular laboratory monitoring compared to warfarin, patients' interactions with the health care system is reduced. Adequate adherence to DOACs is important and reported adherence to anticoagulation is unclear in clinical practice. This study aims to assess self-reported adherence to oral anticoagulants in a specialized Adult Outpatient Thrombosis Service (TS).  METHODS: This cross-sectional study included patients aged ≥ 18 years who were prescribed an oral anticoagulant and had attended at least one appointment with an Adult Outpatient Thrombosis Service (TS) between October 10, 2017, and May 31, 2019. Adherence to oral anticoagulant therapy was assessed using the 12-item validated Adherence to Refills and Medications Scale (ARMS) score. Logistic regression analyses were used to evaluate association between patient characteristics and medication adherence. Adherence rates in DOACs and warfarin were compared.

RESULTS

Three hundred and ninety-nine patients completed and returned the survey. Of the 399 who completed the survey, 74% were prescribed DOACs and 26% received warfarin. Most of the patients (89.3%) were ≥ 50 years of age and half (57.3%) were male. About two-thirds (67%) had at least post-secondary education. The duration of anticoagulation use differed between patients on DOAC and warfarin; a greater proportion of those who had used anticoagulants for less than 1 year was on DOACs compared to warfarin (20.9% vs 4.9%, p = 0.001). For patients who had been on anticoagulation for > 5 years, the proportion of warfarin patients was greater than DOAC (57.8% vs 20.5%, p = 0.001). Self-reported adherence to oral anticoagulant therapy using the 12-item ARMS scale for warfarin and DOACs were 87.3% and 90.9%, respectively. Among the warfarin users, patient satisfaction with TS was associated with medication adherence (OR = 0.22; 95% CI: 0.05-0.89).

CONCLUSIONS

Self-reported medication adherence was similar between warfarin and DOACs. Since suboptimal adherence is associated with poor clinical outcomes and increased costs, various stakeholders should emphasize the importance of medication adherence to oral anticoagulants at each patient encounter.

Understanding Processes, Outcomes, and Contexts in Medication Adherence: The Medication Adherence Context and Outcomes (MACO) Framework

Poor medication adherence is a significant problem, yet interventions to improve it have been largely ineffective. Existing ecological models indicate that adherence is multi-dimensional; however, they do not reflect understanding of context-specific processes and how they lead to adherence outcomes. A framework that reflects context-specific processes is important because it could be used to inform context-specific intervention delivery and measure associated adherence outcomes. The purpose of this paper is to describe the Medication Adherence Context and Outcomes (MACO) framework, which includes contexts (ie, clinics, pharmacies, and home) and context-specific processes (ie, shared decision-making, prescription filling strategies, home medication management) that lead to adherence outcomes (initiation, implementation, discontinuation, and persistence). The Medication and Adherence Contexts and Outcomes (MACO) framework was iteratively developed between 2015 and 2018 based on theory, practice, and research and combining patient experience journey mapping to chronologically describe the environmental contexts and actions (processes) that occur within the contexts and how they contribute to medication adherence as outcome. The three distinct yet interrelated contexts described in the MACO framework are 1) clinical encounters, 2) pharmacy encounters, and 3) day-to-day home management. Within these contexts are specific medication management actions that occur (processes) in order to produce adherence-related outcomes (initiation, implementation, and discontinuation/persistence). The MACO framework distinguishes context-specific processes and outcomes. The MACO framework may be useful to understand at which point(s) along the continuum people experience problems with managing medications. This understanding is potentially useful for developing and delivering context-specific interventions that are based on processes that underlie nonadherence and selecting adherence measures appropriate for the contexts.

Assessment of adherence to statin therapy in patients with coronary artery disease: comparison of three self-reporting measures

OBJECTIVES

To investigate adherence to statin therapy using three self-reporting adherence measures in patients with coronary artery disease and to compare the three measures.

METHODS

A cross-sectional study was carried out at a multidisciplinary outpatient clinic of cardiology at a teaching hospital in south-eastern Brazil in patients with coronary artery disease who were using statins. The sample consisted of 148 patients who were selected from April 2018 to February 2019. Adherence to statin therapy was determined by the Measure of Adherence to Treatment, Visual Analogue Scale of adherence and 7-day recall. A descriptive analysis and determination of the level of agreement between the adherence scales by the Cohen kappa coefficient were performed.

RESULTS

The study included 148 patients (104 (70.3%) men, median age 62 years) diagnosed with coronary artery disease who were using statins. The adherence to statin therapy was 98.6% using the Measure of Adherence to Treatment, 95.9% with the Visual Analogue Scale and 95.3% with 7-day recall. Agreement between the Measure of Adherence to Treatment and the Visual Analogue Scale (0.277) and the Measure of Adherence to Treatment and 7-day recall (0.241) was low. There was a high level of agreement between the Visual Analogue Scale and 7-day recall (0.759).

CONCLUSIONS

The adherence Visual Analogue Scale and 7-day recall were shown to be easy to apply, low-cost adherence measures to identify adherence to statins in patients with coronary artery disease. The Measure of Adherence to Treatment may also be used to provide information regarding the specific reasons for non-adherent behaviour.

Kidney-transplanted Adolescents—Nonadherence and Graft Outcomes During the Transition Phase: A Nationwide Analysis, 2000–2020

BACKGROUND

The transition from pediatric to young adult care is a vulnerable period for the renal transplant patient. We aimed to identify medication nonadherence (noninitiation, nonimplementation, and nonpersistence) and graft loss rates among adolescents and young adults and elucidate the influence of the transition phase on transplant outcomes.

METHODS

A retrospective nationwide cohort analysis of all renal transplantations in Norway from 2000 to 2020 was performed. Data were retrieved from the Norwegian Renal Registry, and adherence data from hospital charts. Patients transplanted aged <50 y, with functioning graft at 6 mo, were included. Recipients transplanted aged <26 y were compared with recipients transplanted aged 26-50 y. Graft loss, acute rejection, and development of de novo donor-specific antibodies were assessed in relation to the transition phase, defined as 14-26 y.

RESULTS

Data from 1830 kidney recipients were included: 371 (20%) transplanted <26 y (64% male, 68% living donor) versus 1459 transplanted 26-50 y (63% male, 44% living donor). There were 298 graft losses, 78 (21%) in the <26-y group versus 220 (15%) in the 26- to 50-y group. During the transition phase, 36 grafts were lost, 29 (81%) after transfer to the adult service. Medication nonadherence was the reason for 58% (21 of 36) of the losses during the transition phase, versus 12% (27 of 220) in the 26- to 50-y group ( P < 0.001). The 5-y graft survival rate was 89% (95% confidence interval, 85%-92%) and 94% (92%-95%), respectively ( P = 0.01).

CONCLUSIONS

Nonadherence was verified as the main cause of kidney graft loss in the transition phase.

Clinical characteristics do not reliably identify non-adherence in patients with uncontrolled hypertension

PURPOSE

Chemical adherence testing is a reliable method to assess adherence to antihypertensive drugs. However, it is expensive and has limited availability in clinical practice. To reduce the number and costs of chemical adherence tests, we aimed to develop and validate a clinical screening tool to identify patients with a low probability of non-adherence in patients with uncontrolled hypertension.

MATERIALS AND METHODS

In 495 patients with uncontrolled hypertension referred to the University Medical Centre Utrecht (UMCU), the Netherlands, a penalised logistic regression model including seven pre-specified easy-to-measure clinical variables was derived to estimate the probability of non-adherence. Non-adherence was defined as not detecting at least one of the prescribed antihypertensive drugs in plasma or urine. Model performance and test characteristics were evaluated in 240 patients with uncontrolled hypertension referred to the Heartlands Hospital, United Kingdom.

RESULTS

Prevalence of non-adherence to antihypertensive drugs was 19% in the UMCU and 44% in the Heartlands Hospital population. After recalibration of the model's intercept, predicted probabilities agreed well with observed frequencies. The c-statistic of the model was 0.63 (95%CI 0.53-0.72). Predicted probability cut-off values of 15%-22.5% prevented testing in 5%-15% of the patients, carrying sensitivities between 97% (64-100) and 90% (80-95), and negative predictive values between 74% (10-99) and 70% (50-85).

CONCLUSION

The combination of seven clinical variables is not sufficient to reliably discriminate adherent from non-adherent individuals to safely reduce the number of chemical adherence tests. This emphasises the complex nature of non-adherence behaviour and thus the need for objective chemical adherence tests in patients with uncontrolled hypertension.

Medication adherence among allogeneic haematopoietic stem cell transplant recipients: a systematic review protocol

INTRODUCTION

Patients receiving a haematopoietic stem cell transplant (HSCT) are subjected to complex oral medications based on prophylactic and immunosuppressive treatments. Adherence to medication plays a role in survival, and medication non-adherence (MNA) is closely associated with graft-versus-host disease and other complications. The aim of this systematic review is to summarise the available evidence regarding prevalence rates of medication adherence, the risk factors of MNA, the effectiveness of interventions to increase medication adherence and the outcomes associated with MNA.

METHODS AND ANALYSIS

We designed a systematic review according to the Joanna Briggs Institute methodology. We will search the Cochrane Library and the CINAHL, EMBASE, MEDLINE via PubMed, PsycINFO and Scopus databases. We will include published and unpublished primary studies: (a) on humans, from inception until 10 May 2022; (b) written in any language; (c) experimental (randomised and non-randomised), observational (prospective, retrospective cohort and case-control), correlational, cross-sectional and longitudinal; and (d) with a low risk of bias, according to the quality assessment we perform. We will exclude secondary and qualitative studies, protocols, publications without original data, including paediatrics or related to autologous HSCT. The primary outcome will be the prevalence of oral medication adherence; the secondary outcomes will be the risk factors of MNA, the interventions aimed at increasing medication adherence and the outcomes of MNA. Two researchers will independently screen the eligible studies, then extract and describe the data. Disagreements will be resolved by a third researcher. We will provide a qualitative narrative synthesis of the findings.

ETHICS AND DISSEMINATION

Ethical approval is not required given that previously published studies will be used. We will disseminate the findings through conference presentations and publications in international peer-reviewed scientific journals.

PROSPERO REGISTRATION NUMBER

CRD42022315298.

Is degree of chronic illness management in heart transplant centers associated with better patient survival? Findings from the intercontinental BRIGHT study

PURPOSE

To explore the association between the degree of Chronic illness management and survival rates at 1-, 3-, 5-years post heart transplantation.

METHODS

Exploratory secondary analysis of a cross-sectional, international study (Building Research Initiative Group study). Latent profile analysis was performed to classify 36 heart transplant centers according to the degree of chronic illness management.

RESULTS

The analysis resulted in 2 classes with 29 centers classified as "low-degree chronic illness management" and 7 centers as "high-degree chronic illness management". After 1-year posttransplantation, the high-degree chronic illness management class had a significantly greater mean survival rate compared to the low-degree chronic illness management class (88.4% vs 84.2%, p = 0.045) and the difference had a medium effect size (η2 = .06). No difference in survival for the other time points was observed. Patients in high-degree chronic illness management centers had 52% lower odds of moderate to severe drinking (95% confidence interval .30-.78, p = 0.003). No significant associations between degree of chronic illness management and the other recommended health behaviors were observed.

CONCLUSIONS

The findings from this exploratory study offer preliminary insight into a system-level pathway (chronic illness management) for improving outcomes for heart transplant recipients. The signals observed in our data support further investigation into the effectiveness of chronic illness management-based interventions in heart transplant follow-up care.

Influence of the Cognitive and Emotional Status of Patients with Chronic Pain on Treatment Success (Reduction in Pain Intensity and Adherence to Pharmacotherapy): A Prospective Study

This prospective study aimed to determine the cognitive and emotional status among patients with chronic pain and to examine the potential influence on the treatment success, measured by the reduction in pain intensity and adherence to pharmacotherapy. A total of seventy patients were followed for two months. The results of the comparison between patients who did and did not follow the physician’s instructions regarding adherence to pharmacotherapy showed a significant difference in cognitive status and a reduction in pain intensity. Patients who followed the physician’s instructions on taking analgesics had significantly higher scores on the Montreal Cognitive Assessment (MoCA) of cognitive status and a substantially higher reduction in pain intensity. Scores on the MoCA test provide statistically significant indications regarding patients’ decision to follow instructions regarding adherence to pharmacotherapy. Scores on the MoCA test, anxiety, age, and pain intensity (measured with a numeric rating scale—NRS) on admission were identified as potential predictors for the reduction in pain intensity. The linear regression model was statistically significant (χ2 = 40.0, p < 0.001), explained between 43.5% and 61.1% of variance regarding the reduction in pain intensity. The findings of this study show that cognitive status, measured with MoCA, and emotional status, measured with the Depression, Anxiety, and Stress Scale (DASS-21), significantly influence the reduction in pain intensity and adherence to pharmacotherapy. The results suggest that cognitive and emotional status may be potential predictors of treatment success. This finding points to the importance of a biopsychosocial approach in the treatment of chronic pain, where an important emphasis can be placed on the psychosocial determinants of pain.

Patterns of statin adherence in primary cardiovascular disease prevention during the pandemic

Background: Study of medication adherence patterns can help identify patients who would benefit from effective interventions to improve adherence. Objectives: To identify and compare groups of statin users based on their adherence patterns before and during the COVID-19 pandemic, to characterize the profile of users in each group, and to analyze predictors of distinct adherence patterns. Methods: Participants of the CARhES (CArdiovascular Risk factors for HEalth Services research) cohort, comprising individuals aged >16 years, residing in Aragón (Spain), with hypertension, diabetes mellitus and/or dyslipidemia, took part in this observational longitudinal study. Individuals who began statin therapy during January-June 2019 were selected and followed up until June 2021. Those with a cardiovascular event before or during follow-up were excluded. Data were obtained from healthcare system data sources. Statin treatment adherence during the implementation phase was estimated bimonthly using the Continuous Medication Availability (CMA9) function in the AdhereR package. Group-based trajectory models were developed to group statin users according to their adherence pattern during July 2019-June 2021. Group characteristics were compared and predictors of each adherence pattern were analyzed using multinomial logistic regression. Results: Of 15,332 new statin users, 30.8% had a mean CMA9 ≥80% for the entire study period. Four distinct adherence patterns were identified: high adherence (37.2% of the study population); poor adherence (35.6%); occasional use (14.9%); and gradual decline (12.3%). The latter two groups included users who showed a change in adherence (increase or decrease) during the pandemic emergence. Users with suboptimal adherence were likely to be younger, not pensioners, not institutionalized, with low morbidity burden and a low number of comorbidities. Female sex and switching between statins of different intensity increased the likelihood of belonging to the occasional use group, in which improved adherence coincided with the pandemic. Conclusion: We identified four distinct adherence patterns in a population of new statin users; two of them modified their adherence during the pandemic. Characterization of these groups could enable more effective distribution of resources in future similar crisis and the routine implementation of patient-centered interventions to improve medication adherence.

Adherence trajectory as an on-treatment risk indicator among drug-resistant TB patients in the Philippines

Introduction

High levels of treatment adherence are critical for achieving optimal treatment outcomes among patients with tuberculosis (TB), especially for drug-resistant TB (DR TB). Current tools for identifying high-risk non-adherence are insufficient. Here, we apply trajectory analysis to characterize adherence behavior early in DR TB treatment and assess whether these patterns predict treatment outcomes.

Methods

We conducted a retrospective analysis of Philippines DR TB patients treated between 2013 and 2016. To identify unique patterns of adherence, we performed group-based trajectory modelling on adherence to the first 12 weeks of treatment. We estimated the association of adherence trajectory group with six-month and final treatment outcomes using univariable and multivariable logistic regression. We also estimated and compared the predictive accuracy of adherence trajectory group and a binary adherence threshold for treatment outcomes.

Results

Of 596 patients, 302 (50.7%) had multidrug resistant TB, 11 (1.8%) extremely drug-resistant (XDR) TB, and 283 (47.5%) pre-XDR TB. We identified three distinct adherence trajectories during the first 12 weeks of treatment: a high adherence group (n = 483), a moderate adherence group (n = 93) and a low adherence group (n = 20). Similar patterns were identified at 4 and 8 weeks. Being in the 12-week moderate or low adherence group was associated with unfavorable six-month (adjusted OR [aOR] 3.42, 95% CI 1.90–6.12) and final (aOR 2.71, 95% 1.73–4.30) treatment outcomes. Adherence trajectory group performed similarly to a binary threshold classification for the prediction of final treatment outcomes (65.9% vs. 65.4% correctly classified), but was more accurate for prediction of six-month treatment outcomes (79.4% vs. 60.0% correctly classified).

Conclusions

Adherence patterns are strongly predictive of DR TB treatment outcomes. Trajectory-based analyses represent an exciting avenue of research into TB patient adherence behavior seeking to inform interventions which rapidly identify and support patients with high-risk adherence patterns.

Interventions Designed to Improve Adherence to Growth Hormone Treatment for Pediatric Patients and Their Families: A Narrative Review

Even though growth hormone (GH) treatment is still the only active treatment option to correct growth failure and increase stature for patients with GH deficiencies, evidence has shown that non-adherence remains high. The aim of this review was to identify and review the existing interventional strategies that have been designed to address and improve adherence to GH treatment for pediatric patients and their families. An extensive search of several electronic databases was undertaken to identify relevant interventional studies, published in English, between 1985 and 2021. Additional search strategies included hand-searching topic review articles to identify eligible studies. Articles were screened against the inclusion eligibility criteria and data on sample characteristics, intervention features, and key findings was extracted. A total of fifteen interventional studies were included in the review. The interventions identified were divided into two broad categories: novel injection devices, and patient choice of device. In conclusions, this review acknowledges that there is a lack of evidence-based, theory-driven intervention strategies, designed with the purpose of optimizing treatment adherence and improve clinical and psychosocial outcomes.

Motivational interviewing to support medication adherence in adults with chronic conditions: Systematic review of randomized controlled trials

OBJECTIVES

To systematically review published randomized controlled trials (RCTs) assessing the efficacy of MI to support medication adherence in adults with chronic conditions.

METHODS

A systematic review (PROSPERO-CRD42020025374) was performed by searching in Pubmed/MEDLINE, PsycINFO, The Cochrane Library and Web of Science. Studies were included for the following: RCTs assessing the impact of MI on medication adherence among adults with chronic diseases. Two reviewers conducted independent screening of records and full-text articles published until July 2020. Quality was assessed with the Risk of Bias 2 tool for RCTs.

RESULTS

From 1262 records identified, 54 RCTs were included. The MI interventions were delivered alone or in combination with other interventions, and varied in mode of delivery (e.g. face-to-face, phone), exposure level (duration, number of sessions), and provider characteristics (profession, training). Most interventions were developed in infectious diseases (n = 16), cardiology (n = 14), psychiatry (n = 8), and endocrinology (n = 7). Medication adherence showed significant improvement in 23 RCTs, and other clinical outcomes were improved in 19 RCTs (e.g. risky behaviors, disease symptoms).

CONCLUSIONS

MI is an approach to medication adherence support with an increasing evidence base in several clinical domains and further potential for adaptation to different settings.

PRACTICE IMPLICATIONS

In further studies, particular attention should focus on methodological issues such as the populations of patients to include - patients with suboptimal adherence, the evaluation of fidelity to the MI spirit and components, and a sound measurement of medication adherence and clinical outcomes.

Novel formulations of oral bisphosphonates in the treatment of osteoporosis

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

Medication Adherence Measurement Methods in Registration Trials Supporting the Approval of New Medicines: A Cross-Sectional Analysis of Centralized Procedures in the European Union 2010-2020

Medication adherence is a key factor impacting efficacy and safety of medicines, yet how it is dealt with in European registration trials is unknown. A cross-sectional analysis of European Medicines Agency (EMA) marketing authorization dossiers for new medicines approved through centralized procedures in the European Union between 2010 and 2020 was performed. Data were extracted from European Public Assessment Reports and Clinical Study Reports. Clinical trials covering five therapeutic areas were included: diabetes, respiratory conditions, cardiovascular diseases, infectious diseases, and oncology. Outcomes included adherence assessment, measurement methods, and rates. Overall, 102 medicines studied in 253 clinical trials were reviewed. All but one study reported measuring adherence. Two hundred twenty trials (87%) measured adherence using quantitative methods, while 32 (13%) trials monitored adherence but did not further quantify. Reported adherence rates were high (> 90%) across trials yet marked disparities in measurement methods and definitions were found. The most frequently used adherence measurement method was pill/dose count (single method: 52.7%; in combination: 37.7%; with patient diary/report: 17.3%; electronic methods: 1.4%; bioanalytical methods: 4.1%). Patient diary/report (6.4%) and electronic methods (2.7%) were also used as single methods. Electronic methods were more often used in respiratory and anti-infective trials, while bioanalytical methods were more frequently used in diabetes. Overall, adherence is measured in EMA registration trials, yet the methods used and the way in which adherence rates are presented vary widely between trials and therapeutic areas. To better understand and compare efficacy of medicines, standardization of adherence definitions and measurement methods is needed.

Interventions for increasing immunosuppressant medication adherence in solid organ transplant recipients

BACKGROUND

Non-adherence to immunosuppressant therapy is a significant concern following a solid organ transplant, given its association with graft failure. Adherence to immunosuppressant therapy is a modifiable patient behaviour, and different approaches to increasing adherence have emerged, including multi-component interventions. There has been limited exploration of the effectiveness of interventions to increase adherence to immunosuppressant therapy.

OBJECTIVES

This review aimed to look at the benefits and harms of using interventions for increasing adherence to immunosuppressant therapies in solid organ transplant recipients, including adults and children with a heart, lung, kidney, liver and pancreas transplant.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 14 October 2021 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

All randomised controlled trials (RCTs), quasi-RCTs, and cluster RCTs examining interventions to increase immunosuppressant adherence following a solid organ transplant (heart, lung, kidney, liver, pancreas) were included. There were no restrictions on language or publication type.

DATA COLLECTION AND ANALYSIS

Two authors independently screened titles and abstracts of identified records, evaluated study quality and assessed the quality of the evidence using the GRADE approach. The risk of bias was assessed using the Cochrane tool. The ABC taxonomy for measuring medication adherence provided the analysis framework, and the primary outcomes were immunosuppressant medication initiation, implementation (taking adherence, dosing adherence, timing adherence, drug holidays) and persistence. Secondary outcomes were surrogate markers of adherence, including self-reported adherence, trough concentration levels of immunosuppressant medication, acute graft rejection, graft loss, death, hospital readmission and health-related quality of life (HRQoL). Meta-analysis was conducted where possible, and narrative synthesis was carried out for the remainder of the results.

MAIN RESULTS

Forty studies involving 3896 randomised participants (3718 adults and 178 adolescents) were included. Studies were heterogeneous in terms of the type of intervention and outcomes assessed. The majority of studies (80%) were conducted in kidney transplant recipients. Two studies examined paediatric solid organ transplant recipients. The risk of bias was generally high or unclear, leading to lower certainty in the results. Initiation of immunosuppression was not measured by the included studies. There is uncertain evidence of an association between immunosuppressant medication adherence interventions and the proportion of participants classified as adherent to taking immunosuppressant medication (4 studies, 445 participants: RR 1.09, 95% CI 0.95 to 1.20; I² = 78%). There was very marked heterogeneity in treatment effects between the four studies evaluating taking adherence, which may have been due to the different types of interventions used. There was evidence of increasing dosing adherence in the intervention group (8 studies, 713 participants: RR 1.14, 95% CI 1.03 to 1.26, I² = 61%).  There was very marked heterogeneity in treatment effects between the eight studies evaluating dosing adherence, which may have been due to the different types of interventions used. It was uncertain if an intervention to increase immunosuppressant adherence had an effect on timing adherence or drug holidays. There was limited evidence that an intervention to increase immunosuppressant adherence had an effect on persistence. There was limited evidence that an intervention to increase immunosuppressant adherence had an effect on secondary outcomes. For self-reported adherence, it is uncertain whether an intervention to increase adherence to immunosuppressant medication increases the proportion of participants classified as medically adherent to immunosuppressant therapy (9 studies, 755 participants: RR 1.21, 95% CI 0.99 to 1.49; I² = 74%; very low certainty evidence). Similarly, it is uncertain whether an intervention to increase adherence to immunosuppressant medication increases the mean adherence score on self-reported adherence measures (5 studies, 471 participants: SMD 0.65, 95% CI -0.31 to 1.60; I² = 96%; very low certainty evidence). For immunosuppressant trough concentration levels, it is uncertain whether an intervention to increase adherence to immunosuppressant medication increases the proportion of participants who reach target immunosuppressant trough concentration levels (4 studies, 348 participants: RR 0.98, 95% CI 0.68 to 1.40; I² = 40%; very low certainty evidence). It is uncertain whether an intervention to increase adherence to immunosuppressant medication may reduce hospitalisations (5 studies, 460 participants: RR 0.67, 95% CI 0.44 to 1.02; I² = 64%; low certainty evidence). There were limited, low certainty effects on patient-reported health outcomes such as HRQoL. There was no clear evidence to determine the effect of interventions on secondary outcomes, including acute graft rejection, graft loss and death. No harms from intervention participation were reported.

AUTHORS' CONCLUSIONS

Interventions to increase taking and dosing adherence to immunosuppressant therapy may be effective; however, our findings suggest that current evidence in support of interventions to increase adherence to immunosuppressant therapy is overall of low methodological quality, attributable to small sample sizes, and heterogeneity identified for the types of interventions. Twenty-four studies are currently ongoing or awaiting assessment (3248 proposed participants); therefore, it is possible that findings may change with the inclusion of these large ongoing studies in future updates.

Categorizing Comorbid Risk for People Living With HIV: A Latent Profile Analysis

BACKGROUND

Categorizing clinical risk amidst heterogeneous multimorbidity in older people living with HIV/AIDS (PLWH) may help prioritize and optimize health care engagements.

METHODS

PLWH and their prevalent conditions in 8 health domains diagnosed before January 1, 2015 were identified using 2014-2016 Medicare claims and the Chronic Conditions Data Warehouse. Latent profile analysis identified 4 distinct clinical subgroups based on the likelihood of conditions occurring together [G1: healthy, G2: substance use (SU), G3: pulmonary (PULM), G4: cardiovascular conditions (CV)]. Restricted mean survival time regression estimated the association of each subgroup with the 365 day mean event-free days until death, first hospitalization, and nursing home admission. Zero-inflated Poisson regression estimated hospitalization frequency in 2-year follow-up.

RESULTS

Of 11,196 older PLWH, 71% were male, and the average age was 61 (SD 9.2) years. Compared with healthy group, SU group had a mean of 30 [95% confidence interval: (19.0 to 40.5)], PULM group had a mean of 28 (22.1 to 34.5), and CV group had a mean of 22 (15.0 to 22.0) fewer hospitalization-free days over 1 year. Compared with healthy group (2.8 deaths/100 person-years), CV group (8.4) had a mean of 4 (3.8 to 6.8) and PULM group (7.9) had a mean of 3 (0.7 to 5.5) fewer days alive; SU group (6.0) was not different. There was no difference in restricted mean survival time for nursing home admission. Compared with healthy group, SU group had 1.42-fold [95% confidence interval: (1.32 to 1.54)], PULM group had 1.71-fold (1.61 to 1.81), and CV group had 1.28-fold (1.20 to 1.37) higher rates of hospitalization.

CONCLUSION

Identifying clinically distinct subgroups with latent profile analysis may be useful to identify targets for interventions and health care optimization in older PLWH.

Monitoring Simvastatin Adherence in Patients With Coronary Heart Disease: A Proof-of-Concept Study Based on Pharmacokinetic Measurements in Blood Plasma

BACKGROUND

Poor statin adherence remains a public health concern associated with adverse outcomes. We evaluated the use of pharmacokinetic measurements to monitor adherence to simvastatin in patients with coronary heart disease (CHD).

METHODS

Eighteen patients with CHD taking an evening dose of simvastatin 20 mg (n = 7), 40 mg (n = 5), or 80 mg (n = 6) were examined at steady-state pharmacokinetics. Ten patients were instructed to interrupt simvastatin dosing and return for blood sampling for the subsequent 3 days. Dose-normalized plasma concentrations of simvastatin lactone and simvastatin acid and the sum of the 2 were evaluated to discriminate between adherent dosing and dose omission. Bioanalytical quantification was performed using liquid chromatography-tandem mass spectrometry.

RESULTS

A simvastatin acid cutoff of 1.0 × 10 -2 nmol -1 ·L -1 ·mg -1 identified 100% of those omitting 2 doses and 60% of those omitting a single dose. Simvastatin acid showed superior ability to discriminate dose omission, as well as the best agreement between samples handled at ambient and cool temperatures (median deviation 3.5%; interquartile range -2.5% to 13%). The cutoff for a morning dose schedule, with a similar ability to discriminate, was estimated at 2.0 × 10 -3 nmol -1 ·L -1 ·mg -1 .

CONCLUSIONS

The present method discriminated between adherence and reduced adherence to simvastatin therapy in patients with CHD. Sample handling is feasible for routine practice, and the assessment of adherence can be performed by direct measurement of simvastatin acid in a blood sample, according to defined cutoff values. Further studies validating the cutoff value and utility for clinical application are encouraged.

Electronically monitored medication adherence in idiopathic pulmonary fibrosis: prevalence, predictors and outcomes

Medication adherence studies in idiopathic pulmonary fibrosis (IPF) are limited, use cross-sectional designs and report discontinuation rates.

We prospectively investigated adherence to pirfenidone in IPF patients using electronic monitoring, which provides insights on whether and when the medication was taken on a day-by-day basis. We investigated the impact of nonadherence on lung function and selected predictors for nonadherence based on the COM-B behavioural model. The longitudinal statistical analyses included generalised estimation equations and linear mixed effects models.

55 patients initiating pirfenidone were followed-up for 2 years after diagnosis (76.4% men, mean age 71.1 years (range 50–87 years), mean forced vital capacity (FVC) 88% predicted (sd 18.3), mean diffusing capacity of the lung for carbon monoxide (D_LCO) 58.1% predicted (sd 14.7)). Our data showed an association (p=0.03) between the proportion of days with three pirfenidone intakes (i.e. dosing adherence) and FVC % predicted, whereby a high dosing adherence seemed necessary to maintain stable or improving FVC % predicted values. 58.2% of the participants were able to implement at least 90% correct dosing days, yet adherence significantly decreased over time. Too short dosing intervals had negative effects on lung function outcomes. Knowledge on IPF and self-reported adherence were significantly associated with electronically measured adherence.

In conclusion, nonadherence is prevalent and might negatively affect lung function. Further research is needed on the impact of nonadherence on outcomes and its predictors, so that tailored interventions can be developed. Meanwhile, a self-report questionnaire could be used to identify adherence issues and teams should equip patients with knowledge about their treatment and how to take it.

This study used electronic monitoring systems for the first time in IPF patients to assess taking and timing of pirfenidone. Medication nonadherence is a prevalent issue that increases over time and is associated with patients’ lung function outcomes.https://bit.ly/3wEFUlq

Efficacy and safety of single-dose antiviral drugs for influenza treatment: A systematic review and network meta-analysis

To conduct network meta-analysis (NMA) of clinical efficacy and safety of single-dose antiviral drugs, grouped by dosage, in treatment of influenza. Systematic retrievals were conducted in databases, including Pubmed, Embase, Web of Science, the Cochrane Register of Clinical Trials and from the website ClinicalTrials.gov, for clinical trials recorded between the interception of the databases and March 31, 2021. Randomized controlled trials (RCTs) of influenza treatment in which single-dose antiviral drugs were administered were selected according to preset inclusion and exclusion criteria by two researchers who screened the literature independently from each other. The quality of the included studies was assessed using the Cochrane bias risk assessment tool. Software such as Stata 16.0 and Review Manager 5.3 was adopted for statistical analysis. Pairwise meta-analysis and NMA were carried out under the random-effects model. For both binary and continuous variables, odds ratio (OR), mean difference (MD) and their 95% confidence intervals (CI) were used to rank treatment efficiencies and analyze the differences. A total of 12 RCTs involving 7296 participants were included in the analysis. According to the NMA results, peramivir 300 mg (MD = -17.68, 95% CI: [-34.05, -1.32]), peramivir 600 mg (MD = -16.15, 95% CI: [-29.35, -2.95]), baloxavir (MD = -14.67, 95% CI: [-26.75, -2.58]) and laninamivir 40 mg (MD = -12.42, 95% CI: [-22.53, -2.31]) remarkably outperformed laninamivir 20 mg in time to alleviation of symptoms (TTAS). However, no intervention statistically outperform others in antipyretic time, virus titer variations against the baseline 24 and 48 h after medication and adverse events (AEs). The efficacy rankings were: peramivir 300 mg (the surface under the cumulative ranking curve [SUCRA] = 80.3%) > peramivir 600 mg (SUCRA = 76.2%) > baloxavir (SUCRA = 68.4%) > laninamivir 40 mg (SUCRA = 55.0%) > laninamivir 20 mg (SUCRA = 16.6%) for TTAS; baloxavir (SUCRA = 76.3%) > peramivir 600 mg (SUCRA = 67.8%) > laninamivir 40 mg (SUCRA = 47.2%) > laninamivir 20 mg (SUCRA = 40.0%) for antipyretic time; baloxavir (SUCRA = 96.7%) > peramivir 300 mg (SUCRA = 64.5%) ≈ peramivir 600 mg (SUCRA = 63.2%), baloxavir (SUCRA = 93.2%) > peramivir 600 mg (SUCRA = 64.0%) ≈ peramivir 300 mg (SUCRA = 55.0%), for virus titer variations against the baseline 24 and 48 h after medication, respectively; and baloxavir (SUCRA = 83.4%) > peramivir 300 mg (SUCRA = 71.4%) > laninamivir 20 mg (SUCRA = 62.4%) > peramivir 600 mg (SUCRA = 56.2%) > laninamivir 40 mg (SUCRA = 36.8%) for adverse events. Among the single-dose anti-influenza virus drugs compared, peramivir is superior to baloxavir and laninamivir in TTAS, whereas baloxavir has the best efficacy in antipyretic time, virus titer variations against the baseline 24 and 48 h after medication and AEs. This study has been registered in the International Prospective Register of Systematic Reviews (PROSPERO), with a registration number of CRD42021238220.

Gender Differences in Non-Persistence with Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers among Older Hypertensive Patients with Peripheral Arterial Disease

The beneficial effects of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) in hypertensive patients with peripheral arterial disease (PAD) depends on long-term persistence. The aims of our study were to analyse gender differences in non-persistence with ACEIs/ARBs, and to identify the characteristics associated with the likelihood of non-persistence. Our study cohort included 7080 hypertensive patients (4005 women and 3075 men) aged ≥65 years, treated with ACEIs/ARBs, in whom PAD was diagnosed between 1 January and 31 December 2012. Non-persistence was identified according to a treatment gap of 6 months without ACEI/ARB prescriptions. The characteristics associated with non-persistence were identified using the Cox regression model. At the end of the 5-year follow-up, 23.2% of the whole study cohort, 22.3% of men, and 23.9% of women were non-persistent with ACEIs/ARBs, with no significant gender differences in persistence. While a number of characteristics were associated with non-persistence, only three characteristics had consistent, statistically significant associations in both genders: being a new ACEI/ARB user increased the likelihood of non-persistence, and general practitioner as index prescriber and increasing the overall number of medications decreased the likelihood of non-persistence. Information on the differences in characteristics that are associated with non-persistence between genders may help to better identify patients for whom special attention should be paid to improve their persistence.

Domains of Structured Oral Anticancer Medication Programs: A Scoping Review

PROBLEM IDENTIFICATION

An interprofessional approach is necessary to support the multifactorial process of patient adherence to oral anticancer medications (OAMs). This scoping review aims to identify structured OAM programs in published literature, identify components within studies, and propose a framework for institutions developing or maintaining OAM programs.

LITERATURE SEARCH

Embase®, PubMed®, and CINAHL® databases were searched for studies published between January 2000 and April 2021.

DATA EVALUATION

Two reviewers screened studies and extracted data. Characteristics and specific domains of the OAM programs were captured. Key components of the programs were identified, and a framework was created to guide program development.

SYNTHESIS

Components identified among the 21 studies were education; counseling; follow-up; dedicated clinician contact; adverse event and toxicity monitoring; adherence monitoring; drug procurement, delivery, and supply; patient- and system-level cost reduction; information technology; and risk assessment.

IMPLICATIONS FOR RESEARCH

Based on the findings, a framework for building and evaluating OAM adherence programs is proposed. Future studies should evaluate the reliability and validity of this framework because further testing may lead to the development of additional components.

Adaptation of communication assessment tool for community pharmacists in medication adherence and minor diseases management

Aim: To develop two versions of the Communication Assessment Tool (CAT) skilled for the setting of community pharmacy and to pilot test it on a selected sample.

Materials: Development of two versions of CAT-tool for community pharmacists. Validity and reliability assessments were required to determine the psychometric properties of developed tool versions. To investigate the construct validity of each adapted tool item, confirmatory factor analysis was performed. Reliability was assessed with the Cronbach’s Alpha evaluation, internal validity by submitting tool versions to patients of eleven pharmacies from North, Center, and South of Italy for pilot testing.

Results: Two CAT versions were developed and tested: CAT-Pharm-community Adherence to therapy and Minor Disease Management versions. First to evaluate pharmacist-patient communication following the dispensing of a prescription drug, second a consultation for minor disease management.

Conclusion: Communication tools are useful to implement optimal management of chronic diseases to minimize non-adherence and patients’ negative health outcomes.

Comparisons in polypharmacy over a decade in community-dwelling older adults-findings from Israel national health and nutrition surveys

Background

Polypharmacy increases with age and is associated with serious health and economic costs. This study reports changes over a decade in medication-use patterns and polypharmacy, in Israeli community-dwelling older adults aged ≥ 65 years.

Methods

Demographic and health data from two representative national health cross-sectional surveys – MABAT ZAHAV 1 (MZ1) in 2005–2006, and MZ2 in 2014–2015 were analyzed. Polypharmacy was defined as use of ≥ 5 medications. Risk factors for polypharmacy were estimated by multivariable logistic regression with adjusted odds ratios (aOR) and their 95% confidence intervals (CI).

Results

Self-reported data on medications taken were available for 1647 participants (91.5%) in MZ1, and for 833 participants (80.2%) in MZ2, 55% women, and about 20% aged ≥ 80, in both surveys. The prevalence of polypharmacy was significantly lower in MZ2 than in MZ1: 64.2% versus 56.3%, p = .0001; with an aOR (95%CI) of 0.64 (0.52, 0.80). The most commonly taken drugs were for hypertension (27.0%, 25.3%), dyslipidemia (9.7%, 12.4%) and anticoagulation (9.2%, 9.8%). For approximately 10% of drugs, indications were either unknown or incorrect. Polypharmacy was significantly associated with poor self-health assessment 2.47 (1.99, 3.06), ≥ 4 versus 1–3 chronic illnesses 6.36 (3.85, 10.50), and age ≥ 80 versus younger 1.72 (1.32, 2.24). Similar associations were observed with major polypharmacy of ≥ 8 medications.

Conclusion

Polypharmacy, although reduced in the last decade, requires constant attention, especially concerning lack of knowledge of indications which leads to poor adherence and adverse side effects. Health-care teams should carry out regular medicine reconciliation in at-risk elderly patients.

Comparing medication adherence in patients receiving bisphosphonates for preventing fragility fractures: a comprehensive systematic review and network meta-analysis

BACKGROUND

Bisphosphonates are effective in preventing fragility fractures; however, high rates of adherence are needed to preserve clinical benefits.

OBJECTIVE

To investigate persistence and compliance to oral and intravenous bisphosphonates (alendronate, ibandronate, risedronate, and zoledronate).

METHODS

Searches of 12 databases, unpublished sources, and trial registries were conducted, covering the period from 2000 to April 2021. Screening, data extraction, and risk of bias assessment (Cochrane Collaboration risk-of-bias tool 1.0 & ROBINS-I) were independently undertaken by two study authors. Randomised controlled trials (RCTs) and observational studies that used prescription claim databases or hospital medical records to examine patients' adherence were included. Network meta-analyses (NMA) embedded within a Bayesian framework were conducted, investigating users' likelihood in discontinuing bisphosphonate treatment. Where meta-analysis was not possible, data were synthesised using the vote-counting synthesis method.

RESULTS

Fifty-nine RCTs and 43 observational studies were identified, resulting in a total population of 2,656,659 participants. Data from 59 RCTs and 24 observational studies were used to populate NMAs. Zoledronate users were the least likely to discontinue their treatment HR = 0.73 (95%CrI: 0.61, 0.88). Higher rates of compliance were observed in those receiving intravenous treatments. The paucity of data and the heterogeneity in the reported medication possession ratio thresholds precluded a NMA of compliance data.

CONCLUSIONS

Users of intravenously administered bisphosphonates were found to be the most adherent to treatment among bisphosphonates' users. Patterns of adherence will permit the more precise estimation of clinical and cost-effectiveness of bisphosphonates.

TRIAL REGISTRATION

PROSPERO 2020 CRD42020177166.

Geriatric Conditions Associated with Nonadherence to Antiretroviral Therapy Among Older People with HIV: The Importance of Frailty

Poor compliance with medications is a growing concern in geriatric care and is increasingly more relevant among people living with HIV (PLWH) as they age. Our goal was to understand geriatric conditions associated with antiretroviral therapy (ART) nonadherence in a Medicare population of older PLWH. We analyzed Medicare data from PLWH aged 50 years or older who were continuously enrolled in fee-for-service Medicare from January 1, 2014 to June 30, 2015. Prevalent geriatric conditions (dementia, depression, falls, hip fracture, sensory deficits, osteoporosis, orthostatic hypotension, urinary incontinence, frailty) were identified in January 1, 2014-December 31, 2014. ART nonadherence was defined as <80% proportion of days covered (PDC) by at least two ART medications in January 1, 2015-June 30, 2015. We examined geriatric condition association with nonadherence using lowest Akaike Information Criterion multi-variate logistic models, controlling for age, sex, race, census region, substance use, Medicaid eligibility, and polypharmacy. Of 8778 PLWH, 23% (n = 2042) had <80% PDC. The average age was 60 years (standard deviation ±8), and >70% were males. In adjusted models, age was not associated with nonadherence, frailty status was the only geriatric condition associated with nonadherence [robust: reference, prefrail odds ratio (OR): 0.97, confidence interval (95% CI) 0.86-1.10, frail OR: 1.34 95% CI 1.11-1.61], and odds of nonadherence were lower for polypharmacy [OR: 0.48 (0.43-0.54)]. Our findings suggest that patient-centered care plans aimed at improving ART adherence among older PLWH would benefit from long-term surveillance; a deeper understanding of the role of frailty and polypharmacy, even at chronologically younger ages in PLWH.

What methods are used to study the association between medication adherence trajectories, estimated with the group-based trajectory modeling (GBTM) method, and health-related outcomes?-a protocol for a systematic review

BACKGROUND

The group-based trajectory modeling (GBTM) method is increasingly used in pharmacoepidemiologic studies to describe medication adherence trajectories over time. However, assessing the associations between these medication adherence trajectories and health-related outcomes remains challenging. The purpose of this review is to identify and systematically review the methods used to assess the association between medication adherence trajectories, estimated from the GBTM method, and health-related outcomes.

METHODS

We will conduct a systematic review according to the recommendations of the Cochrane handbook for systematic reviews of interventions 6.2. Results will be reported following PRISMA 2020 (Preferred Reporting Items for Systematic Reviews and Meta-analyses) recommendations. We will search in the following databases: PubMed, Embase, PsycINFO, Web of Science, CINAHL, and Cochrane Library. Two reviewers will independently select articles and extract data. Discrepancies at every step will be resolved through discussion, and consensus will be reached for all disagreed articles. A third reviewer will act as a referee if needed. We will produce tables to synthesize the modalities used to estimate medication adherence trajectories with GBTM. We will also synthesize the modalities used to assess the association between these medication adherence trajectories and health-related outcomes by identifying the types of health-related outcomes studied and how they are defined, the statistical models used, and how the medication adherence trajectories were used in these models, and the effect measure yield. We will also review the limitations and biases reported by the authors and their attempts to mitigate them. We will provide a narrative synthesis.

DISCUSSION

This review will provide a thorough exploration of the strategies and methods used in medication adherence research to estimate the associations between medication adherence trajectories, estimated with GBTM, and the different health-related outcomes. It will represent the first crucial steps toward optimizing these methods in adherence studies.

SYSTEMATIC REVIEW REGISTRATION

Prospero CRD42021213503 .

Adherence to cardiovascular disease risk factor medications among patients with cancer: a systematic review

PURPOSE

The most common cause of mortality for many cancer survivors is cardiovascular disease (CVD). This requires a shift in thinking where control of CVD risk factor-related comorbidity is paramount. Our objective was to provide an understanding of adherence to medications for the management of CVD risk factor-related comorbidities among cancer survivors.

METHODS

We systematically searched for articles indexed in MEDLINE (via PubMed), Embase, Cochrane (Wiley), PsycINFO, and Scopus (via Elsevier) for articles published from inception to October 31, 2019, and updated the search on June 7, 2021. English language, original research that assessed medication adherence to common CVD risk factor-related comorbidities among cancer survivors was included. We assessed risk of bias using the Mixed Methods Appraisal Tool.

RESULTS

Of the 21 studies included, 57% focused on multiple cancer types. Seventy-one percent used pharmacy-based adherence measures. Two were prospective. Adherence was variable across cancer types and CVD risk factor-related comorbidities. Among the studies that examined changes in comorbid medication adherence, most noted a decline in adherence following cancer diagnosis and throughout cancer treatment. There was a focus on breast cancer populations.

CONCLUSIONS

CVD risk factor-related medication adherence is low among cancer survivors and declines over time. Given the risk for CVD-mortality among cancer survivors, testing of interventions aimed at improving adherence to non-cancer medications is critically needed.

IMPLICATIONS FOR CANCER SURVIVORS

For many cancer survivors, regularly taking medications to manage CVD risk is important for longevity. Engaging with primary care throughout the cancer care trajectory may be important to support cardiovascular health.

Current practice in the measurement and interpretation of intervention adherence in randomised controlled trials: A systematic review

BACKGROUND

Ideally all participants in a randomised controlled trial (RCT) should fully receive their allocated intervention; however, this rarely occurs in practice. Intervention adherence affects Type II error so influences the interpretation of trial results and subsequent implementation. We aimed to describe current practice in the definition, measurement, and reporting of intervention adherence in non-pharmacological RCTs, and how this data is incorporated into a trial's interpretation and conclusions.

METHODS

We conducted a systematic review of phase III RCTs published between January 2018 and June 2020 in the National Institute for Health Research Journals Library for the Health Technology Assessment, Programme Grants for Applied Research, and Public Health Research funding streams.

RESULTS

Of 237 reports published, 76 met the eligibility criteria and were included. Most RCTs (n = 68, 89.5%) reported adherence, though use of terminology varied widely; nearly three quarters of these (n = 49, 72.1%) conducted a sensitivity analysis. Adherence measures varied between intervention types: behavioural change (n = 10, 43.5%), psychological therapy (n = 5, 83.3%) and physiotherapy/rehabilitation (n = 8, 66.7%) interventions predominately measured adherence based on session attendance. Whereas medical device and surgical interventions (n = 17, 73.9%) primarily record the number of participants receiving the allocated intervention, a third (n = 33, 67.3%) of studies reported a difference in findings between primary and sensitivity analyses.

CONCLUSIONS

Although most trials report elements of adherence, terminology was inconsistent, and there was no systematic approach to its measurement, analyses, interpretation, or reporting. Given the importance of adherence within clinical trials, there is a pressing need for a standardised approach or framework.

The value of adherence information during clinical pharmaceutical trials

BACKGROUND/AIMS

The quality of the evidence used to evaluate a drug's safety and efficacy depends, in part, on how well participants adhere to the prescribed drug-taking regime. There are multiple approaches to measure adherence in clinical trials, varying in their cost and accuracy. We demonstrate a method for evaluating the cost-effectiveness of common adherence monitoring methods, considering the costs and data quality for drugs that differ in how forgiving they are of nonadherence.

METHODS

We propose a simulation approach to estimate the value of evidence about adherence, considering both costs of collection and potential errors in interpreting clinical trial results. We demonstrate the approach with a simulated clinical trial of nitrendipine, a common calcium channel blocker. We consider two trial designs, one using pretrial adherence to "enrich" the trial sample and one without an enrichment strategy. We use scenarios combining high and low values of two key properties of a clinical trial: participant adherence and drug forgiveness.

RESULTS

Under the conditions of these simulations, the most cost-effective adherence monitoring approach depends on both trial participant adherence and drug forgiveness. For example, the enrichment strategy is not cost-effective for the base scenario (high forgiveness and high adherence), but is for other scenarios. We also estimate the effects of evaluable patient analysis, a controversial procedure that excludes nonadherent participants from the analyses, after a trial is completed.

CONCLUSIONS

Our proposed approach can guide drug regulators and developers in designing efficient clinical trials and assessing the impact of nonadherence on trial results. It can identify cost-effective adherence-monitoring methods, given available knowledge about the methods, drug, and patients' expected adherence.

Factors influencing five-year adherence to adjuvant endocrine therapy in breast cancer patients: A systematic review

Purpose

This systematic review aimed to determine the rate and identify correlates of adherence and persistence over five years of treatment with adjuvant endocrine therapy in female breast cancer patients.

Methods

Relevant articles were identified from Medline, Embase, AMED, PsycINFO, International Pharmaceutical Abstracts, and APA PsycArticles. Studies that measured patient adherence in the implementation or persistence phase for a period of at least five years using objective or multiple measures of adherence and investigated correlates of adherence were included. The titles, abstracts and full articles were screened and reviewed by two authors and any discrepancies were discussed with a third author.

Results

Twenty-six studies were included. Mean rate of adherence at five-year for implementation phase was 66.2% (SD = 17.3%), and mean persistence was 66.8% (SD = 14.5%). On average, adherence decreased by 25.5% (SD = 9.3%) from the first to fifth year. Higher rate of adherence was observed through self-report in comparison to database or medical record. Older age, younger age, higher comorbidity index, depression and adverse effects were associated with lower adherence. Treatment with aromatase inhibitors, received chemotherapy, and prior medication use were associated with improved adherence.

Conclusion

Adherence to adjuvant endocrine therapy decreased from the first to fifth year of treatment. On average, one-third of patients were not adherent to treatment by the fifth year. Nineteen recurring factors were found to be significantly associated with long-term adherence in multiple studies. Further research using objective or multiple measures of adherence are needed to improve validity of results.

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On average, adherence fell by 25.5% from the first to the fifth year of treatment.

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Self-reported adherence may overestimate patient adherence.

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Nineteen recurring factors were associated with adherence.

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Having adverse effects was negatively associated with adherence.

Effectiveness of Interventions to Promote Medication Adherence in Schizophrenic Populations in Thailand: A Systematic Review

Medication non-adherence is a leading cause of poor treatment outcomes among Thai patients with psychiatric disorders and creates challenges for psychiatric nurses. This systematic review synthesized research on intervention effectiveness for antipsychotic medication adherence in Thai schizophrenic populations. Following PRISMA guidelines, searches were completed in seven databases, including PubMed, PsycINFO, CINAHL, Web of Science, Scopus, ThaiJO, and Google Scholar. No restriction dates were used. Screening and extraction of data were performed systematically. Eligible studies consisted of nine quasi-experimental and two randomized control trial studies. The Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) was used to assess the studies’ methodological quality. This review revealed that individual counseling combined with cognitive-behavioral therapy (CBT) and motivational interviewing (MI) techniques improved and maintained medication adherence behavior over time. Post-testing after intervention completion and at 3- and 6-month follow-ups showed that treatment group participants were more adherent than control group participants (p < 0.01). These findings suggest that incorporating CBT and MI into clinical practice can enhance medication adherence behavior. Booster session efficacy for reinforcing and sustaining adherence should be investigated. Greater rigor is warranted in future intervention studies based on a quality appraisal of previous studies.

Impact of physician' and pharmacy staff supporting activities in usual care on patients' statin adherence

AIMS

Little is known about usual care by physicians and pharmacy teams to support adherence to statins and whether the extent of this care is associated with adherence to statins. Objective of the study was to examine the relationship between the extent of adherence supporting activities of healthcare practitioners (HCPs) and patients' adherence to statins.

METHODS

Cross-sectional study in 48 pharmacies and affiliated physicians' practices, between September 3, 2014 and March 20, 2015. Patients visiting the pharmacy with a statin prescription from participating prescribers were invited to participate. Usual care to support adherence was assessed among HCPs with the Quality of Standard Care questionnaire about usual care activities to support adherence. Adherence to statins was assessed among patients with the MARS-5 questionnaire. The association between the extent of HCPs' adherence supporting activities and patients' adherence was examined by means of multilevel regression analysis.

RESULTS

1,504 patients and 692 HCPs (209 physicians, 118 pharmacists and 365 pharmacy technicians) participated. No association was found between the extent of physicians' adherence supporting activities and patients' adherence to statins. The extent of adherence supporting activities by pharmacy teams in usual care was negatively associated with patients' adherence to statins (B coefficient -0.057 (95%CI: -0.112- -0.002).

CONCLUSIONS

This study suggests that there is no positive relationship between the extent of HCPs' adherence supporting activities in usual care and patients' adherence to statins. Other methods than questionnaires (e.g. electronic monitors (to assess adherence) and observations (to assess usual care) should be applied to confirm the results of this study.

Digital Health Technologies to Improve Medication Adherence and Treatment Outcomes in Patients With Tuberculosis: Systematic Review of Randomized Controlled Trials

Background

Nonadherence to medication in tuberculosis (TB) hampers optimal treatment outcomes. Digital health technology (DHT) seems to be a promising approach to managing problems of nonadherence to medication and improving treatment outcomes.

Objective

This paper systematically reviews the effect of DHT in improving medication adherence and treatment outcomes in patients with TB.

Methods

A literature search in PubMed and Cochrane databases was conducted. Randomized controlled trials (RCTs) that analyzed the effect of DHT interventions on medication adherence outcomes (treatment completion, treatment adherence, missed doses, and noncompleted rate) and treatment outcomes (cure rate and smear conversion) were included. Adult patients with either active or latent TB infection were included. The Jadad score was used for evaluating the study quality. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline was followed to report study findings.

Results

In all, 16 RCTs were selected from 552 studies found, and 6 types of DHT interventions for TB were identified: 3 RCTs examined video directly observed therapy (VDOT), 1 examined video-observed therapy (VOT), 1 examined an ingestible sensor, 1 examined phone call reminders, 2 examined medication monitor boxes, and 8 examined SMS text message reminders. The outcomes used were treatment adherence, including treatment completion, treatment adherence, missed dose, and noncompleted rate, as well as clinical outcomes, including cure rate and smear conversion. In treatment completion, 4 RCTs (VDOT, VOT, ingestible sensor, SMS reminder) found significant effects, with odds ratios and relative risks (RRs) ranging from 1.10 to 7.69. Treatment adherence was increased in 1 study by SMS reminders (RR 1.05; 95% CI 1.04-1.06), and missed dose was reduced in 1 study by a medication monitor box (mean ratio 0.58; 95% CI 0.42-0.79). In contrast, 3 RCTs of VDOT and 3 RCTs of SMS reminders did not find significant effects for treatment completion. Moreover, no improvement was found in treatment adherence in 1 RCT of VDOT, missed dose in 1 RCT of SMS reminder, and noncompleted rate in 1 RCT of a monitor box, and 2 RCTs of SMS reminders. For clinical outcomes such as cure rate, 2 RCTs reported that phone calls (RR 1.30; 95% CI 1.07-1.59) and SMS reminders (OR 2.47; 95% CI 1.13-5.43) significantly affected cure rates. However, 3 RCTs found that SMS reminders did not have a significant impact on cure rate or smear conversion.

Conclusions

It was found that DHT interventions can be a promising approach. However, the interventions exhibited variable effects regarding effect direction and the extent of improving TB medication adherence and clinical outcomes. Developing DHT interventions with personalized feedback is required to have a consistent and beneficial effect on medication adherence and outcomes among patients with TB.

Supporting People With Type 2 Diabetes in the Effective Use of Their Medicine Through Mobile Health Technology Integrated With Clinical Care to Reduce Cardiovascular Risk: Protocol for an Effectiveness and Cost-effectiveness Randomized Controlled Trial

BACKGROUND

Type 2 diabetes is a common lifelong condition that affects over 400 million people worldwide. The use of effective medications and active self-management can reduce the risk of serious complications. However, people often have concerns when starting new medications and face difficulties in taking their medications regularly. Support provided by brief messages delivered through mobile phone-based SMS text messages can be effective in some long-term conditions. We have identified promising behavior change techniques (BCTs) to promote medication adherence in this population via a systematic review and developed SMS text messages that target these BCTs. Feasibility work has shown that these messages have fidelity to intended BCTs, are acceptable to patients, and are successful in changing the intended determinants of medication adherence. We now plan to test this intervention on a larger scale in a clinical trial.

OBJECTIVE

The aim of this trial is to determine the effectiveness and cost-effectiveness of this intervention for reducing cardiovascular risk in people with type 2 diabetes by comparing it with usual care.

METHODS

The trial will be a 12-month, multicenter, individually randomized controlled trial in primary care and will recruit adults (aged ≥35 years) with type 2 diabetes in England. Consenting participants will be randomized to receive short SMS text messages intended to affect a change in medication adherence 3 to 4 times per week in addition to usual care. The aim is to test the effectiveness and cost-effectiveness of the intervention when it is added to usual care. The primary clinical outcome will be a composite cardiovascular risk measure. Data including patient-reported measures will be collected at baseline, at 13 and 26 weeks, and at the end of the 12-month follow-up period. With 958 participants (479 in each group), the trial is powered at 92.5% to detect a 4-percentage point difference in cardiovascular risk. The analysis will follow a prespecified plan. A nested quantitative and qualitative process analysis will be used to examine the putative mechanisms of behavior change and wider contextual influences. A health economic analysis will be used to assess the cost-effectiveness of the intervention.

RESULTS

The trial has completed the recruitment phase and is in the follow-up phase. The publication of results is anticipated in 2024.

CONCLUSIONS

This trial will provide evidence regarding the effectiveness and cost-effectiveness of this intervention for people with type 2 diabetes.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN15952379; https://www.isrctn.com/ISRCTN15952379.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/32918.

PrEP Use, Sexual Behaviour, and PrEP Adherence Among Men who have Sex with Men Living in Wales Prior to and During the COVID-19 Pandemic

We examined PrEP use, condomless anal sex (CAS), and PrEP adherence among men who have sex with men (MSM) attending sexual health clinics in Wales, UK. In addition, we explored the association between the introduction of measures to control transmission of SARS-CoV-2 on these outcomes. We conducted an ecological momentary assessment study of individuals in receipt of PrEP in Wales. Participants used an electronic medication cap to record PrEP use and completed weekly sexual behaviour surveys. We defined adherence to daily PrEP as the percentage of CAS episodes covered by daily PrEP (preceded by ≥ 3 days of PrEP and followed by ≥ 2 days). Sixty participants were recruited between September 2019 and January 2020. PrEP use data prior to the introduction of control measures were available over 5785 person-days (88%) and following their introduction 7537 person-days (80%). Data on CAS episodes were available for 5559 (85%) and 7354 (78%) person-days prior to and following control measures respectively. Prior to the introduction of control measures, PrEP was taken on 3791/5785 (66%) days, there were CAS episodes on 506/5559 (9%) days, and 207/406 (51%) of CAS episodes were covered by an adequate amount of daily PrEP. The introduction of pandemic-related control measures was associated with a reduction in PrEP use (OR 0.44, 95%CI 0.20–0.95), CAS (OR 0.35, 95%CI 0.17–0.69), and PrEP adherence (RR = 0.55, 95%CI 0.34–0.89) and this may have implications for the health and wellbeing of PrEP users and, in addition to disruption across sexual health services, may contribute to wider threats across the HIV prevention cascade.

Illness Perceptions and Medication Nonadherence to Immunosuppressants After Successful Kidney Transplantation: A Cross-Sectional Study

Background: Medication nonadherence to immunosuppressants is a well-known risk factor for suboptimal health outcomes in kidney transplant recipients (KTRs). This study examined the relationship between illness perceptions and medication nonadherence in prevalent Dutch KTRs and whether this relationship depended on post-transplant time.

Methods: Eligible KTRs transplanted in Leiden University Medical Center were invited for this cross-sectional study. The illness perceptions and medication nonadherence were measured via validated questionnaires. Associations between illness perceptions and medication nonadherence were investigated using multivariable logistic regression models.

Results: For the study, 627 participating KTRs were analyzed. 203 (32.4%) KTRs were considered nonadherent to their immunosuppressants with “taking medication more than 2 h from the prescribed dosing time” as the most prevalent nonadherent behaviour (n = 171; 27.3%). Three illness perceptions were significantly associated with medication nonadherence: illness identity (adjusted odds ratio [OR_adj] = 1.07; 95% confidence interval [CI], 1.00–1.14), concern (OR_adj = 1.07; 95%CI,1.00–1.14), and illness coherence (OR_adj = 1.11; 95%CI,1.01–1.22). The relationships between illness perceptions and medication nonadherence did not differ depending on post-transplant time (p-values ranged from 0.48 to 0.96).

Conclusion: Stronger negative illness perceptions are associated with medication nonadherence to immunosuppressants. Targeting negative illness perceptions by means of psychoeducational interventions could optimize medication adherence and consequently improve health outcomes in KTRs.

Effectiveness of a medication adherence management intervention in a community pharmacy setting: a cluster randomised controlled trial

BACKGROUND

Non-adherence to medications continues to be a burden worldwide, with significant negative consequences. Community pharmacist interventions seem to be effective at improving medication adherence. However, more evidence is needed regarding their impact on disease-specific outcomes. The aim was to evaluate the impact of a community pharmacist-led adherence management intervention on adherence and clinical outcomes in patients with hypertension, asthma and chronic obstructive pulmonary disease (COPD).

METHODS

A 6-month cluster randomised controlled trial was conducted in Spanish community pharmacies. Patients suffering from hypertension, asthma and COPD were recruited. Patients in the intervention group received a medication adherence management intervention and the control group received usual care. The intervention was based on theoretical frameworks for changing patient behaviour. Medication adherence, disease-specific outcomes (Asthma Control Questionnaire (ACQ) scores, Clinical COPD Questionnaire (CCQ) scores and blood pressure levels) and disease control were evaluated. A multilevel regression model was used to analyse the data.

RESULTS

Ninety-eight pharmacies and 1186 patients were recruited, with 1038 patients completing the study. Patients receiving the intervention had an OR of 5.12 (95% CI 3.20 to 8.20, p<0.05) of being adherent after the 6 months. At the end of the study, patients in the intervention group had lower diastolic blood pressure levels (mean difference (MD) -2.88, 95% CI -5.33 to -0.43, p=0.02), lower CCQ scores (MD -0.50, 95% CI -0.82 to -0.18, p<0.05) and lower ACQ scores (MD -0.28, 95% CI -0.56 to 0.00, p<0.05) when compared with the control group.

CONCLUSIONS

A community pharmacist-led medication adherence intervention was effective at improving medication adherence and clinical outcomes in patients suffering from hypertension, asthma and COPD. Future research should explore the implementation of these interventions in routine practice.

TRIAL REGISTRATION NUMBER

ACTRN12618000410257.

Perception of pharmacological prevention and subsequent non-adherence to medication in patients with ischaemic heart disease: a population-based cohort study

OBJECTIVE

A patient-focused approach is advocated to embody risk of non-adherence to medication and subsequent adverse clinical outcomes following ischaemic heart disease (IHD). This study aimed to explore how patient perceived information on pharmacological prevention was associated with subsequent non-adherence to medication (measured by non-initiation, non-implementation and non-persistence) in patients with incident IHD.

DESIGN

Cohort study.

SETTING

Denmark.

PARTICIPANTS

Register-based cohort of 829 patients with incident IHD in 2013.

MEASURES

Perception covered whether patients' experienced being adequately informed about their pharmacological prevention. Information on such was obtained from a survey and divided into 'Well informed', 'Moderately informed' and 'Poorly informed'. Information on baseline characteristics, and reimbursed prescriptions of medication (antiplatelets, statins, ACE-inhibitors/angiotensin receptor blockers and β-blockers) during follow-up were obtained by linkage to nationwide public registers. Non-initiation and non-implementation of medication, measured as proportion of days covered, were analysed by Poisson regression. Non-persistence to medication, measured as risk of discontinuation, was analysed by multivariable Cox proportional hazard regression.

PRIMARY AND SECONDARY OUTCOME MEASURES

Non-implementation and non-persistence to medication up to 365 days of follow-up were primary outcomes. Secondary outcomes included non-initiation as well as non-implementation and non-persistence to medication at 180 days of follow-up.

RESULTS

A dose-response association was in general found between perception of pharmacological prevention and risk of non-implementation and non-persistence. For example, the hazard of non-persistence to antiplatelets was 1.18 (95% CI 0.71 to 1.96) times higher for patients reporting 'Moderately informed' and 1.89 (95% CI 1.10 to 3.25) times higher for patients reporting 'Poorly informed', compared with patients reporting 'Well informed of perception of pharmacological prevention' up to 365 days of follow-up.

CONCLUSION

Lower levels of perception of pharmacological prevention were associated with subsequent non-implementation and non-persistence to medication in patients with incident IHD.

Delta T, a Useful Indicator for Pharmacy Dispensing Data to Monitor Medication Adherence

INTRODUCTION

Calculating patients' medication availability from dispensing or refill data is a common method to estimate adherence. The most often used measures, such as the medication possession ratio (MPR), average medication supplies over an arbitrary period. Averaging masks the variability of refill behavior over time.

GOAL

To derive a new absolute adherence estimate from dispensing data.

METHOD

Dispensing histories of patients with 19 refills of direct oral anticoagulants (DOAC) between 1 January 2008 and 31 December 2017 were extracted from 39 community pharmacies in Switzerland. The difference between the calculated and effective refill day (ΔT) was determined for each refill event. We graphed ΔT and its dichotomized version (dΔT) against the MPR, calculated mean ΔT and mean dΔT per refill, and applied cluster analysis.

RESULTS

We characterized 2204 refill events from 116 DOAC patients. MPR was high (0.975 ± 0.129) and showed a positive correlation with mean ΔT. Refills occurred on average 17.8 ± 27.9 days "too early", with a mean of 75.8 ± 20.2 refills being "on time". Four refill behavior patterns were identified including constant gaps within or at the end of the observation period, which were critical.

CONCLUSION

We introduce a new absolute adherence estimate ΔT that characterizes every refill event and shows that the refill behavior of DOAC patients is dynamic.

Mental health conditions and adherence to direct oral anticoagulants in patients with incident atrial fibrillation: A nationwide cohort study

OBJECTIVE

Medication adherence is essential for effective stroke prevention in patients with atrial fibrillation (AF). We aimed to assess whether adherence to direct oral anticoagulants (DOACs) in AF patients is affected by the presence of mental health conditions (MHCs).

METHODS

The nationwide FinACAF cohort covered 74,222 AF patients from all levels of care receiving DOACs during 2011-2018 in Finland. Medication possession ratio (MPR) was used to quantify adherence. Patients with MPR ≥0.90 were defined adherent. MHCs of interest were depression, bipolar disorder, anxiety disorder and schizophrenia.

RESULTS

The patients' (mean age 75.4 ± 9.5 years, 50.8% female) mean MPR was 0.84 (SD 0.22), and 59.5% had MPR ≥0.90. Compared to patients without MHC, the adjusted ORs (95% CI) for adherent DOAC use emerged slightly lower in patients with depression (0.92 (0.84-0.99)) and bipolar disorder (0.77 (0.61-0.97)) and unsignificant in patients with anxiety disorder (1.08 (0.96-1.21)) and schizophrenia (1.13 (0.90-1.43)). However, when only persistent DOAC therapy was analyzed, no MHC was associated with poor adherence, and instead anxiety disorder was associated with adherent DOAC use (1.18 (1.04-1.34)).

CONCLUSION

Adherence to DOACs in AF patients in Finland was relatively high, and no meaningful differences between patients with and without MHCs were observed.

Pediatric Medication Noninitiation in Spain

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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