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

What We Mean When We Talk About Adherence in Respiratory Medicine

Adequate medication adherence is key for optimal benefit of pharmacological treatments. A wealth of research has been conducted to understand and identify opportunities to intervene to improve medication adherence, but variations in adherence definitions within prior research have led to ambiguity in study findings. The lack of a standard taxonomy hinders the development of cumulative science in adherence research. This article reviews the newly established Ascertaining Barriers to Compliance (ABC) taxonomy for medication adherence with a particular focus on its relevance and applicability within the context of asthma and chronic obstructive pulmonary disease management. Building on traditional definitions and concepts within medication adherence, the ABC taxonomy considers the temporal sequence of steps a patient must undertake to be defined as "adherent to treatment": (A) initiation, (B) implementation, and (C) persistence. We explain the clinical and research relevance of differentiating between these phases, point to differences in its applicability in observational and experimental research, review strengths and limitations of available measures, and highlight recent findings on specific determinants of these behaviors. Finally, we provide recommendations for research and practice with a view to supporting and sign posting opportunities to improve future respiratory medication adherence and associated research.

Provision of Medication Therapy Management by Pharmacists to Patients With Type-2 Diabetes Mellitus in a Federally Qualified Health Center

BACKGROUND

Type-2 diabetes mellitus is a complex condition for which pharmacists are well suited to improve patient outcomes by delivering medication therapy management (MTM) services. When diabetes is well controlled, patients can avoid its long-term complications, such as cardiovascular and renal diseases. This article describes an MTM pilot program that was implemented at a federally qualified health center (FQHC).

METHODS

This program was implemented at three clinics involving patients with uncontrolled diabetes, defined as hemoglobin A1c (HbA1c) greater than 8%. The primary endpoint assessed was HbA1c. Secondary endpoints included knowledge scores, medication adherence, and patient satisfaction. Outcomes were compared with a group of patients from the same clinics who did not receive MTM.

RESULTS

Fifty-seven patients met the established criteria and were enrolled in the six-month program. Thirty-seven patients completed the program and had an average 15% reduction in HbA1c (P < 0.05). Their average knowledge scores and medication adherence scores also increased from baseline.

CONCLUSION

MTM provided by pharmacists as part of a health care team at an FQHC led to significant reductions in HbA1c.

Efficacy and Patient Satisfaction of the Weekly DPP-4 Inhibitors Trelagliptin and Omarigliptin in 80 Japanese Patients with Type 2 Diabetes

Objective We investigated the efficacy, safety, and patient satisfaction of once-weekly DPP-4 inhibitors (DPP-4Is). Methods Either of two once-weekly DPP-4Is, trelagliptin or omarigliptin, was administered alone or in combination with other antidiabetic drugs in 80 outpatients with type 2 diabetes mellitus for 3 months. The HbA1c, glycoalbumin (GA), body weight, and the Diabetes Treatment Satisfaction Questionnaire (DTSQ) scores were evaluated. Results Patients switching from other daily DPP-4Is (n=29) showed no significant changes in the HbA1c or GA levels. However, the HbA1c and GA levels of patients who had been naïve to DPP-4Is (n=37) significantly improved from 9.31±2.53% to 7.02±1.20% (p<0.001) and 26.7±11.8% to 17.3±5.7% (p<0.001), respectively. Several non-serious adverse events were reported, including nausea (n=1), abdominal distension (n=1), and constipation (n=1). In the DTSQs, the total score for six questions on the primary factors representing patient treatment satisfaction was not markedly changed in patients switching from daily to weekly DPP-4Is but was significantly improved from 21.0 to 28.0 (p<0.001) in patients naïve to DPP-4Is. Conclusion These findings suggest that the use of a once-weekly DPP-4I is effective and well-tolerated in diabetes treatment and improves treatment satisfaction.

When and How Can Real World Data Analyses Substitute for Randomized Controlled Trials?

Regulators consider randomized controlled trials (RCTs) as the gold standard for evaluating the safety and effectiveness of medications, but their costs, duration, and limited generalizability have caused some to look for alternatives. Real world evidence based on data collected outside of RCTs, such as registries and longitudinal healthcare databases, can sometimes substitute for RCTs, but concerns about validity have limited their impact. Greater reliance on such real world data (RWD) in regulatory decision making requires understanding why some studies fail while others succeed in producing results similar to RCTs. Key questions when considering whether RWD analyses can substitute for RCTs for regulatory decision making are WHEN one can study drug effects without randomization and HOW to implement a valid RWD analysis if one has decided to pursue that option. The WHEN is primarily driven by externalities not controlled by investigators, whereas the HOW is focused on avoiding known mistakes in RWD analyses.

Trends for prevalence and incidence of resistant hypertension: population based cohort study in the UK 1995-2015

Objective To estimate the incidence and prevalence of resistant hypertension among a UK population treated for hypertension from 1995 to 2015.Design Cohort study.Setting Electronic health records from the UK Clinical Practice Research Datalink in primary care.Participants 1 317 290 users of antihypertensive drugs with a diagnosis of hypertension.Main outcome measures Resistant hypertension was defined as concurrent use of three antihypertensive drugs inclusive of a diuretic, uncontrolled hypertension (≥140/90 mm Hg), and adherence to the prescribed drug regimen, or concurrent use of four antihypertensive drugs inclusive of a diuretic and adherence to the prescribed drug regimen. To determine incidence, the numerator was new cases of resistant hypertension and the denominator was person years of those with treated hypertension and at risk of developing resistant hypertension. To determine prevalence, the numerator was total number of cases with resistant hypertension and the denominator was those with treated hypertension. Prevalence and incidence were age standardised to the 2015 hypertensive population.Results The age standardised incidence of resistant hypertension increased from 0.93 cases per 100 person years (95% confidence interval 0.87 to 1.00) in 1996 to a peak level of 2.07 cases per 100 person years (2.03 to 2.12) in 2004. Incidence then decreased to 0.42 cases per 100 person years (0.40 to 0.44) in 2015. Age standardised prevalence increased from 1.75% (95% confidence interval 1.66% to 1.83%) in 1995 to a peak of 7.76% (7.70% to 7.83%) in 2007. Prevalence then plateaued and subsequently declined to 6.46% (6.38% to 6.54%) in 2015. Compared with patients aged 65-69 years, those aged 80 or more years were more likely to have prevalent resistant hypertension throughout the study period.Conclusions Prevalent resistant hypertension has plateaued and decreased in recent years, consistent with a decrease in incidence from 2004 onwards. Despite this, resistant hypertension is common in the UK hypertensive population. Given the importance of hypertension as a modifiable risk factor for cardiovascular disease, reducing uncontrolled hypertension should remain a population health focus.

Adherence and dosing interval of subcutaneous antitumour necrosis factor biologics among patients with inflammatory arthritis: analysis from a Canadian administrative database

OBJECTIVES

Subcutaneous tumour necrosis factor alpha TNFαinhibitors (SC-TNFis) such as golimumab (GLM), adalimumab (ADA), etanercept (ETA) and certolizumab pegol (CZP) have been used for many years for the treatment of inflammatory arthritis. Non-adherence to therapy is an important modifiable factor that may compromise patient outcomes. The aim of this analysis was to compare adherence and dosing interval of SC-TNFis in the treatment of people with inflammatory arthritis.

DESIGN

We used the IMS Brogan database combining both Canadian private and public drug plan databases of Ontario and Quebec. Target drugs included SC-TNFis for inflammatory arthritis. The index period was from 1 January 2010 to 30 June 2012 and patients were followed for 24 months through 30 June 2014. Inclusion criteria were adult patients newly prescribed a SC-TNFis with at least three prescriptions and retained on therapy at 24 months.Dosing regimens as per the product monographs were used to compare actual versus expected drug utilisation. The mean possession ratio was used as a marker for adherence. Patients who scored >80% were considered adherent. The average days between units was estimated by taking the total days on therapy and divided by the number of units the patient received.

RESULTS

4035 patients were included: 683 (16.9%), 1400 (34.7%), 1765 (43.7%) and 187 (4.6%) were treated with GLM, ADA, ETA and CZP, respectively. The proportion of adherent patients in the GLM cohort (n=595/683, 87%, p<0.0001) was greater compared with ADA (n=1044/1400, 75%), ETA (n=1285/1765, 73%) and CZP-treated patients (132/187, 71%). In addition, the number of patients receiving biological drug at a shorter dosing interval was similar between cohorts, and was 5%, 6%, 12% and 4% in GLM (≤26 days), ADA (≤12 days), ETA (≤6 days) and CZP-treated patients (≤12 days), respectively.

CONCLUSIONS

In this real-life administrative database, GLM had better adherence compared with other SC-TNFis.

Elderly polypharmacy patients' needs and concerns regarding medication assessed using the structured patient-pharmacist consultation model

OBJECTIVE

To evaluate elderly polypharmacy patients' needs and concerns regarding medication through the Structured Patient-Pharmacist Consultation (SPPC).

METHODS

Older patients on chronic treatment with ≥5 medications were asked to fill in the SPPC form at home. A consultation with the community pharmacist, structured according to patient's answers, followed within 2-4 weeks. Logistic regression associated patients' individual treatment with care issues and consultation outcomes.

RESULTS

Out of 440 patients, 39.5% experienced problems, and 46.1% had concerns about medication use. 122 patients reported reasons for discontinuing treatment. The main outcome of the consultation was a better understanding of medication use (75.5%). Side effects and/or non-adherence were identified in 50% of patients, and 26.6% were referred to the doctor. Atrial fibrillation, COPD, anticoagulants, benzodiazepines, and beta agonists/corticosteroids were associated with problems during medication use. Patients with diabetes improved their understanding of medication use significantly.

CONCLUSION

Patients on benzodiazepines, anticoagulants, and beta agonists/corticosteroids, with atrial fibrillation and/or COPD, may have a higher potential for non-adherence. Counseling patients based on the SPPC model may be particularly useful for patients with diabetes.

PRACTICE IMPLICATIONS

The SPPC model is a useful tool for counseling based on patient needs.

Patients Given Take Home Medications Instead of Paper Prescriptions Are More Likely to Return to Emergency Department

Objective: The aim of this study was to compare the 30-day emergency department (ED) return rate between patients given a Take Home Medication pack (THM) versus a standard paper prescription (SPP) prior to discharge. Methods: This was an observational, prospective cohort study in an urban, university-affiliated, level I trauma center. Patients were identified through daily pharmacy reports. Consecutive adult patients discharged from the ED with either a THM or equivalent SPP were included. For each patient, baseline characteristics including age, gender, primary care provider (PCP), primary language, ethnicity, marital status, and insurance status were recorded from the electronic medical record (EMR). Review of the EMR was used to determine whether patients returned to the ED within 30 days and whether the return visit was for all-causes or for the same complaint targeted by the THM or SPP from the index visit. Similarly, visits to other providers in the health system within 30 days were recorded. Results: A total of 711 patients were included in the study, with 268 receiving a THM and 443 receiving a SPP. In comparison with the SPP group, the THM group was more likely to have an all-cause return (Relative Risk [RR] = 1.7, P < .01). Variables associated with increased odds of returning to the ED within 30 days included study group (adjusted Odds Ratio [aOR]: 1.7), male gender (aOR: 1.6), African American ethnicity (aOR: 3.0), public insurance (aOR: 3.3), and institutional financial assistance (aOR: 5.0). The difference between study groups for index visit complaint-specific returns was not significant. Conclusions: Patients receiving a THM demonstrated a higher all-cause return rate than patients receiving a SPP. A randomized study is needed evaluating the effect of THM on return ED visits.

The availability of pharmacies in the United States: 2007-2015

Importance

Despite their increasingly important role in health care delivery, little is known about the availability, and characteristics, of community pharmacies in the United States.

Objectives

(1) To examine trends in the availability of community pharmacies and pharmacy characteristics (24-hour, drive-up, home delivery, e-prescribing, and multilingual staffing) associated with access to prescription medications in the U.S. between 2007 and 2015; and (2) to determine whether and how these patterns varied by pharmacy type (retail chains, independents, mass retailers, food stores, government and clinic-based) and across counties.

Methods

Retrospective analysis using annual data from the National Council for Prescription Drug Programs. Pharmacy locations were mapped and linked to the several publically-available data to derive information on county-level population demographics, including annual estimates of total population, percent of population that is non-English speaking, percent with an ambulatory disability and percent aged ≥65 years. The key outcomes were availability of pharmacies (total number and per-capita) and pharmacy characteristics overall, by pharmacy type, and across counties.

Results

The number of community pharmacies increased by 6.3% from 63,752 (2007) to 67,753 (2015). Retail chain and independent pharmacies persistently accounted for 40% and 35% of all pharmacies, respectively, while the remainder were comprised of mass retailer (12%), food store, (10%), clinic-based (3%) or government (<1%) pharmacies. With the exception of e-prescribing, there was no substantial change in pharmacy characteristics over time. While the number of pharmacies per 10,000 people (2.11) did not change between 2007 and 2015 at the national-level, it varied substantially across counties ranging from 0 to 13.6 per-capita in 2015. We also found that the majority of pharmacies do not offer accommodations that facilitate access to prescription medications, including home-delivery, with considerable variation by pharmacy type and across counties. For example, the provision of home-delivery services ranged from less than <1% of mass retailers to 67% of independent stores and was not associated with county demographics, including ambulatory disability population and percent of the population aged ≥65 years.

Conclusions

Despite modest growth of pharmacies in the U.S., the availability of pharmacies, and pharmacy characteristics associated with access to prescription medications, vary substantially across local areas. Policy efforts aimed at improving access to prescription medications should ensure the availability of pharmacies and their accommodations align with local population needs.

Comparative adherence to diabetes drugs: An analysis of electronic health records and claims data

Non-adherence to medications is a major challenge in diabetes care. The objective of this brief report is to compare adherence rates for 6 major classes of diabetes medications: metformin, sulfonylurea, thiazolidinedione, basal insulin, DPP-4 inhibitors, and GLP-1 receptor agonists. We used a data source that linked electronic prescriptions with insurance claims to assess whether new electronic prescriptions for diabetes medications were followed by dispensing claims consistent with that prescription. After one year of follow-up, the daily medication possession probability (MPP) - a measure of overall adherence - at one year for sulfonylurea was 0.49 and for metformin was 0.46. Thiazolidinediones and basal insulin had a similar final daily MPP at 0.36 and 0.39, respectively, which was significantly lower than that for sulfonylurea or metformin (P < .05). GLP-1 receptor agonists and DPP-4 inhibitors were also comparable to one another at a final daily MPP of .30 and .21, respectively (P < .05 compared to any of the aforementioned drug classes). In summary, the rates at which diabetes drugs are prescribed, and the rates at which patients actually take them, differ substantially. Physicians should be aware of potentially significant challenges concerning adherence to newer agents.

Non-adherence to medication regimens among older African-American adults

Background

Despite concerns about racial differences on adherence to prescribed medication rigimens among older adults, current information about nonadherence among underserved elderly African Americans with co-morbidities is limited. This study examines the association between adherence to drug regimens and an array of medication-related factors, including polypharmacy, medication regimen complexity, use of Potentially Inappropriate Medications (PIM), and knowledge about the therapeutic purpose and instructions of medication use.

Methods

Four-hundred African Americans, aged 65 years and older, were recruited from South Los Angeles. Structured, face-to-face interviews and visual inspection of participants’ medications were conducted. From the medication container labels, information including strength of the drug, expiration date, instructions, and special warnings were recorded. The Medication Regimen Complexity Index (MRCI) was measured to quantify multiple features of drug regimen complexity. The Beers Criteria was used to measure the PIM use.

Results

Participants reported taking an average of 5.7 prescription drugs. Over 56% could not identify the purpose of at least one of their medications. Only two-thirds knew dosage regimen of their medications. Thirty-five percent of participants indicated that they purposely had skipped taking at least one of their medications within last three days. Only 8% of participants admitted that they forgot to take their medications. The results of multivariate analysis showed that co-payment for drugs, memory deficits, MRCI, and medication-related knowledge were all associated with adherence to dosage regimen of medications. Participants with a higher level of knowledge about therapeutic purpose and knowledge about dosage regimen of their medications were seven times (CI: 4.2–10.8) more likely to adhere to frequency and dose of medications. Participants with a low complexity index were two times (CI: 1.1–3.9) more likely to adhere to the dosage regimen of their medications, compared with participants with high drug regimen complexity index.

Conclusions

While other studies have documented that non-adherence remains an important issue among older adults, our study shows that for underserved elderly African Americans, these issues are particularly striking. A periodic comprehensive assessment of all medications that they use remains a critical initial step to identify medication related issues. Assessment of their disease and medication related knowledge (e.g., therapeutic purposes, side-effects, special instructions, etc.) and their ability to follow complicated medication regimens and modification of their drug regimens requires inter-professional collaboration.

Agreement and validity of electronic health record prescribing data relative to pharmacy claims data: A validation study from a US electronic health record database

BACKGROUND

Granular clinical and laboratory data available in electronic health record (EHR) databases provide researchers the opportunity to conduct investigations that would not be possible in insurance claims databases; however, for pharmacoepidemiology studies, accurate classification of medication exposure is critical.

OBJECTIVE

The aim of this study was to evaluate the validity of classifying medication exposure using EHR prescribing (EHR-Rx) data.

METHODS

We conducted a retrospective cohort study among patients with linked claims and EHR data in OptumLabs™ Data Warehouse. The agreement between EHR-Rx data and pharmacy claims (PC-Rx) data (for 40 medications) was determined using the positive predictive value (PPV) and medication possession ratio (MPR)-calculated in 1- and 12-month medication exposure periods (MEPs). Secondary analyses were restricted to incident vs prevalent EHR-Rxs, age ≥65 vs <65, white vs black race, males vs females, and number of EHR-Rxs.

RESULTS

The validity metrics varied substantially among the 40 medications assessed. Across all medications, the period PPV and MPR were 62% and 63% in the 1-month MEP. They were 78% and 43% in the 12-month MEP. Overall, PPV and MPR were higher for patients with a prevalent EHR-Rx and age <65.

CONCLUSIONS

Despite substantial variability among different medications, there was very good agreement between EHR-Rx data and PC-Rx data. To maximize the validity of classifying medication exposure with EHR prescribing data, researchers may consider using longer MEPs (eg, 12 months) and potentially require multiple EHR-Rxs to classify baseline medication exposure.

[Evaluation of primary adherence to medications in patients with chronic conditions: A retrospective cohort study]

OBJECTIVES

To assess the proportion of members of a private health insurance at the Hospital Italiano de Buenos Aires with primary adherence to, 1) bisphosphonates for secondary prevention of osteoporotic fractures, 2) insulin and metformin in type 2 diabetes, and 3) tamoxifen in the context of treatment of breast cancer.

DESIGN

Retrospective cohort study to determine the proportion of primary treatment adherence during 2012 and 2013. SITE: Hospital Italiano de Buenos Aires, Argentina.

PARTICIPANTS

Members of the Hospital Italiano de Buenos Aires private health insurance, who had received a new electronic prescription (alendronate or ibandronate for secondary prevention of fractures following an osteoporotic fracture; insulin and/or metformin for type 2 diabetes; or tamoxifen as a treatment for breast cancer) during the years 2012 and 2013. An analysis was performed on 1,403 new electronic prescriptions, of which 673 were excluded for not meeting the inclusion criteria.

MAIN MEASUREMENTS

Primary adherence has been defined as the execution of a first-time treatment after it was agreed with the health care provider. The primary analysis assessed the proportion of primary adherence for the three medications. A bivariate analysis was performed to compare the characteristics and potential predictors of primary adherence.

RESULTS

Primary adherence for each drug group was, 93% Bisphosphonates, 88% Metformin, 96% Insulin, and 92% Tamoxifen.

CONCLUSIONS

To the best of our knowledge, this is the first study that has evaluated primary adherence in Argentina, and the first for Tamoxifen world wide. The primary adherence documented in our study was somewhat higher than that reported in the literature.

A call to action for outpatient antibiotic stewardship

OBJECTIVES

To address the public health threat of antibiotic resistance, there has been an enhanced call for antibiotic stewardship programs throughout the health care continuum.

SUMMARY

While antibiotic stewardship programs have been well described in the inpatient setting, data on effectiveness and guidance on implementing outpatient programs is scarce. Establishing stewardship practices in the outpatient setting is necessary because more than 60% of human antibiotic use occurs in this setting.

CONCLUSION

In this article, we highlight the importance and need for stewardship in the outpatient setting, discuss strategies for the development of stewardship teams, and discuss potential metrics that can be used to assess effectiveness of antibiotic stewardship interventions.

Effect of Out-of-Pocket Cost on Medication Initiation, Adherence, and Persistence among Patients with Type 2 Diabetes: The Diabetes Study of Northern California (DISTANCE)

OBJECTIVE

To estimate the effect of out-of-pocket (OOP) cost on nonadherence to classes of cardiometabolic medications among patients with diabetes.

DATA SOURCES/SETTING

Electronic health records from a large, health care delivery system for 223,730 patients with diabetes prescribed 842,899 new cardiometabolic medications during 2006-2012.

STUDY DESIGN

Observational, new prescription cohort study of the effect of OOP cost on medication initiation and adherence.

DATA COLLECTION

Adherence and OOP costs were based on pharmacy dispensing records and benefits.

PRINCIPAL FINDINGS

Primary nonadherence (never dispensed) increased monotonically with OOP cost after adjusting for demographics, neighborhood socioeconomic status, Medicare, medical financial assistance, OOP maximum, deductibles, mail order pharmacy incentive and use, drug type, generic or brand, day's supply, and comorbidity index; 7 percent were never dispensed the new medication when OOP cost ≥$11, 5 percent with OOP cost of $1-$10, and 3 percent when the medication was free of charge (p < .0001). Higher OOP cost was also strongly associated with inadequate secondary adherence (≥20 percent of time without adequate medication). There was no clinically significant or consistent relationship between OOP costs and early nonpersistence (dispensed once, never refilled) or later stage nonpersistence (discontinued within 24 months).

CONCLUSIONS

Cost-sharing may deter clinically vulnerable patients from initiating essential medications, undermining adherence and risk factor control.

The effectiveness of a nursing discharge programme to improve medication adherence and patient satisfaction in the psychiatric intensive care unit

AIMS AND OBJECTIVES

To observe the extent to which a nursing discharge plan is effective in promoting therapeutic adherence and improving patient satisfaction with their treatment based on information interventions provided by nursing staff, direct hospital medication distribution and follow-up telephone calls.

BACKGROUND

Patient adherence is a fundamental requirement for the treatment of chronic diseases. Among psychiatric patients, adherence to the prescribed course of treatment allows patients to keep the symptoms of their disease under control, allowing for improvements in the management of their condition, minimising the risks of relapse and reducing the number of hospitalisations.

DESIGN

This study uses a prospective correlational design.

METHODS

The Morisky Medication Adherence Scale, the Satisfaction with Information about Medicine Scale and the General Satisfaction Questionnaire were used.

RESULTS

Of the 135 patients enrolled in the study, 57% of the sample was female, and, on average, patients were aged 33 years. About 72.9% were unmarried, and 88.1% were educated at less than high school level. This study showed that patients who received more information on their health status and on what would be done for them after their hospitalisation had a higher adherence to treatment. In addition, patients who were more satisfied with the nursing care provided had a higher rate of adherence to their treatment plan.

CONCLUSIONS

The interpersonal and educational nursing intervention improves adherence to a treatment plan by allowing patients to express themselves not only as individuals who rely on health care but also as protagonists able to effectively manage their disease and to empower themselves by acquiring disease management skills.

RELEVANCE TO CLINICAL PRACTICE

A patient-nurse communication programme could help to analyse the individual patient circumstances that might become barriers to adherence and to apply nursing interventions that promote better patient adherence.

Economic benefit of back titration in the treatment of hypertension in Jos, Nigeria

Purpose

Treatment of hypertension is expensive and cost is one of the reasons for inadequate blood pressure control. Where there are no social cost cushions, the burden is borne by patients. With pervasive poverty and inadequate control, complications are unchecked. Back titration in appropriate circumstances should, therefore, translate to economic benefit. This is an attempt to compute, in economic terms, the benefit of back titration.

Patients and methods

Thirty-nine patients who entered an antihypertensive back titration program for 12 months and who had been earlier reported on, form the subject of this study. A survey of the cost of antihypertensives in pharmacy outlets in Jos, Nigeria was undertaken. Regimens of antihypertensives that patients were on at the onset and end of the 12 months of back titration were costed in Nigerian currency and compared.

Results

Back titration translated to economic benefit in all patients with a cost reduction varying from 2.3% to 100%. This reflected in reduction in mean daily cost of treatment of N107.09–N54.61.

Conclusion

The benefit of antihypertensive back titration apart from psychological relief of lower pill burden and side effect profile is in pharmacoeconomics. This permits greater adherence and prevents morbi-mortality consequences of hypertension. In this study, back titration over 12 months translated to average cost reduction of >50%, making treatment more affordable. In appropriate circumstances, back titration of antihypertensives results in economic relief for patients. This should improve adherence, reduce morbi-mortality and is recommended for wider application.

Use of pharmacy records to measure treatment adherence: a critical review of the literature

The current frame of reference on adherence to pharmacotherapy includes a set of behaviors experienced by the user, with observation of the detailed and continuous history of the use of each dose of the medication. Indicators based on pharmacy records have been used to measure adherence. The current review aimed to identify and describe indicators based on pharmacy records and to discuss their adequacy and limitations for measuring adherence. An exploratory literature review was conducted in three databases using the terms "adherence", "pharmacy records/administrative data", and "measure" to compose the descriptors for the selection of 81 articles and the elaboration of a chart with the denomination, sources, methods for calculation, description, and interpretation of the operational and referential meaning of 14 indicators. Given the most recent taxonomy for adherence proposed in the literature, we concluded that the indicators can be useful for identifying patients with medication-seeking behavior-related problems and analysis of persistence. The distance between supply-related events and difficulties in treatment follow-up can influence an analysis based exclusively on the use of these indicators.

Impact of Participation in the Adalimumab (Humira) Patient Support Program on Rheumatoid Arthritis Treatment Course: Results from the PASSION Study

INTRODUCTION

Patients with rheumatoid arthritis (RA) who are treated with adalimumab (ADA) are offered a proprietary patient support program (PSP, AbbVie Care^®). The main objective of this study was to examine the effectiveness of ADA on RA treatment course over time in the context of PSP utilization.

METHODS

PASSION was a 78-week post-marketing observational study of RA patients with an insufficient response to ≥1 DMARD newly initiating ADA in routine clinical care that was conducted in Europe, Israel, Mexico, Puerto Rico, and Australia. One prior biologic DMARD was allowed. The primary endpoint was percentage of patients achieving the minimal clinically important difference (MCID; improvement of ≥0.22 compared to baseline) in Health Assessment Questionnaire (HAQ) Disability Index (HAQ-DI) at week 78. Additionally, multiple clinical and patient-reported outcomes (PROs) were evaluated over time. Patients were categorized based on their participation in the PSP: ever (PSP users) vs. never (PSP non-users). Safety events were monitored throughout the study.

RESULTS

Overall, 42.8% of PSP users achieved the MCID in HAQ-DI at week 78 (improvement of at least 0.22 compared to baseline). From 1025 enrolled, 48.7% of patients were PSP users while treated with ADA. The percentage of patients achieving MCID in the HAQ-DI was higher in PSP users vs. PSP non-users (48.1 vs. 37.8%) at week 78 (p < 0.001, NRI). Most of the studied clinical outcomes and PROs showed significant improvements (p < 0.05) from baseline to week 78 favoring PSP users over PSP non-users.

CONCLUSIONS

In patients with moderate-to-severe RA who initiated ADA, improvements in clinical, functional, and PROs were achieved in real-world settings with significantly greater improvements among PSP users in comparison with PSP non-users.

FUNDING

AbbVie.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT01383421.

Primary Nonadherence to Overactive Bladder Medications in an Integrated Managed Care Health Care System

BACKGROUND

Treatment for overactive bladder (OAB) remains suboptimal, in part because of patient nonadherence to medications. Primary nonadherence is when patients fail to pick up their initial prescriptions.

OBJECTIVE

To measure primary nonadherence to OAB medications within 30 days of a first OAB prescription order using electronic medical records from a U.S. managed care health care system METHODS: A retrospective cohort study was conducted using electronic medical records from the Kaiser Permanente Southern California (KPSC) database to identify patients with new OAB prescriptions between January 1, 2007, and December 31, 2013. The index date was defined as the first order of an OAB prescription. Patients had to be aged ≥ 18 years on the index date and were required to have 12 months of continuous membership with drug benefit eligibility before, during, and after the index date. Patients were defined as primary nonadherent if they did not pick up their new OAB prescriptions within 30 days of the order date. Descriptive statistics and a multivariable logistic regression analysis with backward selection were conducted to identify factors associated with patients who were primary nonadherent versus adherent.

RESULTS

There were 9,050 patients with a new OAB prescription order; 1,662 (18%) of these were primary nonadherent. Patients with primary nonadherence were younger in age (56.9 [SD ± 16.0] years vs. 63.9 [SD ± 14.8] years; P < 0.001) and more likely to have commercial insurance (65.9% vs. 46.2%; P < 0.001). They also had lower mean Charlson Comorbidity Index (CCI) scores (1.99 vs. 2.70; P < 0.001), fewer OAB-related comorbidities, fewer concomitant medications (P < 0.005), and fewer overall prescriptions dispensed in the previous 12 months (P < 0.001) compared with adherent patients. Significant factors such as commercial insurance (P = 0.013), race other than white (P = 0.020), CCI = 0 versus CCI ≥ 2 (P = 0.001), urinary tract infections (P < 0.001), and falls (P = 0.047) were associated with a higher likelihood of primary nonadherence versus adherence.

CONCLUSIONS

Nearly 1 in 5 patients did not pick up their new OAB medications within 30 days of the order date. Knowledge of factors associated with primary nonadherence may inform strategies for improving management of OAB.

DISCLOSURES

This study was supported by a research grant provided by Astellas Pharma Global Development. Rashid and Lin do not have any financial interests or potential conflict of interest with regard to the work. Vassilakis, Kristy, and Ng were employees of Astellas Pharma Global Development when this study was conducted. Study concept and design were contributed by Rashid and Ng, along with the other authors. Rashid and Lin collected the data, and data interpretation was performed by Rashid, Ng, and Lin, along with Vassilakis and Kristy. The manuscript was written by Rashid and Ng, along with Vassilakis and Lin, and revised by Rashid, Ng, and Lin.

Patterns and Predictors of Adherence to Statin Therapy Among Older Patients: Protocol for a Systematic Review

Background

The benefits of statin therapy are significantly compromised by noncompliance. Although elderly patients may have particular challenges with medication adherence and persistence, previous reviews on statin adherence have not focused on this population. Additionally, comparisons of adherence and persistence specific to statin indication (primary or secondary prevention) have not been thoroughly explored.

Objective

We aim to assess the extent of, and factors associated with, adherence and persistence to statin therapy among older populations (aged ≥65 years).

Methods

A systematic review will be undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. Searches will be performed using multiple electronic databases (Ovid MEDLINE, EMBASE, PsycINFO, CINAHL, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, and the National Health Service Economic Evaluation Database) to identify relevant randomized trials and observational studies that evaluated statin adherence and/or persistence as an outcome. Eligible studies will include those involving community-living or outpatient elderly individuals. The methodological quality of randomized controlled trials (RCTs) will be assessed via the Joanna Briggs Institute’s critical appraisal checklist for RCTs, and the quality assessment of observational studies will be undertaken using a set of questions formulated with resort to the National Institute of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. When possible, meta-analyses will be conducted using random-effect modeling and generic inverse variance analyses for adjusted-effect estimates. Heterogeneity across studies will be quantified using the I² statistic. The presence of publication bias will be assessed using funnel plots and Egger’s regression tests. A leave-one-out sensitivity analysis will also be conducted to assess the impact of individual study results on pooled estimates. To explore possible sources of heterogeneity across studies, subgroup analyses will be performed based on covariates such as study design, statin indication, country of study, and length of patient follow-up.

Results

The electronic database searches were completed in December 2016. Retrieved articles are currently being screened and the entire study is expected to be completed by June 2017.

Conclusions

This systematic review will provide further understanding of the patterns of, and barriers to, statin adherence and persistence among older patients. The findings will inform clinical practice and the design of appropriate interventions.

Trial Registration

PROSPERO CRD42016053191

Current Situation of Medication Adherence in Hypertension

Despite increased awareness, poor adherence to treatments for chronic diseases remains a global problem. Adherence issues are common in patients taking antihypertensive therapy and associated with increased risks of coronary and cerebrovascular events. Whilst there has been a gradual trend toward improved control of hypertension, the number of patients with blood pressure values above goal has remained constant. This has both personal and economic consequences. Medication adherence is a multifaceted issue and consists of three components: initiation, implementation, and persistence. A combination of methods is recommended to measure adherence, with electronic monitoring and drug measurement being the most accurate. Pill burden, resulting from free combinations of blood pressure lowering treatments, makes the daily routine of medication taking complex, which can be a barrier to optimal adherence. Single-pill fixed-dose combinations simplify the habit of medication taking and improve medication adherence. Re-packing of medication is also being utilized as a method of improving adherence. This paper presents the outcomes of discussions by a European group of experts on the current situation of medication adherence in hypertension.

Assessment of the rates and characteristics of unclaimed prescriptions

OBJECTIVES

The purpose of this study was to describe the rates of and characteristics associated with unclaimed prescriptions during 3 seasonal months.

DESIGN

Retrospective cohort study.

SETTING

This study was conducted using Kaiser Permanente Colorado administrative data.

PARTICIPANTS

All patients who had a prescription prepared at 1 of 28 outpatient pharmacies during the months of November 2014, February 2015, and May 2015 were included. An unclaimed prescription was defined as any prescription medication not dispensed to a patient within 15 days after preparation. Patients with an unclaimed prescription were compared to patients without an unclaimed prescription during the study months.

MAIN OUTCOME MEASURES

The rates of unclaimed prescriptions, characteristics of patients with and without unclaimed prescriptions, and medication characteristics between unclaimed and claimed prescriptions.

RESULTS

A total of 866,554 prescriptions were prepared during the study months, with 44,836 being unclaimed (5.2%; 95% CI 5.1%-5.2%). Of the 225,510 patients with a prescription prepared during the study months, 30,800 patients (13.7%) had at least 1 unclaimed prescription. Neither the size of the pharmacy nor the season in which the prescription was prepared had a meaningful impact on the unclaimed prescription rate. Miscellaneous (e.g., disinfectants, antidotes, medical devices) and respiratory medication classes had the highest rates of unclaimed prescriptions. Patient characteristics associated with having had an unclaimed prescription included having had a hospice, skilled nursing facility, or long-term care facility stay after the prescription was prepared (odds ratio 2.48 [95% CI 1.91-3.23]) and at least 1 other medication dispensed previously (odds ratio 1.83 [95% CI 1.73-1.94]).

CONCLUSION

The rate of unclaimed prescriptions was relatively low; however, approximately 1 in 8 patients with a prepared prescription had at least 1 unclaimed prescription. Future research is needed to identify effective interventions to reduce unclaimed prescriptions in order to prevent potential negative health outcomes.

Initial medication non-adherence: prevalence and predictive factors in a cohort of 1.6 million primary care patients

AIMS

Adherence to medicines is vital in treating diseases. Initial medication non-adherence (IMNA) - defined as not obtaining a medication the first time it is prescribed - has been poorly explored. Previous studies show IMNA rates between 6 and 28% in primary care (PC). The aims of this study were to determine prevalence and predictive factors of IMNA in the most prescribed and expensive pharmacotherapeutic groups in the Catalan health system.

METHODS

This is a retrospective, register-based cohort study which linked the Catalan PC System (Spain) prescription and invoicing databases. Medication was considered non-initiated when it was not collected from the pharmacy by the end of the month following the one in which it was prescribed. IMNA prevalence was calculated using July 2013-June 2014 prescription data. Predictive factors related to patients, general practitioners and PC centres were identified through multilevel logistic regression analyses. Missing data were attributed using simple imputation.

RESULTS

Some 1.6 million patients with 2.9 million prescriptions were included in the study sample. Total IMNA prevalence was 17.6% of prescriptions. The highest IMNA rate was observed in anilides (22.6%) and the lowest in angiotensin-converting-enzyme (ACE) inhibitors (7.4%). Predictors of IMNA are younger age, American nationality, having a pain-related or mental disorder and being treated by a substitute/resident general practitioner in a resident-training centre.

CONCLUSIONS

The rate of IMNA is high when all medications are taken into account. Attempts to strengthen trust in resident general practitioners and improve motivation to initiate a needed medication in the general young and older immigrant population should be addressed in Catalan PC.

Reformulating the Common Sense Model of Self-Regulation: Toward Parent-Child Shared Regulation

Asthma is one of the most common chronic diseases of childhood with nearly 7 million children affected in the United States. Nonadherence to controller medication is a substantial issue that results in higher pediatric asthma disease morbidity. The common sense model of self-regulation is a useful theoretical framework to understand chronic disease self-management in adults, but has not been used in the context of pediatric chronic disease. Using Fawcett's framework, the authors analyze and evaluate the common sense model. To conclude, the authors propose a reformulation of the model that incorporates parent-child shared regulation of pediatric asthma.

The relationship between risk factors and medication adherence among breast cancer survivors: What explanatory role might depression play?

OBJECTIVE

Despite the efficacy of clinical treatments (eg, adjuvant hormonal therapy) for breast cancer survivors (BCS), nonadherence rates remain high, increasing the risk of recurrence and mortality. The current study tested a theoretical model of medical nonadherence that proposes depression to be the most proximal predictor of medical nonadherence among BCS.

METHODS

Breast cancer survivors were recruited from radiation clinics in Missouri. Survey data were collected 12 months after the end of primary treatment. The sample size included 133 BCS.

RESULTS

Findings show substantial support for the model, demonstrating that depression mediated the relation between physical symptoms, cognitive symptoms, social support, and adherence to medication. This finding was replicated with a measure of mood disturbance.

CONCLUSIONS

These findings support the prediction that medication nonadherence among BCS multiply determined process and have compelling implications for healthcare providers and interventions designed to increase medication adherence among BCS.

Improving outpatient primary medication adherence with physician guided, automated dispensing

BACKGROUND

Physician dispensing, different from pharmacist dispensing, is a way for practitioners to supply their patients with medications, at the point of care. The InstyMeds dispenser and logistics system can automate much of the dispensing, insurance adjudication, inventory management, and regulatory reporting that is required of physician dispensing.

OBJECTIVE

To understand the percentage of patients that exhibit primary adherence to medication in the outpatient setting when choosing InstyMeds.

METHOD

The InstyMeds dispensing database was de-identified and analyzed for primary adherence. This is the ratio of patients who dispensed their medication to those who received an eligible prescription.

RESULTS

The average InstyMeds emergency department installation has a primary adherence rate of 91.7%. The maximum rate for an installed device was 98.5%.

CONCLUSION

Although national rates of primary adherence have been found to be in the range of 70%, automated physician dispensing vastly improves the rate of adherence. Improved adherence should lead to better patient outcomes, fewer return visits, and lower healthcare costs.

Risks and benefits of psychotropic medication in pregnancy: cohort studies based on UK electronic primary care health records

BACKGROUND

Although many women treated with psychotropic medication become pregnant, no psychotropic medication has been licensed for use in pregnancy. This leaves women and their health-care professionals in a treatment dilemma, as they need to balance the health of the woman with that of the unborn child. The aim of this project was to investigate the risks and benefits of psychotropic medication in women treated for psychosis who become pregnant.

OBJECTIVE(S)

(1) To provide a descriptive account of psychotropic medication prescribed before pregnancy, during pregnancy and up to 15 months after delivery in UK primary care from 1995 to 2012; (2) to identify risk factors predictive of discontinuation and restarting of lithium (multiple manufacturers), anticonvulsant mood stabilisers and antipsychotic medication; (3) to examine the extent to which pregnancy is a determinant for discontinuation of psychotropic medication; (4) to examine prevalence of records suggestive of adverse mental health, deterioration or relapse 18 months before and during pregnancy, and up to 15 months after delivery; and (5) to estimate absolute and relative risks of adverse maternal and child outcomes of psychotropic treatment in pregnancy.

DESIGN

Retrospective cohort studies.

SETTING

Primary care.

PARTICIPANTS

Women treated for psychosis who became pregnant, and their children.

INTERVENTIONS

Treatment with antipsychotics, lithium or anticonvulsant mood stabilisers.

MAIN OUTCOME MEASURES

Discontinuation and restarting of treatment; worsening of mental health; acute pre-eclampsia/gestational hypertension; gestational diabetes; caesarean section; perinatal death; major congenital malformations; poor birth outcome (low birthweight, preterm birth, small for gestational age, low Apgar score); transient poor birth outcomes (tremor, agitation, breathing and muscle tone problems); and neurodevelopmental and behavioural disorders.

DATA SOURCES

Clinical Practice Research Datalink database and The Health Improvement Network primary care database.

RESULTS

Prescribing of psychotropic medication was relatively constant before pregnancy, decreased sharply in early pregnancy and peaked after delivery. Antipsychotic and anticonvulsant treatment increased over the study period. The recording of markers of worsening mental health peaked after delivery. Pregnancy was a strong determinant for discontinuation of psychotropic medication. However, between 40% and 76% of women who discontinued psychotropic medication before or in early pregnancy restarted treatment by 15 months after delivery. The risk of major congenital malformations, and neurodevelopmental and behavioural outcomes in valproate (multiple manufacturers) users was twice that in users of other anticonvulsants. The risks of adverse maternal and child outcomes in women who continued antipsychotic use in pregnancy were not greater than in those who discontinued treatment before pregnancy.

LIMITATIONS

A few women would have received parts of their care outside primary care, which may not be captured in this analysis. Likewise, the analyses were based on prescribing data, which may differ from usage.

CONCLUSIONS

Psychotropic medication is prescribed before, during and after pregnancy. Many women discontinue treatment before or during early pregnancy and then restart again in late pregnancy or after delivery. Our results support previous associations between valproate and adverse child outcomes but we found no evidence of such an association for antipsychotics.

FUTURE WORK

Future research should focus on (1) curtailing the use of sodium valproate; (2) estimating the benefits of psychotropic drug use in pregnancy; and (3) investigating the risks associated with lifestyle choices that are more prevalent among women using psychotropic drugs.

FUNDING DETAILS

The National Institute for Health Research Health Technology Assessment programme.

Why Don't Our Patients with Chronic Obstructive Pulmonary Disease Listen to Us? The Enigma of Nonadherence

Nonadherence--not taking pharmacologic or nonpharmacologic treatments according to agreed recommendations from a health care provider--is common in patients with chronic obstructive pulmonary disease. Nonadherence in taking maintenance medications, smoking cessation, maintaining regular physical activity and exercise, starting and staying in pulmonary rehabilitation and continuing on with the postrehabilitation exercise/activity prescription, and successfully following self-management directions results in adverse outcomes across multiple areas. These include a faster decline in airway function, higher symptom burden, impaired health status, and increased health care use and mortality risk. Although nonadherence can also occur in health care providers (not following established treatment guidelines), this perspective focuses on patient nonadherence. Factors such as social/economic, health system, therapy-related, patient-related, and condition-related factors all impact this problem. To improve patient adherence, we need to consider these factors in the context of people with chronic obstructive pulmonary disease and implement strategies directly targeting underlying issues. Strategies may include customizing and simplifying learning and intervention regimes, identifying barriers to adherence and addressing them, ensuring patient support structures are in place, and improving self-efficacy. Future directions should focus on research and development in educational design; use of technology to assist education; psychological intervention strategies to support learning, motivation, self-efficacy and behavior change; and ways to improve healthcare providers' engagement with patients.

Primary Nonadherence, Associated Clinical Outcomes, and Health Care Resource Use Among Patients with Rheumatoid Arthritis Prescribed Treatment with Injectable Biologic Disease-Modifying Antirheumatic Drugs

BACKGROUND

Adherence to biologic disease-modifying antirheumatic drugs (bDMARDs) among patients with rheumatoid arthritis (RA) is often suboptimal in routine clinical practice. Low or nonadherence can reduce the effectiveness of bDMARD therapies.

OBJECTIVE

To evaluate filling of newly prescribed initial bDMARDs for the treatment of RA and evaluate potential for characterizing treatment decisions and patient outcomes.

METHODS

In this retrospective cohort analysis, patients aged ≥ 18 years with an RA diagnosis (ICD-9-CM code 714.xx) were selected from a de-identified database of clinical information from the Electronic Health Record (EHR; Humedica) database linked to health care claims (Optum) from commercial and Medicare Advantage health plans (2007-2013). The first biologic prescription date in EHR was the index date. Patients were categorized as filling the prescription within 30 days (early fillers), 31-180 days (late fillers), or not at all within 180 days (nonfillers) of index date.

RESULTS

Of 373 patients meeting inclusion criteria, 170 (45.6%), 59 (15.8%), and 144 (38.6%) were categorized as early fillers, late fillers, and nonfillers, respectively. Most prescriptions were written or ordered for tumor necrosis factor inhibitors (88.7%). Compared with late and nonfillers, early fillers were younger and more likely to be female, with higher pain scores (among those reporting pain scores) and RA severity scores pre-index, and filled more prescriptions for any reason pre-index. More nonfillers (66.0%) were Medicare patients than early (17.7%) and late (35.6%) fillers. During days 0-30 post-index, conventional synthetic DMARD use was greatest for early fillers (45.9%) and lowest among nonfillers (24.3%); however, during days 31-180 post-index, the proportion was highest for late fillers (61.0%) and lowest for nonfillers (35.4%). Of early fillers, 12.9% did not fill/receive a bDMARD after 30 days. Only 23 patients had pre/post-index pain scores, and 47 patients had a rationale for stopping or not filling a bDMARD. In patients with pharmacy and medical coverage for 180 days post-index, early fillers had greater RA-related pharmacy and medical resource use and costs than late and nonfillers combined.

CONCLUSIONS

These findings confirm a high rate of primary nonadherence to bDMARDs among patients with RA.

Selective Serotonin Reuptake Inhibitor (SSRI) Antidepressants in Pregnancy and Congenital Anomalies: Analysis of Linked Databases in Wales, Norway and Funen, Denmark

Background

Hypothesised associations between in utero exposure to selective serotonin reuptake inhibitors (SSRIs) and congenital anomalies, particularly congenital heart defects (CHD), remain controversial. We investigated the putative teratogenicity of SSRI prescription in the 91 days either side of first day of last menstrual period (LMP).

Methods and Findings

Three population-based EUROCAT congenital anomaly registries- Norway (2004–2010), Wales (2000–2010) and Funen, Denmark (2000–2010)—were linked to the electronic healthcare databases holding prospectively collected prescription information for all pregnancies in the timeframes available. We included 519,117 deliveries, including foetuses terminated for congenital anomalies, with data covering pregnancy and the preceding quarter, including 462,641 with data covering pregnancy and one year either side. For SSRI exposures 91 days either side of LMP, separately and together, odds ratios with 95% confidence intervals (ORs, 95%CI) for all major anomalies were estimated. We also explored: pausing or discontinuing SSRIs preconception, confounding, high dose regimens, and, in Wales, diagnosis of depression. Results were combined in meta-analyses. SSRI prescription 91 days either side of LMP was associated with increased prevalence of severe congenital heart defects (CHD) (as defined by EUROCAT guide 1.3, 2005) (34/12,962 [0.26%] vs. 865/506,155 [0.17%] OR 1.50, 1.06–2.11), and the composite adverse outcome of 'anomaly or stillbirth' (473/12962, 3.65% vs. 15829/506,155, 3.13%, OR 1.13, 1.03–1.24). The increased prevalence of all major anomalies combined did not reach statistical significance (3.09% [400/12,962] vs. 2.67% [13,536/506,155] OR 1.09, 0.99–1.21). Adjusting for socio-economic status left ORs largely unchanged. The prevalence of anomalies and severe CHD was reduced when SSRI prescriptions were stopped or paused preconception, and increased when >1 prescription was recorded, but differences were not statistically significant. The dose-response relationship between severe CHD and SSRI dose (meta-regression OR 1.49, 1.12–1.97) was consistent with SSRI-exposure related risk. Analyses in Wales suggested no associations between anomalies and diagnosed depression.

Conclusion

The additional absolute risk of teratogenesis associated with SSRIs, if causal, is small. However, the high prevalence of SSRI use augments its public health importance, justifying modifications to preconception care.

Evaluating the Validity and Reliability of the Beliefs About Medicines Questionnaire in Low-Income, Spanish-Speaking Patients With Diabetes in the United States

Purpose The purpose of this study was to examine the reliability and validity of a Spanish version of the Beliefs about Medicines Questionnaire (BMQ) as a measure to evaluate beliefs about medications and to differentiate adherent from nonadherent patients among low-income Latino patients with diabetes in the United States. Methods Seventy-three patients were administered the BMQ and surveyed for evidence of medication nonadherence. Internal consistency of the BMQ was assessed by Cronbach's alpha along with performing a confirmatory factor analysis. Criterion validity was assessed by comparing mean scores on 3 subscales of the BMQ (General Overuse, General Harm, and Specific Necessity-Concerns difference score) between adherent patients and patients reporting nonadherence for 3 different reasons (unintentional nonadherence, cost-related nonadherence, and nonadherence due to reasons other than cost) using independent samples t tests. Results The BMQ is a reliable instrument to examine beliefs about medications in this Spanish-speaking population. Construct validity testing shows nearly identical factor loading as the original construct map. General Overuse scores were significantly more negative for patients reporting each reason for nonadherence compared with their adherent counterparts. Necessity-Concerns difference scores were significantly more negative for patients reporting nonadherence for reasons other than cost compared with those who did not report this reason for nonadherence. Conclusion The Spanish version of the BMQ is appropriate to assess beliefs about medications in Latino patients with type 2 diabetes in the United States and may help identify patients who become nonadherent to medications for reasons other than out-of-pocket costs.

Evaluating the Impact of Sample Medication on Subsequent Patient Adherence

BACKGROUND

Medication nonadherence is problematic throughout health care practice. Patient nonadherence is a result of several factors, such as financial issues, confusion about the medication, or concerns about possible side effects. Efforts to improve adherence have been implemented, but new strategies are needed to ensure that patients fill their medication prescriptions and adhere to their prescribed use.

OBJECTIVE

To investigate whether providing patients with a free 30-day supply of medication at the point of care via a dispensing kiosk-a secure, computerized cabinet placed in the prescriber's office-that provides sample medication and educational materials had a measurable impact on adherence and health care cost.

METHODS

The study sample consisted of patients drawn from the electronic health records of a large health care provider who were prescribed medications to treat diabetes, hypertension, and dyslipidemia. The comparison groups included a treatment group of patients who each received a 30-day generic sample of medication and a control group of patients who did not receive a sample. The study outcome was primary medication non-adherence (PMN), defined as whether a patient filled a prescription within 90, 180, or 365 days of prescribing. Only patients receiving a prescription for the first time were considered; patients on a medication before receipt of the sample were dropped. Postprescription medication adherence (PPMA), measured as proportion of days covered (PDC) and proportion of days covered ≥ 80% (PDC80), was also examined. Propensity score methods and multivariate regression models were used to examine the outcomes and group differences. Costs to the patient before and after the prescription were also analyzed. Key informant interviews were conducted with physicians, and qualitative analyses were performed.

RESULTS

Patients who received a 30-day generic medication sample had a higher probability of filling a first prescription within 90 days (72.2% for treatment patients vs. 37.6% for controls, P < 0.001); 180 days (79.1% vs. 43.3%, respectively, P < 0.001); and 365 days (85.5% vs. 48.6%, P < 0.001). The medication sample had a positive effect on PDC for 90 days, with treatment patients having 72.8% adherent days versus 35.1% adherent days for controls (average treatment effect [ATE] = 37.5%, P < 0.001). At 180 days, PDC adherence was 57.1% for treatment patients versus 35.4% for controls (ATE = 21.5%, P < 0.001), and 43.6% versus 33.9%, respectively (ATE = 9.5%, P < 0.001) for the 365-day period. PDC80 was significantly better among treatment patients at 90 days (53.5% vs. 31.2%, respectively, ATE = 22.4%, P < 0.001) and 180 days (38.4% vs. 29.1%, ATE = 9.2%, P < 0.001), but not at 365 days (23.7% vs. 23.7%, ATE = -0.02, not significant). Costs were reduced by $395 for the treatment group. Interviews with clinicians indicated a positive view of the program.

CONCLUSIONS

Providing a free sample medication improved the probability of patients filling their initial prescriptions and adhering to those medications. This program can affect health care costs, as evidenced by lower costs for the treatment group.

DISCLOSURES

Financial support for this study was provided by MedVantx. UMPC Health Plan reviewed and commented on the manuscript. Hogue is an employee of MedVantx and also reviewed the manuscript. Manolis is employed by UPMC Health Plan. The remaining authors report no other conflicts of interest. Study concept and design were contributed by Pringle. Aldridge took the lead in data collection, along with Kearney. Data interpretation was performed primarily by Radack, along with Kearney and Grasso. The manuscript was written by Kearney, Aldridge, and Radack and revised by Kearney, Manolis, Hogue, and Radack.

Are patient's simply unaware? A cross-sectional study of website promotion of community pharmacy adherence-related services in Tennessee

BACKGROUND

Medication adherence rates can impact patient outcomes, quality of life, and health care costs. Community pharmacists who offer adherence-related services are well positioned to bolster medication adherence rates. One means for patients to learn more about these services is through the pharmacy's website. However, the prevalence of pharmacies' promotion of adherence services through the internet is unknown.

OBJECTIVES

The present study aimed to quantify the online promotion of pharmacies' adherence-related services.

METHODS

This was a cross-sectional, observational study of websites representing licensed community pharmacies. One-hundred and sixty-nine community pharmacy websites, representing 1161 of community pharmacies in Tennessee (U.S. State), were included in the observational analysis.

RESULTS

The most commonly promoted adherence-related service was online refills (81.1%). Auto refill, medication synchronization, and packaging systems were promoted on <20% pharmacy websites. Types of promoted adherence services differed between chain and independent pharmacy websites.

CONCLUSIONS

Despite 67% of pharmacies offering adherence-related services, only a fraction of them promote these services online. Patient awareness represents a hidden and often unaddressed variable in increasing adherence. Future studies should investigate whether increasing website promotion of these services would increase service use, and potentially improve adherence rates.

Antibiotic prescriptions in the community by type of provider in the United States, 2005-2010

OBJECTIVES

Although antibiotic prescriptions are decreasing in the United States, broad-spectrum prescribing is increasing. It is unknown if decreases observed in national antibiotic prescribing differ by provider group. Understanding prescribing trends over time by provider group can be helpful for customizing antimicrobial stewardship efforts. Therefore, the purposes of this study were to describe outpatient antibiotic prescribing by provider group overall and adjusted for population and number of providers. In addition, trends in prescribing by class and seasonal variation are described by provider group over 6 years.

DESIGN

Cross-sectional observation of outpatient antibiotic prescriptions.

SETTING AND PARTICIPANTS

A population-level analysis of U.S. prescribing from 2005 to 2010 with the use of the IMS Health Xponent dataset.

MAIN OUTCOME MEASURES

Number and rates of prescriptions dispensed overall and by provider group.

RESULTS

The majority (81.0%) of antibiotics were prescribed by physicians, followed by dentists (10.4%), nurse practitioners (NPs; 4.5%), and physician assistants (PAs; 4.2%). The percentage of antibiotic prescriptions decreased for physicians, but increased significantly for NPs and PAs. Provider-based and population-based prescribing rates decreased for physicians and dentists and increased for NPs and PAs. Penicillins were prescribed most frequently by all provider groups, decreasing for physicians and dentists. Increased prescribing of broad-spectrum agents was observed for NPs and PAs. With the exception of dentists, antibiotic prescriptions were higher in winter than in summer, with the largest seasonal increase by NPs.

CONCLUSION

Over 6 years, antibiotic prescriptions overall and for broad-spectrum agents decreased for physicians and increased for NPs and PAs. Thus, increasing trends in the US of broad-spectrum antibiotic prescriptions can be attributed to midlevel providers. Interventions should be designed to reverse increasing prescribing trends, especially of broad-spectrum agents prescribed by NPs and PAs. Stewardship efforts should also be targeted towards dentists, since this group prescribes a higher proportion of antibiotics compared with midlevel providers.

Assessing adherence to inhaled corticosteroids in asthma patients using an integrated measure based on primary and secondary adherence

PURPOSE

There are very few studies on primary adherence (i.e., first filling of a prescription) to inhaled corticosteroids (ICS) in asthma patients; two have involved children. Moreover, adherence can be overestimated when considering only secondary adherence (i.e., following the medication recommendations for a defined period) and ignoring primary adherence. We aimed thus to evaluate the real-world primary and secondary adherence to ICS and to develop an integrated primary and secondary adherence (IPSA) measure.

METHODS

From two clinical databases of pediatric and adult asthma patients, we included 198 children and 206 adults with one ICS prescription recorded in their medical chart between 2010 and 2012 and follow-up data for ≥12 months. Adherence was estimated from written prescriptions and prescription claims data. Primary adherence was defined as filling the ICS prescription at a pharmacy within 12 months. Secondary adherence was defined as the proportion of days covered (PDC) in subjects who filled their prescription at least once. The IPSA was based on the PDC with a correction factor for primary adherence.

RESULTS

Primary adherence to ICS at 12 months was 89.4 % in children and 69.4 % in adults. Secondary adherence at 12 months in children was 33.9 %, and the IPSA was 30.3 %. These values were 52.8 and 36.6 %, respectively, in adults.

CONCLUSIONS

Primary adherence to ICS is low in adults and secondary adherence is poor in children and adults. Using the PDC as a unique measure of adherence led to significant overestimation in adults; IPSA leads to more valid estimates of adherence to ICS.

Inflammation is associated with a reduced number of pro-angiogenic Tie-2 monocytes and endothelial progenitor cells in patients with critical limb ischemia

BACKGROUND

Inflammation is the driving force in atherosclerosis. One central strategy in the treatment for PAD is the promotion of angiogenesis. Here, pro-angiogenic Tie-2-expressing monocytes (TEM) and endothelial progenitor cells (EPC) play a crucial role. Critical limb ischemia (CLI) is characterized by a severe, chronic inflammatory response; thus, progression of the disease might be related to the deleterious effects of inflammation on pro-angiogenic cells.

METHODS

Forty-five patients with intermittent claudication (IC) [three groups: Rutherford (R)-1, -2, or -3; each n = 15], 20 patients with CLI [n = 20; Rutherford 4 (15 %), 5 (40 %), and 6 (45 %)], and 20 healthy controls were included in the study. Analysis of TEM and EPC was performed from whole blood by flow cytometry. Treatment for IC patients was conservative, and CLI patients underwent surgical revascularization. Follow-up was performed after mean of 7.1 months.

RESULTS

In comparison with healthy controls, we found increased proportions of TEM and EPC in dependence of the severity of PAD, with the highest level in patients with severe claudication (R3) (p < 0.01). In contrast, for patients with CLI, we found a significantly reduced expression of both TEM and EPC in comparison with healthy controls (p < 0.05) or IC patients (R-1, R-2, and R-3) (all p < 0.001). At follow-up, TEM and EPC in CLI patients increased significantly (both p < 0.001). Serum levels of fibrinogen and CRP were significantly increased in CLI patients (all p < 0.001), but decreased at follow-up (all p < 0.05). TEM and EPC proportions correlated inversely with levels of fibrinogen [(TEM: r = −0.266; p < 0.01) (EPC: r = −0.297; p < 0.001)], CRP (TEM: r = −0.283; p < 0.01) (EPC: r = −0.260; p < 0.01).

CONCLUSIONS

We found a strong association of diverse inflammatory markers with a reduced proportion of pro-angiogenic TEM or EPC in patients with CLI, giving rise to the speculation that a severe chronic inflammation might lead to deleterious effects on TEM and EPC, possibly interfering with angiogenesis, thus promoting an aggravation of the disease.

Examining Factors That Impact Inpatient Management of Diabetes and the Role of Insulin Pen Devices

Insulin administration in the acute care setting is an integral component of inpatient diabetes management. Although some institutions have moved to insulin pen devices, many acute care settings continue to employ the vial and syringe method of insulin administration. The aim of this study was to evaluate the impact of insulin pen implementation in the acute care setting on patients, healthcare workers and health resource utilization. A review of published literature, including guidelines, was conducted to identify how insulin pen devices in the acute care setting may impact inpatient diabetes management. Previously published studies have revealed that insulin pen devices have the potential to improve inpatient management through better glycemic control, increased adherence and improved self-management education. Furthermore, insulin pen devices may result in cost savings and improved safety for healthcare workers. There are benefits to the use of insulin pen devices in acute care and, as such, their implementation should be considered.

Initial Medication Adherence in the Elderly Using PACE Claim Reversals: A Pilot Study

BACKGROUND

The Medicare Modernization Act, with its requirements for Medicare Part D to comply with electronic prescribing (e-prescribing), bolstered the adoption of e-prescribing, which increased to 73% in 2013. Therefore, understanding whether electronic prescriptions are less likely to be picked up is important as e-prescribing continues to be emphasized.

OBJECTIVE

To assess whether prescription origin is among the factors associated with initial medication adherence, using claim reversals as a proxy measure.

METHODS

A cross-sectional study was completed using a sample of reversed claims from the Pharmaceutical Assistance Contract for the Elderly (PACE) program for September 2014. The total number of reversed claims for new prescriptions (15,966) was categorized by prescription origin (written, telephone, electronic, fax, and pharmacy). Using a chi-square analysis, the reversed claims were compared among prescription origin to determine if there is a difference in the proportion of electronic prescriptions reversed compared with those from other origins.

RESULTS

When compared with all other prescription origins, electronic prescriptions (E) were more likely to be reversed at day 0 (E = 50%, any other [AO] = 49%, P < 0.05) and after day 0 (E = 58%, AO = 42%, P < 0.05).

CONCLUSIONS

Electronic prescriptions are associated with a higher rate of claim reversals and may reflect poorer initial adherence. Electronic prescriptions may more likely be forgotten or not picked up because they were not presented to the pharmacy by the patient. The growing adoption of electronic prescriptions merits particular attention, since it may be a factor in initial medication adherence in the elderly.

DISCLOSURES

This study was not supported by any funding. Peterson reports advisory board and consultancy fees from IMS Health and Pfizer and employment by Genentech. Klaiman is currently employed by AccessMatters. No other financial or other conflicts of interests were reported. Study concept and design were primarily contributed by Forestal, along with Klaiman and Peterson. Heller took the lead in data collection, along with Forestal, and data interpretation was performed by Forestal, Klaiman, and Peterson. Forestal, Klaiman, and Heller were responsible for manuscript preparation.

Identifying and Investigating Unexpected Response to Treatment: A Diabetes Case Study

The availability of electronic health records creates fertile ground for developing computational models of various medical conditions. We present a new approach for detecting and analyzing patients with unexpected responses to treatment, building on machine learning and statistical methodology. Given a specific patient, we compute a statistical score for the deviation of the patient's response from responses observed in other patients having similar characteristics and medication regimens. These scores are used to define cohorts of patients showing deviant responses. Statistical tests are then applied to identify clinical features that correlate with these cohorts. We implement this methodology in a tool that is designed to assist researchers in the pharmaceutical field to uncover new features associated with reduced response to a treatment. It can also aid physicians by flagging patients who are not responding to treatment as expected and hence deserve more attention. The tool provides comprehensive visualizations of the analysis results and the supporting data, both at the cohort level and at the level of individual patients. We demonstrate the utility of our methodology and tool in a population of type II diabetic patients, treated with antidiabetic drugs, and monitored by the HbA1C test.

Initial Medication Adherence in the Elderly Using PACE Claim Reversals: A Pilot Study

BACKGROUND

The Medicare Modernization Act, with its requirements for Medicare Part D to comply with electronic prescribing (e-prescribing), bolstered the adoption of e-prescribing, which increased to 73% in 2013. Therefore, understanding whether electronic prescriptions are less likely to be picked up is important as e-prescribing continues to be emphasized.

OBJECTIVE

To assess whether prescription origin is among the factors associated with initial medication adherence, using claim reversals as a proxy measure.

METHODS

A cross-sectional study was completed using a sample of reversed claims from the Pharmaceutical Assistance Contract for the Elderly (PACE) program for September 2014. The total number of reversed claims for new prescriptions (15,966) was categorized by prescription origin (written, telephone, electronic, fax, and pharmacy). Using a chi-square analysis, the reversed claims were compared among prescription origin to determine if there is a difference in the proportion of electronic prescriptions reversed compared with those from other origins.

RESULTS

When compared with all other prescription origins, electronic prescriptions (E) were more likely to be reversed at day 0 (E = 50%, any other [AO] = 49%, P < 0.05) and after day 0 (E = 58%, AO = 42%, P < 0.05).

CONCLUSIONS

Electronic prescriptions are associated with a higher rate of claim reversals and may reflect poorer initial adherence. Electronic prescriptions may more likely be forgotten or not picked up because they were not presented to the pharmacy by the patient. The growing adoption of electronic prescriptions merits particular attention, since it may be a factor in initial medication adherence in the elderly.

DISCLOSURES

This study was not supported by any funding. Peterson reports advisory board and consultancy fees from IMS Health and Pfizer and employment by Genentech. Klaiman is currently employed by AccessMatters. No other financial or other conflicts of interests were reported. Study concept and design were primarily contributed by Forestal, along with Klaiman and Peterson. Heller took the lead in data collection, along with Forestal, and data interpretation was performed by Forestal, Klaiman, and Peterson. Forestal, Klaiman, and Heller were responsible for manuscript preparation.

Pharmacy Medication Synchronization Service Works to Improve Medication Adherence

Medication adherence plays an important role in the effective management of chronic conditions, yet nonadherence related to therapeutic complexity and numerous visits to the pharmacy is well documented in the literature. Medication Synchronization (Med Sync) programs work to overcome this barrier by standardizing medication refills for a less frequent, generally once monthly pickup. Features of Med Sync programs as well the impact on adherence will be discussed.