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

Prevalence of and factors associated with primary medication non-adherence in chronic disease: A systematic review and meta-analysis

BACKGROUND

Primary medication non-adherence (PMN), defined as failure to obtain newly prescribed medications, results in adverse clinical and economic outcomes. We aimed to (a) assess the prevalence of PMN in six common chronic diseases: asthma and/ or chronic obstructive pulmonary disease, depression, diabetes mellitus, hyperlipidaemia, hypertension and osteoporosis; (b) identify and categorise factors associated with PMN; (c) explore characteristics that contributed to heterogeneity between studies.

METHODS

We performed a systematic search in MEDLINE, Embase, Cochrane Library, CINAHL and PsycINFO. Studies published in English between January 2008 and August 2018 assessing PMN in subjects aged ≥18 years were included. We used the Cochrane risk of bias tool, Newcastle-Ottawa Scale and National Heart, Lung and Blood Institute Quality Assessment Tool to assess the quality of randomised controlled trials, cohort and cross-sectional studies, respectively. Findings were reported using the PRISMA checklist. PMN rates were pooled using a random effects model. We summarised factors associated with PMN descriptively. Subgroup analysis was performed to explore sources of heterogeneity.

RESULTS

We screened 3083 articles and included 33 (5 randomised controlled trials, 26 cohort and 2 cross-sectional studies, n = 539 156), of which 31 (n = 519 971) were used in meta-analysis. The pooled PMN rate was 17% (95% CI: 15%-20%). Pooled PMN rates were highest in osteoporosis (25%, 95% CI: 7%-44%) and hyperlipidaemia (25%, 95% CI: 18%-32%) and lowest in diabetes mellitus (10%, 95% CI: 7%-12%). Factors commonly associated with PMN include younger age, number of concurrent medications, practitioner specialty and higher co-payment. Type of chronic disease, age, study setting and PMN definition contributed to heterogeneity between studies (all P < 0.001).

CONCLUSION

Primary medication non-adherence is common among patients with chronic diseases and more needs to be done to address this issue in order to improve patient outcomes. Future PMN studies could benefit from greater standardisation to enhance comparability.

Factors Associated With Pickup of Pediatric Discharge Prescriptions

BACKGROUND AND OBJECTIVES

Lack of medication pickup is associated with worse clinical outcomes for select patients. Identification of risk factors for not picking up discharge medications or approaches to this problem have received little study. We sought to identify factors associated with medication pickup rates after hospitalization at a tertiary care children's hospital.

METHODS

We conducted a retrospective cohort study of 178 discharges from a children's hospital. We contacted pharmacies that received electronic prescriptions to ascertain whether patients and families picked up medications. The principal outcome was pickup of all medications within 48 hours of discharge. Covariates included demographic data, insurance type, discharge diagnosis, home zip code median income, medication number and/or class, and pharmacy type (on-site versus off-site). We performed a multivariable logistic regression analysis.

RESULTS

Overall, 142 of 178 (80%) discharges involved medication pickup. Patient age and sex, diagnosis, discharge day, primary language, and hospitalization length had no statistically significant association with medication pickup. On the multivariable analysis, a higher home zip code median income (P = .045; highest versus lowest groups) had a statistically significant association with increased medication pickup. Private insurance had a statistically significant association with higher pickup rate on the univariable analysis (P = .01) but not on the multivariable analysis, which included zip code income (P = .072). On-site pharmacy use (P = .048) and prescription of an anti-infective (P = .003) had statistically significant associations with higher medication pickup rates.

CONCLUSIONS

Certain factors are associated with rates of medication pickup after discharge. Use of an on-site hospital pharmacy may represent a strategy to improve medication pickup rates in children who are hospitalized.

Why patients want to take or refuse to take antibiotics: an inventory of motives

BACKGROUND

Inappropriate use of antibiotics is a worldwide issue. In order to help public health institutions and each particular physician to change patterns of consumption among patients, it is important to understand better the reasons why people accept to take or refuse to take the antibiotic drugs. This study explored the motives people give for taking or refusing to take antibiotics.

METHODS

Four hundred eighteen adults filled out a 60-item questionnaire that consisted of assertions referring to reasons for which the person had taken antibiotics in the past and a 70-item questionnaire that listed reasons for which the person had sometimes refused to take antibiotics.

RESULTS

A six-factor structure of motives to take antibiotics was found: Appropriate Prescription, Protective Device, Enjoyment (antibiotics as a quick fix allowing someone to go out), Others' Pressure, Work Imperative, and Personal Autonomy. A four-factor structure of motives not to take antibiotics was found: Secondary Gain (through prolonged illness), Bacterial Resistance, Self-defense (the body is able to defend itself) and Lack of trust. Scores on these factors were related to participants' demographics and previous experience with antibiotics.

CONCLUSION

Although people are generally willing to follow their physician's prescription of antibiotics, a notable proportion of them report adopting behaviors that are beneficial to micro-organisms and, as a result, potentially detrimental to humans.

Polypharmacy is associated with treatment response and serious adverse events: results from the British Society for Rheumatology Biologics Register for Rheumatoid Arthritis

Objective

To evaluate whether polypharmacy is associated with treatment response and serious adverse events (SAEs) in patients with RA using data from the British Society for Rheumatology Biologics Register (BSRBR-RA).

Methods

The BSRBR-RA is a prospective observational cohort study of biologic therapy starters and a DMARD comparator arm. A logistic regression model was used to calculate the odds of a EULAR ‘good response’ after 12 months of biologic therapy by medication count. Cox proportional hazards models were used to identify risk of SAEs. The utility of the models were compared with the Rheumatic Disease Comorbidity Index using Receiver Operator Characteristic and Harrell’s C statistic.

Results

The analysis included 22 005 patients, of which 83% were initiated on biologics. Each additional medication reduced the odds of a EULAR good response by 8% [odds ratios 0.92 (95% CI 0.91, 0.93) P < 0.001] and 3% in the adjusted model [adjusted odds ratios 0.97 (95% CI 0.95, 0.98) P < 0.001]. The Receiver Operator Characteristic demonstrated significantly greater areas under the curve with the polypharmacy model than the Rheumatic Disease Comorbidity Index. There were 12 547 SAEs reported in 7286 patients. Each additional medication equated to a 13% increased risk of an SAE [hazard ratio 1.13 (95% CI 1.12, 1.13) P < 0.001] and 6% in the adjusted model [adjusted hazard ratio 1.06 (95% CI 1.05, 1.07) P < 0.001]. Predictive values for SAEs were comparable between the polypharmacy and Rheumatic Disease Comorbidity Index model.

Conclusion

Polypharmacy is a simple but valuable predictor of clinical outcomes in patients with RA. This study supports medication count as a valid measure for use in epidemiologic analyses.

Adherence to Dihydroartemisinin-Piperaquine Treatment among Patients with Uncomplicated Malaria in Northern Ghana

Treatment adherence has been described as the process whereby patients take medications, follow diet, and effect other lifestyle changes that relate to agreed recommendations from healthcare providers. The determinants of such treatment adherence include patient, the health condition, therapy type, socioeconomic conditions, and the healthcare system. The study examined adherence in malaria patients treated with dihydroartemisinin-piperaquine in routine clinical care in northern Ghana. The study was conducted in Navrongo Health Research Centre in the Kassena-Nankana district of northern Ghana. Patients confirmed with uncomplicated malaria were prescribed dihydroartemisinin-piperaquine in blister packs to be taken daily for three days. Follow-up visits were made on days 3 and 28 after diagnosis to collect data on adherence, drug safety and therapeutic effectiveness. During follow-up visits, in-depth interviews were conducted and the blister packs directly observed for the number of tablets remaining. The in-depth interviews documented day-by-day account of doses taken, number of tablets taken during each dose, time of each dose, reasons for any leftover or missed dose, and whether or not there was vomiting. Treatment adherence was classified as definitely nonadherent, incomplete adherence, and completely adherent. A total of 405 patients were screened; 299 were positive by rapid diagnostic testing and 216 by microscopy. The average age was 12 years and females represented 54.0%. All participants completed day 3 follow-up but 12.7% had leftover pills. Treatment adherence was 50.9% (95% CI 44.1, 57.8), 36.1% (95% CI 29.7, 42.9), and 13.0% (95% CI 8.8, 18.2) for completely adherent, incomplete adherence, and definitely nonadherent, respectively. All completely adherent patients were free of parasitemia on day 28 of follow-up. A total of 49 adverse events related to malaria symptoms were documented. Effort to improve adherence should be individualized as it is dependent on a number of factors such as the patients' temperament, the disease, support at home, and complexity of treatment.

Rates and Determinants of Use of Pharmacotherapy and Psychotherapy by Patients With Major Depressive Disorder

OBJECTIVE

Rates and determinants of pharmacological and psychotherapy use were assessed after a major depressive disorder diagnosis.

METHODS

In a retrospective claims study that included 2007-2016 records from the IBM MarketScan research databases, use of pharmacotherapy and psychotherapy was tracked in a population of 24,579 patients with a diagnosis of major depressive disorder. Univariate and multiple variable analyses were used to identify determinants of antidepressant adherence (proportion of days covered ≥.8) and intensive psychotherapy at the beginning of treatment (at least four psychotherapy visits in the first 4 weeks after initiating psychotherapy).

RESULTS

In the 12 months following a diagnosis of major depressive disorder, most individuals received pharmacotherapy or psychotherapy (94.7%), and unimodal therapy was more common (58.5%) than bimodal therapy (36.2%). When antidepressants were initiated (N=13,524), 41.7% and 32.0% of patients were adherent in the acute and continuation phases, respectively. Initial antidepressant dosages were outside guideline recommendations for 34.5% of patients prescribed these medications. When psychotherapy was initiated, the median number of visits in the year after a patient's diagnosis was seven. Most patients (54.7%) did not continue to receive either antidepressant or psychotherapy treatment after month 5 following their diagnosis. A shorter time from diagnosis to treatment and a lower percentage of treatment costs paid by the patient were associated with increased antidepressant adherence and intensive psychotherapy use.

CONCLUSIONS

Findings indicate that treatment guideline recommendations are not followed for a large proportion of patients with major depressive disorder and that improvement is needed in multiple areas to enhance effective treatment.

Assessment of adherence to medication in patients after myocardial infarction treated with percutaneous coronary intervention. Is there a place for newself-reported questionnaires?

INTRODUCTION

Non-adherence to medication regimen after myocardial infarction (MI) leads to increased morbidity and mortality and generates additional cost to the healthcare system.

OBJECTIVES

The aim of this systematic review was to critically discuss assessment methods of adherence to medication in patients after myocardial infarction treated with percutaneous coronary intervention and the possible application of a new self-reported questionnaire.

METHODS

A systematic investigation of all published literature was conducted to minimize the risk of bias. A database search (PubMed, CENTRAL and Google Scholar databases) from January 1998 through December 2017.

RESULTS

Adequate assessment of patient adherence to treatment is necessary to understand the potential for adverse outcomes. Methods developed for adherence evaluation are classified as subjective and objective or as direct and indirect. Direct, objective measures reflect pharmacokinetics and include measurement of the drug or its metabolite concentration, evaluation of the presence of biological markers given with the drug and direct observation of patients' medication-taking behavior. Several indirect, objective methods are based on evaluation of the availability of prescribed medications assuming that medication is taken exactly as prescribed. Assessment of the effectiveness of treatment, both at the pharmacodynamic and clinical level, indirectly but objectively reflects adherence to treatment. Subjective methods, including patient-kept diaries, patient interviews and self-reported questionnaires, due to their simplicity, real-time feedback and low cost, are often used for adherence evaluation in clinical practice.

CONCLUSIONS

In spite of the availability, convenience and variety of methods, measuring adherence still remains a real challenge. Using a well designed questionnaire provides an opportunity to identify patients at increased risk of non-adherence and the obstacles impeding implementation of the treatment plan, allowing implementation of tailored interventions in order to improve patient medication-taking behavior.

Participation in an innovative patient support program reduces prescription abandonment for adalimumab-treated patients in a commercial population

PURPOSE

Nonadherence to indicated therapy reduces treatment effectiveness and may increase cost of care. HUMIRA Complete, a Patient Support Program (PSP), aims to reduce nonadherence in patients prescribed adalimumab (ADA). The objective of this study was to assess the relationship between participation in the PSP and prescription abandonment rates among ADA-treated patients.

PATIENTS AND METHODS

This longitudinal study using patient-level data from AbbVie's PSP linked with medical and pharmacy claims data included patients ≥18 years with an ADA-approved indication, ≥1 pharmacy claim for ADA, and available data ≥3 months before and ≥6 months after the index date (defined as the initial ADA claim [01/2015 to 02/2017]). Abandonment was defined as reversal of initial ADA prescription with no paid claim during 3-month follow-up. Abandonment rates were compared between PSP and non-PSP cohorts using multivariable logistic regression controlling for potentially confounding baseline characteristics.

RESULTS

In 17,371 patients (9,851 PSP; 7,520 non-PSP), the overall abandonment rate was 10.8-16.8% across indications. The odds of ADA abandonment were 70% less for PSP vs non-PSP patients (5.6% vs 20.4%, odds ratio [OR]=0.30, [95% confidence interval (CI)=0.27-0.33] P<0.001), 38% less for patients using specialty vs retail pharmacy (OR=0.62, 95% CI=0.56-0.69, P<0.001), 20% less for those with income of $50-99K vs $0-49K (OR=0.80, 95% CI=0.69-0.92, P<0.01), and 78% greater for those with copayment of $26-100 vs $0-25 (OR=1.78, 95% CI=1.55-2.05, P<0.001).

CONCLUSION

Participation in the PSP, higher income, and using a specialty pharmacy were associated with lower odds of abandoning ADA therapy, whereas increased copayments were associated with greater abandonment. PSPs should be considered to improve initiation of ADA therapy.

Reducing Stroke Risk in Atrial Fibrillation: Adherence to Guidelines Has Improved, but Patient Persistence with Anticoagulant Therapy Remains Suboptimal

Atrial fibrillation (AF) is a significant risk factor for avoidable stroke. Among high-risk patients with AF, stroke risk can be mitigated using oral anticoagulants (OACs), however reduction is largely contingent on physician prescription and patient persistence with OAC therapy. Over the past decade significant advances have occurred, with revisions to clinical practice guidelines relating to management of stroke risk in AF in several countries, and the introduction of non-vitamin K antagonist OACs (NOACs). This paper summarises the evolving body of research examining guideline-based clinician prescription over the past decade, and patient-level factors associated with OAC persistence. The review shows clinicians' management over the past decade has increasingly reflected guideline recommendations, with an increasing proportion of high-risk patients receiving OACs, driven by an upswing in NOACs. However, a treatment gap remains, as 25–35% of high-risk patients still do not receive OAC treatment, with great variation between countries. Reduction in stroke risk directly relates to level of OAC prescription and therapy persistence. Persistence and adherence to OAC thromboprophylaxis remains an ongoing issue, with 2-year persistence as low as 50%, again with wide variation between countries and practice settings. Multiple patient-level factors contribute to poor persistence, in addition to concerns about bleeding. Considered review of individual patient's factors and circumstances will assist clinicians to implement appropriate strategies to address poor persistence. This review highlights the interplay of both clinician's awareness of guideline recommendations and understanding of individual patient-level factors which impact adherence and persistence, which are required to reduce the incidence of preventable stroke attributable to AF.

Renal Denervation in High-risk Patients with Hypertension

Collapse

Implementation of a text message reminder service in an independent community pharmacy: A retrospective analysis of time to prescription pickup and satisfaction

OBJECTIVE

Approximately 30% of individuals admit that their medication nonadherence is due to forgetfulness, and 20%-30% of new prescriptions are never picked up. The primary objective of this study is to determine the impact of a text messaging reminder service on time to prescription pickup in an independent community pharmacy setting.

METHODS

We conducted a retrospective evaluation using a pre-post design involving 42 individuals who voluntarily enrolled in a text messaging reminder service. The periods 3 months before and 3 months after the initiation of the service were compared. Text messages were sent to individuals when their prescriptions were ready to be picked up. Time to prescription pickup was the primary dependent variable, and the number of medications, distance from the pharmacy, age, and sex were examined. In addition, we sent a text message inquiring about satisfaction with the service.

RESULTS

In an analysis of 487 prescription pickup instances, 212 occurred before and 275 after the service for the 42 enrolled individuals. The average time to prescription pickup significantly improved by 12.3 hours (P = 0.001) after implementing the service. After adjusting for age, sex, distance to the pharmacy, number of medications per instance, and number of text messages per instance, the time to prescription pickup improved significantly by 15.8 hours (P = 0.03) after implementation. Thirty-three individuals (79%) reported satisfaction with the text messaging service, whereas 9 patients (21%) did not respond to the survey. Individuals living between 2 and 5 miles from the pharmacy and those 50-64 years old were less likely to respond to the satisfaction survey compared with the other distance and age categories.

CONCLUSION

A text message reminder service significantly improved the time to prescription pickup by almost 16 hours in an independent pharmacy. Overall, individuals were satisfied with the service.

Using conversational agents to explain medication instructions to older adults

In an effort to guide the development of a computer agent (CA)-based adviser system that presents patient-centered language to older adults (e.g., medication instructions in portal environments or smartphone apps), we evaluated 360 older and younger adults' responses to medication information delivered by a set of CAs. We assessed patient memory for medication information, their affective responses to the information, their perception of the CA's teaching effectiveness and expressiveness, and their perceived level of similarity with each CA. Each participant saw CAs varying in appearance and levels of realism (Photo-realistic vs Cartoon vs Emoji, as control condition). To investigate the impact of affective cues on patients, we varied CA message framing, with effects described either as gains of taking or losses of not taking the medication. Our results corroborate the idea that CAs can produce a significant effect on older adults' learning in part by engendering social responses.

Estimating Adherence Based on Prescription or Dispensation Information: Impact on Thresholds and Outcomes. A Real-World Study With Atrial Fibrillation Patients Treated With Oral Anticoagulants in Spain

Objective: To estimate drug exposure, Proportion of Days Covered (PDC) and percentage of patients with PDC ≥ 80% from a cohort of atrial fibrillation patients initiating oral anticoagulant (OAC) treatment. We employed three different approaches to estimate PDC, using either data from prescription and dispensing (PD cohort) or two common designs based on dispensing information only, requiring at least one (D1) or at least two (D2) refills for inclusion in the cohorts. Finally, we assessed the impact of adherence on health outcomes according to each method. Methods: Population-based retrospective cohort of all patients with Non Valvular Atrial Fibrillation (NVAF), who were newly prescribed acenocoumarol, apixaban, dabigatran or rivaroxaban from November 2011 to December 2015 in the region of Valencia (Spain). Patients were followed for 12 months to assess adherence using three different approaches (PD, D1 and D2 cohorts). To analyze the relationship between adherence (PDC ≥ 80) defined according to each method of calculation and health outcomes (death for any cause, stroke or bleeding) Cox regression models were used. For the identification of clinical events patients were followed from the end of the adherence assessment period to the end of the available follow-up period. Results: PD cohort included all patients with an OAC prescription (n = 38,802), D1 cohort excluded fully non-adherent patients (n = 265) and D2 cohort also excluded patients without two refills separated by 180 days (n = 2,614). PDC ≥ 80% ranged from 94% in the PD cohort to 75% in the D1 cohort. Drug exposure among adherent (PDC ≥ 80%) and non-adherent (PDC < 80%) patients was different between cohorts. In adjusted analysis, high adherence was associated with a reduced risk of death [Hazard Ratio (HR): from 0.82 to 0.86] and (except in the PD cohort) the risk for ischemic stroke (HR: from 0.61 to 0.64) without increasing the risk of bleeding. Conclusion: Common approaches to assess adherence using measures based on days' supply exclude groups of non-adherent patients and, also, misattribute periods of doctors' discontinuation to patient non-adherence, misestimating adherence overall. Physician-initiated discontinuation is a major contributor to reduced OAC exposure. When using the PDC80 threshold, very different groups of patients may be classified as adherent or non-adherent depending on the method used for the calculation of days' supply measures. High adherence and high exposure to OAC treatment in NVAF patients is associated with better health outcomes.

A Systematic Review of Medication Adherence Thresholds Dependent of Clinical Outcomes

Background: In pharmacotherapy, the achievement of a target clinical outcome requires a certain level of medication intake or adherence. Based on Haynes's early empirical definition of sufficient adherence to antihypertensive medications as taking ≥80% of medication, many researchers used this threshold to distinguish adherent from non-adherent patients. However, we propose that different diseases, medications and patient's characteristics influence the cut-off point of the adherence rate above which the clinical outcome is satisfactory (thereafter medication adherence threshold). Moreover, the assessment of adherence and clinical outcomes may differ greatly and should be taken into consideration. To our knowledge, very few studies have defined adherence rates linked to clinical outcomes. We aimed at investigating medication adherence thresholds in relation to clinical outcomes.

Method: We searched for studies that determined the relationship between adherence rates and clinical outcomes in the databases PubMed, Embase^Ⓡ and Web of Science™ until December 2017, limited to English-language. Our outcome measure was any threshold value of adherence. The inclusion criteria of the retrieved studies were (1) any measurement of medication adherence, (2) any assessment of clinical outcomes, and (3) any method to define medication adherence thresholds in relation to clinical outcomes. We excluded articles considered as a tutorial. Two authors (PB and IA) independently screened titles and abstracts for relevance, reviewed full-texts, and extracted items. The results of the included studies are presented qualitatively.

Result: We analyzed 6 articles that assessed clinical outcomes linked to adherence rates in 7 chronic disease states. Medication adherence was measured with Medication Possession Ratio (MPR, n = 3), Proportion of Days Covered (PDC, n = 1), both (n = 1), or Medication Event Monitoring System (MEMS). Clinical outcomes were event free episodes, hospitalization, cortisone use, reported symptoms and reduction of lipid levels. To find the relationship between the targeted clinical outcome and adherence rates, three studies applied logistic regression and three used survival analysis. Five studies defined adherence thresholds between 46 and 92%. One study confirmed the 80% threshold as valid to distinguish adherent from non-adherent patients.

Conclusion: The analyzed studies were highly heterogeneous, predominantly concerning methods of calculating adherence. We could not compare studies quantitatively, mostly because adherence rates could not be standardized. Therefore, we cannot reject or confirm the validity of the historical 80% threshold. Nevertheless, the 80% threshold was clearly questioned as a general standard.

Time to Filling of New Prescriptions for Chronic Disease Medications Among a Cohort of Elderly Patients in the USA

BACKGROUND

Data on primary nonadherence remains sparse, due to a lack of data resources that combine information on medication prescribing and dispensing. In addition, previous work on primary nonadherence has used follow-up periods ranging from 30 days up to 18 months, making results difficult to compare.

OBJECTIVE

To evaluate the prevalence and predictors of primary nonadherence by measuring time until filling in a cohort of elderly patients.

DESIGN

Retrospective cohort study of new prescription episodes.

PATIENTS

Data comes from a linked database of electronic health records and claims for patients aged ≥ 65 years enrolled in Medicare Parts A, B, and D during 2007-2014. We identified patients receiving a new prescription for a chronic disease medication with continuous Medicare enrollment for 180 days prior to the index prescription order and no fills or orders for the medication during this period.

MAIN MEASURES

Time until filling of the index prescription for up to 1 year.

KEY RESULTS

In 32,586 new medication orders, the majority (75%; 95% confidence interval [CI] 74-75%) of new prescriptions were filled within 7 days, 81% (81-82%) were filled within 30 days, and 91% (91-92%) were filled within 1 year. The rate and timing of dispensing were similar across therapeutic areas. Timing of initial filling within 7 days or within 30 days could be predicted with moderate accuracy (C-statistics = 0.70-0.74). Patients with > 5 current medications on hand at the time of the index prescription and average out-of-pocket medication costs < $5 filled 89% of prescriptions within 7 days. Patients with no current medications and out-of-pocket costs > $50 filled only 25% of prescriptions within 7 days.

CONCLUSIONS

Nearly 20% of patients do not fill a new chronic disease prescription within 30 days. Patients with fewer recent fills and higher out-of-pocket costs are at higher risk of primary nonadherence.

The role of psychological science in efforts to improve cardiovascular medication adherence

Poor adherence to cardiovascular disease medications carries significant psychological, physical, and economic costs, including failure to achieve therapeutic goals, high rates of hospitalization and health care costs, and incidence of death. Despite much effort to design and evaluate adherence interventions, rates of adherence to cardiovascular-related medications have remained relatively stagnant. We identify two major reasons for this: First, interventions have not addressed the time-varying reasons for nonadherence, and 2nd, interventions have not explicitly targeted the self-regulatory processes involved in adherence behavior. Inclusion of basic and applied psychological science in intervention development may improve the efficacy and effectiveness of behavioral interventions to improve adherence. In this article, we use a taxonomy of time-based phases of adherence-including initiation, implementation, and discontinuation-as context within which to review illustrative studies of barriers to adherence, interventions to improve adherence, and self-regulatory processes involved in adherence. Finally, we suggest a framework to translate basic psychological science regarding self-regulation into multicomponent interventions that can address multiple and time-varying barriers to nonadherence across the three adherence phases. The field of psychology is essential to improving medication adherence and associated health outcomes, and concrete steps need to be taken to implement this knowledge in future interventions. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Prescription fill rates for acute and chronic medications in claims-EMR linked data

Nonadherence to prescribed medications poses a significant public health problem. Prescription data in electronic medical records (EMRs) linked with pharmacy claims data provides an opportunity to examine the prescription fill rates and factors associated with it.Using a claims-EMR linked data, patients who had a prescription for either an antibiotic, antihypertensive, or antidiabetic in EMR were identified (index prescription). Prescription fill was defined as a pharmacy claim found within the 90 days following the EMR prescription. For each medication group, patient characteristics and fill rates were examined using descriptive statistics. Multivariate logistic regression was used to evaluate the association between fill rates and factors such as age, race, brand vs generic, and prior treatment during 365 days before the index date.Among 77,996 patients with index antibiotic prescription, 78,462 with index antihypertensive prescription, and 24,013 with index antidiabetic prescription, the prescription fill rate was 73%, 74%, and 76%, respectively. Overall, African American race was negatively associated with fill rates (odds ratio [OR] 0.8 for all 3 groups). Prior treatment history was positively associated with antihypertensives (OR 5.6, 95% confidence interval [CI] 5.4-5.7) or antidiabetics (OR 4.1, CI 3.8-4.4) but negatively with antibiotics (OR 0.6, CI 0.6-0.6). Older age was an additional factor that was negatively associated with first time fill rate among patients without prior treatment.Significant proportions of patients, especially patients with no prior treatment history, did not fill prescriptions for antibiotics, antihypertensives, or antidiabetics. The association between patient factors and medication fill rates varied across different medication groups.

Topical Estrogen Prescription Fill Rates for Women With a History of Breast Cancer Who Are Taking Hormone Therapy

OBJECTIVE

To evaluate how often women with a history of breast cancer who are taking hormone therapy (HT) filled prescriptions for topical estrogens and whether this frequency varied over time and by type of HT used.

METHODS

We performed a retrospective cohort study using medical and outpatient drug claims from a large commercial claims database for the years 2010-2015. Women younger than age 65 years taking HT for breast cancer were classified as users of 1) tamoxifen only, 2) aromatase inhibitor(s) only, or 3) any other or multiple HTs. Our outcome variable was filling a prescription for topical estrogen in a given year. We used multivariable logistic regression models estimated with generalized estimating equations to determine whether the fill rate varied over time and by HT category adjusting for age, receipt of surgical or radiation treatment, types of outpatient health care provider visits, and comorbidities.

RESULTS

We identified 352,118 records from 176,012 unique patients (mean age 54.3 years, range 18-64 years) who met eligibility criteria. Aromatase inhibitors were used more commonly (56.0% of patient-years) than tamoxifen (38.8%). Overall, 3.0% (range 2.9-3.1%) of women filled any topical estrogen prescription in a given calendar year. More than half of filled topical estrogen prescriptions were for tablets (57.0%) with the remainder for creams (25.8%) and rings (17.3%). In adjusted analyses, the fill rate for women taking tamoxifen was significantly less (2.4%; 95% CI 2.3-2.5%) than for women taking aromatase inhibitors (3.3%; 95% CI 3.2-3.4%). There was a small but statistically significant increase in fill rates across years (odds ratio 1.03, 95% CI 1.02-1.04).

CONCLUSION

A small proportion of women with a history of breast cancer who were taking HT filled a topical estrogen prescription, with significant differences by type of HT. More evidence is needed to inform national guidelines regarding safety and appropriate use of topical estrogens in this patient population.

Prevalence and predictors of physician recommendations for medication adjustment in bipolar disorder treatment

BACKGROUND

Successful medication management for bipolar disorder requires clinicians to monitor and adjust regimens as needed, to achieve maximum effectiveness and patient adherence. This study aims to measure the prevalence of indications for medication adjustment at visits for bipolar disorder treatment; the frequency with which physicians recommend medication adjustments; and how strongly the indications predict the adjustments.

METHODS

Data included 3,094 visits for 457 patients in Bipolar CHOICE, a comparative effectiveness study that compared treatment with lithium versus quetiapine. A set of indications for adjustment was matched to reports of whether the physician recommended a medication adjustment at that visit, and what type. Associations between indication and adjustment were examined using bivariate tests and hierarchical logistic mixed effects models.

RESULTS

Medication adjustment was recommended at 63% of the visits where one of the indications was present, and at 53% of all visits. In multivariable analyses, adjustment was more likely to be recommended if there was an indication of non-response or side effects, for patients who started on quetiapine rather than lithium, or for patients who were female, married, employed or more educated.

LIMITATIONS

The study's cross-sectional design implies that observed associations could result from confounding variables. Also, the CHOICE trial placed certain restrictions on physicians' medication choices, although this is not likely to have resulted in major alterations of prescribing patterns.

CONCLUSIONS

Clinical inertia may help explain the lack of any adjustment recommendation at 37% of the visits where one of the indications was present. Other explanations could also apply, such as watchful waiting.

Neighbourhood Material and Social Deprivation and Exposure to Antidepressant Drug Treatment: A Cohort Study Using Administrative Data

OBJECTIVE

To assess whether neighbourhood deprivation is associated with exposure to an antidepressant drug treatment (ADT) and its quality among individuals diagnosed with unipolar depression and insured by the Quebec public drug plan.

METHOD

We conducted an administrative database cohort study of adults covered by the Quebec public drug plan who were diagnosed with a new episode of unipolar depression. We assessed material and social deprivation using an area-based index. We considered exposure to an ADT as having ≥1 claim for an ADT within the 365 days following depression diagnosis. Among those exposed to ADT, ADT quality was assessed with 3 indicators: first-line recommended ADT, persistence with the ADT, and compliance with the ADT. Generalized linear models were used to estimate adjusted prevalence ratios (aPR) and 95% confidence intervals (95% CI).

RESULTS

Of 100,432 individuals with unipolar depression, 65,436 (65%) were exposed to an ADT in the year following the diagnosis. Individuals living in the most materially deprived areas were slightly more likely to be exposed to an ADT than those living in the least deprived areas (aPR, 1.04; 95% CI, 1.03 to 1.06). The likelihoods of being exposed to a first-line ADT, persisting for the minimum recommended duration and complying with the ADT were independent of the deprivation levels.

CONCLUSIONS

Neighbourhood deprivation was not associated with ADT quality among individuals insured by the Quebec public drug plan. It might be partly attributable to the public drug plan whose goal is to provide equitable access to prescription drugs regardless of income.

Primary versus secondary source of data in observational studies and heterogeneity in meta-analyses of drug effects: a survey of major medical journals

Background

The data from individual observational studies included in meta-analyses of drug effects are collected either from ad hoc methods (i.e. “primary data”) or databases that were established for non-research purposes (i.e. “secondary data”). The use of secondary sources may be prone to measurement bias and confounding due to over-the-counter and out-of-pocket drug consumption, or non-adherence to treatment. In fact, it has been noted that failing to consider the origin of the data as a potential cause of heterogeneity may change the conclusions of a meta-analysis. We aimed to assess to what extent the origin of data is explored as a source of heterogeneity in meta-analyses of observational studies.

Methods

We searched for meta-analyses of drugs effects published between 2012 and 2018 in general and internal medicine journals with an impact factor > 15. We evaluated, when reported, the type of data source (primary vs secondary) used in the individual observational studies included in each meta-analysis, and the exposure- and outcome-related variables included in sensitivity, subgroup or meta-regression analyses.

Results

We found 217 articles, 23 of which fulfilled our eligibility criteria. Eight meta-analyses (8/23, 34.8%) reported the source of data. Three meta-analyses (3/23, 13.0%) included the method of outcome assessment as a variable in the analysis of heterogeneity, and only one compared and discussed the results considering the different sources of data (primary vs secondary).

Conclusions

In meta-analyses of drug effects published in seven high impact general medicine journals, the origin of the data, either primary or secondary, is underexplored as a source of heterogeneity.

Electronic supplementary material

The online version of this article (10.1186/s12874-018-0561-3) contains supplementary material, which is available to authorized users.

Primary Nonadherence to Oral Anticoagulants in Patients with Atrial Fibrillation: Real-World Data from a Population-Based Cohort

BACKGROUND

Primary nonadherence (not filling a first prescription) is an important yet unstudied aspect of adherence to oral anticoagulant (OAC) therapy.

OBJECTIVE

To estimate the rates of primary nonadherence to OACs and determine associated factors in real-world practice.

METHODS

This population-based retrospective cohort study set in the Valencia region of Spain (about 5 million inhabitants) included all patients with atrial fibrillation who were newly prescribed OACs during 2011-2014 (N = 18,715). Primary nonadherence was obtained by linking electronic prescription and dispensing data and assessed by type of OAC-vitamin K antagonists (VKAs) or non-VKA oral anticoagulants (NOACs). Covariates were obtained from diverse databases, including electronic medical records. Multivariate logistic regression models were used to assess characteristics associated with primary nonadherence, adjusting for a propensity score to minimize confounding by indication.

RESULTS

Primary nonadherence to OACs was 5.62% (VKA 4.29% vs. NOAC 10.81%; P < 0.001), with varying rates among specific drugs (acenocoumarol 4.2%, warfarin 10.9%, apixaban 5.0%, dabigatran 7.9%, and rivaroxaban 15.5%). After adjusting for potential confounders, the likelihood of not filling the first prescription was higher for NOAC patients than for VKA patients (OR = 2.76, 95% CI = 2.41-3.15). High coinsurance in the older groups (OR = 2.63, 95% CI = 1.47-4.69 for patients aged 66-75 years and OR = 3.02, 95% CI = 1.58-5.76 for patients aged > 75 years); being a non-Spanish European (OR = 1.49, 95% CI = 1.12-1.99); and having dementia (OR = 1.72, 95% CI = 1.37-2.16) were positively associated with primary nonadherence. Electronic transmission of prescriptions (OR = 0.85, 95% CI = 0.74-0.96); liver disease (OR = 0.73, 95% CI = 0.54-0.99); and polypharmacy (OR = 0.59, 95% CI = 0.50-0.70) were inversely associated with primary nonadherence.

CONCLUSIONS

Overall, primary nonadherence to OACs was relatively low (5%). However, important differences were found between VKAs and NOACs. After adjustment, patients prescribed NOACs nearly tripled the likelihood of nonadherence compared with patients prescribed VKAs, which could negatively affect their effectiveness in clinical practice. Identified correlates were similar to those shown in the limited evidence for other medications.

DISCLOSURES

This work was partially supported by the 2013 Collaboration Agreement between the Fundación para el Fomento de la Investigación Sanitaria y Biomédica (FISABIO) from the Valencia Ministry of Health and Boehringer Ingelheim, a nonconditioned program to conduct independent research in chronic health care, pharmacoepidemiology, and medical practice variation. Rodriguez-Bernal was funded by the Instituto de Salud Carlos III, Spanish Ministry of Health, and cofinanced by the European Regional Development Fund (grant number RD12/0001/0005). The views presented here are those of the authors and not necessarily those of the FISABIO Foundation, the Valencia Ministry of Health, or the study sponsors. The funding sources had no access to study data and did not participate in any way in the design or conduct of the study, data analysis, decisions regarding the dissemination of findings, the development of the manuscript, or its publication. Peiró has received fees for participation in scientific meetings and courses sponsored by Novartis and Ferrer International. In 2014, Sanfélix-Gimeno participated in an advisory meeting of Boehringer Ingelheim. García-Sempere is a former employee of Boehringer Ingelheim. Rodriguez-Bernal and Hurtado have no relationships relevant to the contents of this article to disclose. This work was previously submitted as an abstract (podium presentation) at the 31st International Society of Pharmacoepidemiology (ISPE) Annual Conference; August 22-26, 2015; Boston, Massachusetts.

Measurement Error and Misclassification in Electronic Medical Records: Methods to Mitigate Bias

PURPOSE OF REVIEW

We sought to: 1) examine common sources of measurement error in research using data from electronic medical records (EMR), 2) discuss methods to assess the extent and type of measurement error, and 3) describe recent developments in methods to address this source of bias.

RECENT FINDINGS

We identified eight sources of measurement error frequently encountered in EMR studies, the most prominent being that EMR data usually reflect only the health services and medications delivered within the specific health facility/system contributing to the EMR data. Methods for assessing measurement error in EMR data usually require gold standard or validation data, which may be possible using data linkage. Recent methodological developments to address the impact of measurement error in EMR analyses were particularly rich in the multiple imputation literature.

SUMMARY

Presently, sources of measurement error impacting EMR studies are still being elucidated, as are methods for assessing and addressing them. Given the magnitude of measurement error that has been reported, investigators are urged to carefully evaluate and rigorously address this potential source of bias in studies based in EMR data.

Moving from the Trial to the Real World: Improving Medication Adherence Using Insights of Implementation Science

Medication nonadherence is a serious public health concern. Although there are promising interventions that improve medication adherence, most interventions are developed and tested in tightly controlled research environments that are dissimilar from the real-world settings where the majority of patients receive health care. Implementation science methods have the potential to facilitate and accelerate the translation shift from the trial world to the real world. We demonstrate their potential by reviewing published, high-quality medication adherence studies that could potentially be translated into clinical practice yet lack essential implementation science building blocks. We further illustrate this point by describing an adherence study that demonstrates how implementation science creates a junction between research and real-world settings. This article is a call to action for researchers, clinicians, policy makers, pharmaceutical companies, and others involved in the delivery of care to adopt the implementation science paradigm in the scale-up of adherence (research) programs.

Strategies to Prevent Readmission in High-Risk Patients with Diabetes: the Importance of an Interdisciplinary Approach

PURPOSE OF REVIEW

Patients with diabetes are known to have higher 30-day readmission rates compared to the general inpatient population. A number of strategies have been shown to be effective in lowering readmission rates.

RECENT FINDINGS

A review of the current literature revealed several strategies that have been associated with a decreased risk of readmission in high-risk patients with diabetes. These strategies include inpatient diabetes survival skills education and medication reconciliation prior to discharge to send the patient home with the "right" medications. Other key strategies include scheduling a follow-up phone call soon after discharge and an office visit to adjust the diabetes regimen. The authors identified the most successful strategies to reduce readmissions as well as some institutional barriers to following a transitional care program. Recent studies have identified risk factors in the diabetes population that are associated with an increased risk of readmission as well as interventions to lower this risk. A standardized transitional care program that focuses on providing interventions while reducing barriers to implementation can contribute to a decreased risk of readmission.

Factors Affecting Rural Patients' Primary Compliance with e-Prescription: A Developing Country Perspective

Background:The electronic prescription system has emerged to reduce the ambiguity and misunderstanding associated with handwritten prescriptions. The opportunities and challenges of e-prescription system, its impact on reducing medication error, and improving patient's safety have been widely studied. However, not enough studies were conducted to explore and quantify the factors that affect rural patients' compliance with e-prescription, especially from the perspective of Asian developing countries where most of the world's population resides.

Objective:The objective of this study is to explore and assess the factors that affect rural patients' primary compliance with e-prescription in Bangladesh.

Methods:Data were collected from 95 randomly selected rural patients who received e-prescription through a field survey with a structured questionnaire from Bheramara subdistrict, Bangladesh, during June and July 2016. Logistic regression analysis was performed to test the research hypotheses.

Results:The study found patients' gender as the most significantly influential factor (regression coefficient [Coef.] = 2.02, odds ratio [OR] = 7.51, p < 0.05) followed by visiting frequency (Coef. = 0.99, OR = 2.70, p < 0.05); education (Coef. = 0.92, OR = 2.51, p < 0.05); and distance to healthcare facility (Coef. = 0.82, OR = 2.26, p < 0.01). However, patients' age, monthly family expenditure, and use of cell phone were found insignificant. The model explains 59.40% deviance (R² = 0.5940) in the response variable with its constructs. And the “Hosmer–Lemeshow” goodness-of-fit score (0.99) is also above the standard threshold (0.05), which indicates the data fit well with the model.

Conclusions:The findings of this study are expected to be helpful for e-health service providers to gain a better understanding of the factors that influence their patients to comply with e-prescriptions.

Counseling our aging population: A training program for pharmacy students on hearing loss

BACKGROUND AND PURPOSE

Hearing loss affects approximately one-third of adults age 61-70 and >80% of those older than 85 years. This can impede the ability to hear medication administration instructions, leading to poor adherence and unnecessary disease progression and complications. The study purpose was to educate students on hearing loss and identify program impact.

EDUCATIONAL ACTIVITY AND SETTING

An online program for advanced pharmacy practice experience (APPE) students was developed to train students how to counsel patients with hearing loss to improve medication understanding and adherence. The purpose of the training program was to provide background on hearing loss, increase understanding of the impact hearing loss, and to prepare students to counsel this population. A link from SurveyMonkey was provided upon training program completion.

FINDINGS

Ninety-two students completed the survey. Prior to training, < 20% (18.5%) were comfortable interacting with patients with hearing impairment, despite ∼50% of these students completing more than three APPEs with direct patient care. The majority (88%) recognized that hearing loss contributes to poor medication adherence. More than 80% believed that the training program improved their understanding of the psychological consequences of hearing loss and ability to counsel patients with hearing loss. Over 70% agreed that the training program made them feel more prepared to counsel patients with hearing loss.

DISCUSSION AND SUMMARY

It is crucial to prepare students to better understand this population in order to meet their needs. This program enhanced students' knowledge of hearing loss and increased their understanding of communication barriers.

Patient counseling materials: The effect of patient health literacy on the comprehension of printed prescription drug information

BACKGROUND

Counseling patients with written materials relies equally on patients' health literacy to understand their disease and its treatment, and the written materials' effectiveness communicating clearly in accessible and actionable ways. Only about 12% of the US population is adequately health literate.

OBJECTIVES

To explore the impact of reducing the health literacy demands of written patient health information.

METHODS

805 patients were screened for health literacy, and recruited for balanced cohorts of adequate and low literacy, and high and normal blood pressure. Half of each patient cohort received either standard or "health literacy-friendly" drug summaries (i.e. Patient Package Inserts, or PPIs or "leaflets") along with a standardized health literacy assessment scale.

RESULTS

The literacy-friendly drug summary improved comprehension of drug-related information overall from 50% to 71% correct responses. Adequate literacy patients improved from 58% correct to 90%, while lower literacy patients improved from 42% to 52% correct in response to the health literacy-friendly PPIs.

CONCLUSIONS

Health literacy demands require special attention in developing and using written drug summary materials. Additionally, pharmacists should be provided additional information and counseling support materials to facilitate communications with low health literacy level patients.

Pharmacoepidemiology in Pharmacogenetics

Epidemiologic methods provide rigorous means by which to study the interplay between genetic factors and drug response. In this chapter, we describe the differences between experimental and observational study designs, and illustrate how to implement the highly efficient case-control study design. We discuss analytic approaches to evaluating gene-drug interactions within typical study designs and review sources of bias that must be assessed and accounted for in epidemiologic analyses.

Addressing primary nonadherence: A collaboration between a community pharmacy and a large pediatric clinic

OBJECTIVES

To decrease nonadherence rates through the design and implementation of a collaborative prescription management program involving a community pharmacy and a large pediatric primary care center.

PRACTICE INNOVATION

Kroger and Cincinnati Children's Pediatric Primary Care Center collaborated to identify and address patients' barriers to filling new prescriptions. After filling new medications for clinic patients, pharmacists telephoned patients to inform them that their prescription was ready and to reinforce the importance of initiating the therapy. Pharmacists followed up with families to address barriers when prescriptions remained at the pharmacy after 48 hours. Pharmacists communicated with prescribers if prescriptions were not filled, allowing the clinic staff to follow up.

EVALUATION

The primary outcome of this prospective pilot study with a comparison group was primary nonadherence (PNA), defined as the proportion of patients who did not pick up prescriptions or a reasonable alternative within 30 days after the pharmacy received the prescription. Secondary outcomes were the impact on secondary nonadherence and identification of adherence barriers.

RESULTS

Fifty-nine patients were enrolled from November 2016 to April 2017. Characteristics between the intervention group and a standard-care group were similar. The majority of prescribed medications were for acute conditions, the average patient age was 4.9 years, and 86% of patients were covered by Medicaid. Intervention patients had significantly less PNA compared with the standard-care group (14.0% vs. 53.3%, respectively; P < 0.001). Intervention patients had significantly greater secondary adherence rates compared with standard-care patients (38.8% vs. 7%; P < 0.001). Common barriers likely resulting in PNA included lack of time, lack of urgency, transportation challenges, and cost.

CONCLUSION

Increased communication between the primary care provider and the community pharmacy, coupled with targeted patient-specific interventions before the initial fill of medications, resulted in significant reductions in PNA.

Poverty, Transportation Access, and Medication Nonadherence

BACKGROUND AND OBJECTIVES

Variability in primary medication nonadherence (PMN), or failure to fill a new prescription, influences disparities and widens equity gaps. This study sought to evaluate PMN across 1 metropolitan area and assess relationships with underlying zip code-level measures.

METHODS

This was a retrospective observational study using data extracted from 1 regional community pharmacy market-share leader (October 2016-April 2017). Data included patient age, sex, payer, medication type, and home zip code. This zip code was connected to US census measures enumerating poverty and vehicle access, which were treated as continuous variables and within quintiles. The prescription-level outcome was whether prescriptions were not filled within 30 days of reaching the pharmacy. The ecological-level outcome was PMN calculated for each zip code (numerator, unfilled prescriptions; denominator, received prescriptions).

RESULTS

There were 213 719 prescriptions received by 54 included pharmacies; 12.2% were unfilled. Older children, boys, and those with public insurance were more likely to have prescriptions not filled. Prescriptions originating from the highest poverty quintile were significantly more likely to not be filled than those from the lowest poverty quintile (adjusted odds ratio 1.60; 95% confidence interval 1.52-1.69); a similar pattern was noted for vehicle access (adjusted odds ratio 1.77; 95% confidence interval 1.68-1.87). At the ecological level, there were significant, graded relationships between PMN rates and poverty and vehicle access (both P < .0001); these gradients extended across all medication classes.

CONCLUSIONS

Poverty and vehicle access are related to significant differences in prescription- and ecological-level PMN across 1 metropolitan area. Pharmacists and pharmacies can be key partners in population health efforts.

The effect of a practice-based multicomponent intervention that includes health coaching on medication adherence and blood pressure control in rural primary care

Low adherence to anti-hypertensive medications contributes to worse outcomes. The authors conducted a secondary data analysis to examine the effects of a health-coaching intervention on medication adherence and blood pressure (BP), and to explore whether changes in medication adherence over time were associated with changes in BP longitudinally in 477 patients with hypertension. Data regarding medication adherence and BP were collected at baseline, 6, 12, 18, and 24 months. The intervention resulted in increases in medication adherence (5.75→5.94, P = .04) and decreases in diastolic BP (81.6→76.1 mm Hg, P < .001) over time. The changes in medication adherence were associated with reductions in diastolic BP longitudinally (P = .047). Patients with low medication adherence at baseline had significantly greater improvement in medication adherence and BP over time than those with high medication adherence. The intervention demonstrated improvements in medication adherence and diastolic BP and offers promise as a clinically applicable intervention in rural primary care.

Advancing the Science and Practice of Medication Adherence

Medication adherence remains a significant unmet challenge for optimizing patient outcomes. Recent advances in the conceptualization, measurement, and support of medication adherence offer fresh opportunities to make a meaningful impact on adherence-related behavior and outcomes. These advances emphasize the multifaceted and dynamic nature of medication adherence, provide novel methods for monitoring medication adherence in clinical care, and articulate a set of multilevel strategies to more effectively improve and sustain medication adherence. Here, we offer recommendations for how clinicians can better engage with, and benefit from, these innovations to improve patient medication adherence and associated treatment outcomes.

Factors associated with patient recall of key information in ambulatory specialty care visits: Results of an innovative methodology

While some studies have assessed patient recall of important information from ambulatory care visits, none has done so recently. Furthermore, little is known about features of clinical interactions which are associated with patient understanding and recall, without which shared decision making, a widely shared ideal for patient care, cannot occur. Our objective was to evaluate characteristics of patients and outpatient encounters associated with patient recall of information after one week, along with observation of elements of shared decision making. This was an observational study based on coded transcripts of 189 outpatient encounters, and post-visit interviews with patients 1 week later. Coding used three previously validated systems, adopted for this study. Forty-nine percent of decisions and recommendations were recalled accurately without prompting; 36% recalled with a prompt; 15% recalled erroneously or not at all. Provider behaviors hypothesized to be associated with patient recall, such as open-questioning and “teach back,” were rare. Patients with less than high school education recalled 38% of items freely and accurately, while patients with a college degree recalled 65% (p < .0001). In a multivariate model, the total number of items to be recalled per visit, and percentage of utterances in decision-making processes by the provider (“verbal dominance”), were significant predictors of poorer recall. The item count was associated with poorer recall for lower, but not higher, educated patients.

The role of external eyelid weights in acute facial palsy: functional and aesthetic considerations

Purpose

Patients with acute paralytic lagophthalmos are at high risk for ocular surface breakdown due to exposure. External eyelid weights are a temporary solution for paralytic lagophthalmos that aim to reduce exposure and optimize blink excursion. Despite easy application and high efficacy, this product is under-utilized in clinical practice with few physicians employing this treatment adjunct.

Results

Ocular surface health was maintained in all patients, and overall aesthetic satisfaction was high.

Conclusion

External eyelid weights are a valuable adjunct in the treatment of facial palsy but are under-utilized in clinical practice. This article highlights the benefits of external eyelid weights as an accessible adjunct to restore eyelid function and maintain cosmesis. The device can be implemented without specialist involvement and adds a dimension of independence for general practitioners to manage ocular complications of facial palsy.

Primary nonadherence to chronic disease medications: a meta-analysis

BACKGROUND

Medication nonadherence is a global problem that requires urgent attention. Primary nonadherence occurs when a patient consults with a medical doctor, receives a referral for medical therapy but never fills the first dispensation for the prescription medication. Nonadherence to chronic disease medications costs the USA ~$290 billion (USD) every year in avoidable health care costs. In Canada, it is estimated that 5.4% of all hospitalizations are due to medication nonadherence.

OBJECTIVES

The objective of this study was to quantify the extent of primary nonadherence for four of the most common chronic disease medications. The second objective was to identify factors associated with primary nonadherence to chronic disease medications.

MATERIALS AND METHODS

We conducted an extensive systematic literature review of eight databases with a wide range of keywords. We identified relevant articles for primary nonadherence to antihypertensives, lipid-lowering agents, hypoglycemics, and antidepressants. After further screening and assessment of methodologic quality, relevant data were extracted and analyzed using a random-effects model.

RESULTS

Twenty-four articles were included for our meta-analysis after full review and assessment for risk of bias. The pooled primary nonadherence rate for the four chronic disease medications was 14.6% (95% CI: 13.1%-16.2%). Primary medication nonadherence was higher for lipid-lowering medications among the four chronic disease medications assessed (20.8%; 95% CI: 16.0%-25.6%). The rates in North America (17.0%; 95% CI: 14.4%-19.5%) were twice those from Europe (8.5%; 95% CI: 7.1%-9.9%). The absence of social support (20%; 95% CI: 14.4%-26.6%) was the most common sociodemographic variable associated with chronic disease medication primary nonadherence.

CONCLUSION

Evidence suggests that a considerable percentage of patients do not initially fill their medications for treatable chronic diseases or conditions. This represents a major health care problem that can be successfully addressed. Efforts should be directed toward proper medication counseling, patient social support, and clinical follow-up, especially when the indications for the prescribed medication aim to provide primary prevention.

Effect of different methods for estimating persistence and adherence to new glucose-lowering drugs: results of an observational, inception cohort study in Portugal

PURPOSE

Several methods have been developed for assessing medication-taking behavior; understanding the determinants and variability in estimates obtained is crucial in interpreting results. We estimated persistence and adherence levels to new glucose-lowering drugs (GLDs) in type 2 diabetes mellitus (T2DM) patients using different methods: through the collection of pharmacy records and combining pharmacy records with self-reported data.

METHODS

We conducted a prospective observational cohort study of T2DM patients initiating a new GLD. Data were collected at baseline through interviews (demographic and clinical data). Follow-up data included pharmacy records (refill dates and medication possession) and telephone questionnaires (self-declared monitored GLD refill in another pharmacy, reasons for drug withdrawal). The cohort was divided into incident and prevalent new users. Persistence and adherence (proportion of days covered) were estimated for patients using pharmacy records exclusively (Method 1) and ≥1 self-declared statement of being persistent (Method 2). Log-rank tests were used to compare Kaplan-Meier curves of time to nonpersistence.

RESULTS

A total of 1,328 patients were recruited. When considering Method 1, 38.7% (95% confidence interval [95% CI]: 36.0-41.5) of patients were persistent, whereas combining with self-reported information, this estimate increased to 65.6% (95% CI: 62.9-68.2). Using Method 1, the risk of persistence failure was associated with using an oral GLD, living alone and living in a suburban/urban setting. Three hundred and twenty-seven (24.8%) patients stopped to use the inception GLD.

CONCLUSION

Regardless of the method used, results indicated low levels of persistence and adherence to a new GLD; however, when combining self-reported information, higher estimates were obtained. Considering pharmacy records exclusively, prevalent new users, who were more complex patients in terms of T2DM disease but more likely to be pharmacy-loyal patients, were significantly more adherent than the incident new users. Barriers and reasons leading to GLD withdrawal, namely adverse drug event management, should be addressed, since they represent half of the reasons for treatment switching or discontinuation.

Medication adherence in chronic illness: do beliefs about medications play a role?

BACKGROUND

Several medicines are prescribed for chronic disease management; however, adherence to long-term therapy remains poor. Culture influences beliefs about medications and, ultimately, adherence to treatment. There is a paucity of data with regard to beliefs about medications in the Middle East region, and it remains to be determined how these beliefs would impact treatment adherence.

OBJECTIVES

To investigate the relationship between patients' beliefs about medications with self-reported adherence to treatment among a chronically ill multicultural patient population.

METHODS

A prospective cross-sectional study was conducted among patients treated for chronic illnesses in the Ministry of Health primary care clinics in Kuwait. Patients completed a questionnaire that consisted of questions to collect information about their health status and demographics using validated instruments: the Beliefs about Medication, Sensitive Soma Assessment Scale, and Medication Adherence Report Scale-5 items. The main outcome measures were self-reported adherence to medications, beliefs, and perceived sensitivity toward medications.

RESULTS

Of the 1,150 questionnaires distributed, 783 were collected - giving a response rate of 68.1%. Of the 783 patients, 56.7% were male, 73.7% were married, 53.3% were non-Kuwaitis, and 49.4% had low income (<1,000 KD/3,350 USD monthly). Patients self-reported having a cardiovascular illness (80.2%), diabetes mellitus (67.7%), respiratory disease (24.3%), or mood disorder (28.6%). Participants had a mean of two comorbid illnesses and indicated taking an average of four prescription medicines to treat them. A structural equation model analysis showed adherence to medications was negatively impacted by higher negative beliefs toward medications (beta = -0.46). Factors associated with negative beliefs toward medications included marital status (being unmarried; beta = -0.14), nationality (being Kuwaiti; beta = 0.15), having lower education level (beta = -0.14), and higher illness severity (beta = 0.15). Younger age (beta = 0.10) and higher illness severity (beta = -0.9) were independently associated with lower medication adherence. Income and gender did not influence medication adherence or beliefs about medications. The combined effect of variables tested in the model explained 24% of the variance in medication adherence.

CONCLUSION

Medication adherence is a complex, multifaceted issue and patient beliefs about medications contribute significantly, although partially, to adherence among a multicultural Middle Eastern patient population.

Predictors of Medication Nonadherence From Outpatient Pharmacy Data Within a Large, Academic Health System

BACKGROUND

Medication nonadherence is a worldwide issue that can lead to poor clinical outcomes and increased health-care costs.

OBJECTIVE

To determine the predictors of medication nonadherence.

METHODS

A retrospective chart review was conducted for patients who received prescription medications from Cleveland Clinic outpatient pharmacies. Prediction variables consisted of demographics, socioeconomic status, number of medications, and number of daily administrations. These variables were analyzed using a logistic regression to determine independent predictors of medication adherence.

RESULTS

Between January and September 2015, over 300 000 eligible prescriptions were filled, corresponding with over 70 000 unique patients. Of these, 29 134 patients were included. After multivariable regression, increasing age (odds ratio [OR]: 1.01), household income (OR: 1.03), and medication count (OR: 1.05) were found to be associated with adherence. Male gender (OR: 0.88), African American (OR: 0.45), Hispanic (OR: 0.62), or other race (OR: 0.87), being single (OR: 0.92), and increasing frequency of administrations per day (OR: 0.76) were associated with nonadherence.

CONCLUSION

Medication nonadherence was associated with nonwhite race, single status, male gender, low socioeconomic status, and increasing frequency of medication administration. Based on these results, a risk prediction tool could be created to determine which patients are at the highest risk of medication nonadherence.

Evaluating the Impact of Prescription Fill Rates on Risk Stratification Model Performance

BACKGROUND

Risk adjustment models are traditionally derived from administrative claims. Prescription fill rates-extracted by comparing electronic health record prescriptions and pharmacy claims fills-represent a novel measure of medication adherence and may improve the performance of risk adjustment models.

OBJECTIVE

We evaluated the impact of prescription fill rates on claims-based risk adjustment models in predicting both concurrent and prospective costs and utilization.

METHODS

We conducted a retrospective cohort study of 43,097 primary care patients from HealthPartners network between 2011 and 2012. Diagnosis and/or pharmacy claims of 2011 were used to build 3 base models using the Johns Hopkins ACG system, in addition to demographics. Model performances were compared before and after adding 3 types of prescription fill rates: primary 0-7 days, primary 0-30 days, and overall. Overall fill rates utilized all ordered prescriptions from electronic health record while primary fill rates excluded refill orders.

RESULTS

The overall, primary 0-7, and 0-30 days fill rates were 72.30%, 59.82%, and 67.33%. The fill rates were similar between sexes but varied across different medication classifications, whereas the youngest had the highest rate. Adding fill rates modestly improved the performance of all models in explaining medical costs (improving concurrent R by 1.15% to 2.07%), followed by total costs (0.58% to 1.43%), and pharmacy costs (0.07% to 0.65%). The impact was greater for concurrent costs compared with prospective costs. Base models without diagnosis information showed the highest improvement using prescription fill rates.

CONCLUSIONS

Prescription fill rates can modestly enhance claims-based risk prediction models; however, population-level improvements in predicting utilization are limited.

Drug exposure and the risk of multiple sclerosis: A systematic review

BACKGROUND

Several environmental and lifestyle factors have been associated with multiple sclerosis (MS) risk, including some pharmacological treatments. We systematically reviewed the literature on prescription drug exposure and MS risk.

METHODS

Six databases were searched for original observational studies reporting drug exposure and MS risk published before 2017.

RESULTS

Thirteen articles fulfilled inclusion criteria. Exposure to neither amiloride nor valproic acid was associated with MS (adjusted hazard ratio (adj.HR = 1.34;95% CI:0.81-2.20; adj.HR = 1.30;95%CI:0.44-3.80, respectively). Four studies explored oral contraceptive exposure and reported no association with MS; while a single study found an increased risk (odds ratio [adj.OR] = 1.52;95%CI:1.21-1.91). While penicillin exposure was associated with reduced risk of developing MS (adj.OR = 0.5;95%CI:0.3-0.9), a later study observed an elevated risk for penicillin (adj.OR = 1.21;95%CI:1.10-1.27) and all antibiotics (adj.OR = 1.41;95%CI:1.29-1.53), which was potentially attributed to underlying infection. Anti-tumor necrosis factor-alpha (TNFα) was not associated with MS risk in persons with inflammatory bowel disease (standard morbidity ratio = 4.2;95%CI:0.1-23.0) and arthritis (standardized incidence ratio = 1.38;95%CI:0.69-2.77); however, men exposed to anti-TNFα who also had arthritis and individuals with ankylosing spondylitis were at an increased risk (standardized incidence ratios = 3.91;95%CI:1.47-10.42 and 3.48;95%CI:1.45-8.37, respectively). A reduced risk of MS was observed with exposure to the beta2-adrenergic agonist fenoterol (adj.OR = 0.58;95%CI:0.45-0.76), and the sedating histamine 1-receptor antagonists (adj.OR = 0.2;95%CI:0.1-0.8), but not the non-sedating equivalent (adj.OR = 0.8;95%CI:0.4-1.6).

CONCLUSIONS

The suggestion that some drugs may prevent MS is intriguing and warrants further study. In addition, further pharmacovigilance is needed to assess the safety of anti-TNFα drugs in specific populations in the context of MS risk.

Type 2 Diabetes in the Real World: The Elusive Nature of Glycemic Control

Despite U.S. Food and Drug Administration (FDA) approval of over 40 new treatment options for type 2 diabetes since 2005, the latest data from the National Health and Nutrition Examination Survey show that the proportion of patients achieving glycated hemoglobin (HbA_1c) <7.0% (<53 mmol/mol) remains around 50%, with a negligible decline between the periods 2003-2006 and 2011-2014. The Healthcare Effectiveness Data and Information Set reports even more alarming rates, with only about 40% and 30% of patients achieving HbA_1c <7.0% (<53 mmol/mol) in the commercially insured (HMO) and Medicaid populations, respectively, again with virtually no change over the past decade. A recent retrospective cohort study using a large U.S. claims database explored why clinical outcomes are not keeping pace with the availability of new treatment options. The study found that HbA_1c reductions fell far short of those reported in randomized clinical trials (RCTs), with poor medication adherence emerging as the key driver behind the disconnect. In this Perspective, we examine the implications of these findings in conjunction with other data to highlight the discrepancy between RCT findings and the real world, all pointing toward the underrealized promise of FDA-approved therapies and the critical importance of medication adherence. While poor medication adherence is not a new issue, it has yet to be effectively addressed in clinical practice-often, we suspect, because it goes unrecognized. To support the busy health care professional, innovative approaches are sorely needed.

"Trying, But Failing" - The Role of Inhaler Technique and Mode of Delivery in Respiratory Medication Adherence

Inhaled therapies are the backbone of asthma and chronic obstructive pulmonary disease management, helping to target therapy at the airways. Adherence to prescribed treatment is necessary to ensure achievement of the clinician's desired therapeutic effect. In the case of inhaled therapies, this requires patients' acceptance of their need for inhaled therapy together with successful mastery of the inhaler technique specific to their device(s). This article reviews a number of challenges and barriers that inhaled mode of delivery can pose to optimum adherence-to therapy initiation and, thereafter, to successful implementation and persistence. The potential effects on adherence of different categories of devices, their use in multiplicity, and the mixing of device categories are discussed. Common inhaler errors identified by the international Implementing Helping Asthma in Real People (iHARP) study are summarized, and adherence intervention opportunities for health care professionals are offered. Better knowledge of common errors can help practicing clinicians identify their occurrence among patients and prompt remedial actions, such as tailored education, inhaler technique retraining, and/or shared decision making with patients regarding suitable alternatives. Optimizing existing therapy delivery, or switching to a suitable alternative, can help avoid unnecessary escalation of treatment and health care resources.