A meta-analysis of the association between adherence to drug therapy and mortality

Late Evening Snack with Branched-Chain Amino Acids Supplementation Improves Survival in Patients with Cirrhosis

The clinical efficacy of a late evening snack (LES) is well documented in patients with cirrhosis, but its effect on survival remains unclear. This cohort study aimed to compare the overall survival between LES-treated patients and untreated patients. We conducted a retrospective cohort study to determine the effect of LES, which is defined as an oral intake of a branched-chain amino acids (BCAA)-enriched nutrient before bedtime, on survival in 523 patients with cirrhosis seen at a tertiary referral center in Japan from March 2004 to April 2019. The association between LES and all-cause mortality was evaluated using propensity score matching and inverse probability of treatment weighting analyses. The median age of the 523 participants was 66 years; 286 (55%) patients were men and 87 (17%) received LES therapy. Of the 231 propensity-matched patients, 20 (26%) LES-treated patients and 72 (47%) untreated patients died during a median follow-up of 2.0 years (interquartile range, 0.5-4.8). Propensity score matching analysis showed that the overall survival was significantly higher in LES-treated patients than in untreated patients (hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.34-0.93). The survival benefit of LES therapy was most prominent in patients with Child-Pugh C cirrhosis (HR, 0.40; 95% CI, 0.20-0.81). Inverse probability of treatment weighting analysis also revealed that LES significantly improved the prognosis of patients with cirrhosis (HR, 0.57; 95% CI, 0.33-0.99). In this retrospective study of patients with cirrhosis, we found that nocturnal BCAA supplementation was associated with a significant reduction in the risk of death in patients with liver cirrhosis.

Individual factors increasing complexity of drug treatment-a narrative review

Purpose

Complexity of drug treatment is known to be a risk factor for administration errors and nonadherence promoting higher healthcare costs, hospital admissions and increased mortality. Number of drugs and dose frequency are parameters often used to assess complexity related to the medication regimen. However, factors resulting from complex processes of care or arising from patient characteristics are only sporadically analyzed. Hence, the objective of this review is to give a comprehensive overview of relevant, patient-centered factors influencing complexity of drug treatment.

Methods

A purposeful literature search was performed in MEDLINE to identify potential complexity factors relating to the prescribed drug (i.e. dosage forms or other product characteristics), the specific medication regimen (i.e. dosage schemes or additional instructions), specific patient characteristics and process characteristics. Factors were included if they were associated to administration errors, nonadherence and related adverse drug events detected in community dwelling adult patients.

Results

Ninety-one influencing factors were identified: fourteen in “dosage forms”, five in “product characteristics”, twelve in “dosage schemes”, nine in “additional instructions”, thirty-one in “patient characteristics” and twenty in “process characteristics”.

Conclusions

Although the findings are limited by the non-systematic search process and the heterogeneous results, the search shows the influence of many factors on the complexity of drug treatment. However, to evaluate their relevance for individual patients, prospective studies are necessary.

Electronic supplementary material

The online version of this article (10.1007/s00228-019-02818-7) contains supplementary material, which is available to authorized users.

Prescribing Placebos: An Experimental Examination of the Role of Dose, Expectancies, and Adherence in Open-Label Placebo Effects

Background

Recent evidence indicates that placebo effects can occur even when patients know that they are taking a placebo, termed the open-label placebo effect.

Aim

To assess whether placebo dose (one pill per day vs. four pills per day), treatment expectancies, and adherence contribute to open-label placebo effects.

Method

Healthy undergraduate participants were randomly assigned to take one or four open-label placebo pills per day or to a no-treatment control group. Placebo-treated participants took a 5-day course of an open-label placebo described as enhancing physical (symptoms and sleep) and psychological (positive and negative emotional experience) well-being. Expectancies about placebo effectiveness and well-being were assessed at baseline, and well-being and adherence were assessed after the 5-day course of treatment.

Results

Medium-to-large open-label placebo effects were evidenced in all well-being outcomes including sleep quality. Dose did not influence these effects. Both treatment expectancies and adherence were significant independent predictors of enhanced well-being in the two psychological well-being outcomes and the experience of physical symptoms, but sleep quality improved independently.

Conclusions

This is the first study to demonstrate the effect of open-label placebos in improving well-being and sleep quality and to show that open-label placebo reposes do not appear to be dose-dependent, but for most well-being outcomes are independently predicted by both positive expectancies and treatment adherence.

Monitoring and managing medication adherence in community pharmacies in Quebec, Canada

Background

Community pharmacists have direct access to prescription refill information and regularly interact with their patients. Therefore, they are in a unique position to promote optimal medication use.

Objectives

To describe how community pharmacists in Quebec, Canada, identify nonadherent patients, monitor medication use and promote optimal medication adherence.

Methods

An invitation to complete a web-based survey was published online through different platforms, including a Facebook pharmacists' group, an electronic newsletter, a pharmacy network forum and e-mail. The survey included questions on participant characteristics, methods used by pharmacists to identify nonadherent patients and monitor medication use and interventions they used to promote medication adherence.

Results

In total, 342 community pharmacists completed the survey. The participants were mainly women (71.6%), staff pharmacists (56.7%) and aged 30 to 39 years (34.2%). The most common method to identify nonadherent patients was to check gaps between prescription refills (98.8%). The most common intervention to promote adherence was patient counselling (82.5%). The most common barriers to identifying nonadherent patients were lack of time (73.1%) and lack of prescription information (65.8%), whereas the most common barriers to intervening were anticipation of a negative reaction from their patients (91.2%) and lack of time (64%).

Conclusion

Lack of time and lack of prescription information are frequent challenges encountered by community pharmacists regarding effective monitoring and management of patients with poor medication adherence. Pharmacists could benefit from electronic tools based on prescription refills that would provide quick and easily interpretable information on their patients' medication adherence. Can Pharm J (Ott) 2020;153:xx-xx.

Antipsychotic Medication Adherence and Diabetes-Related Hospitalizations Among Medicaid Recipients With Diabetes and Schizophrenia

OBJECTIVE

This cross-sectional study examined the relationship between antipsychotic medication adherence and preventable diabetes-related hospitalizations for individuals with diabetes and schizophrenia.

METHODS

Hospitalizations related to diabetes, an ambulatory care sensitive condition, were assessed among Medicaid recipients in New York State with comorbid diabetes and schizophrenia (N=14,365) for three levels of antipsychotic medication adherence: very low to no engagement (two or fewer prescriptions or none in first 6 months), moderate to low adherence, and adherent (proportion of days covered ≥80%).

RESULTS

Rates of preventable diabetes hospitalization were highest among individuals with very low to no engagement in antipsychotic treatment (4.7%), followed by those with moderate to low adherence (3.3%). Diabetes hospitalizations among adherent individuals were comparable with those of the total diabetes population (both 2.0%). The odds of a preventable diabetes hospitalization were significantly higher among individuals with very low to no engagement in antipsychotic treatment (adjusted odds ratio [AOR]=2.42) and among those with moderate to low adherence (AOR=1.57) than among adherent individuals. Black individuals were also at increased risk of a preventable diabetes hospitalization after the analyses adjusted for antipsychotic adherence and other variables (AOR=1.38).

CONCLUSIONS

This study indicates a relationship between antipsychotic adherence and improved diabetes outcomes among individuals with schizophrenia. Engagement in mental health treatment may be a critical path toward improving health disparities for individuals with schizophrenia. Individuals with very low to no engagement were a particularly vulnerable group, and the exclusion of persons with less than two prescriptions from research and quality measures should be revisited.

Adherence to a Rehabilitation Regimen in Stroke Patients: A Concept Analysis

BACKGROUND

Adherence to rehabilitation regimens is a major issue in the treatment of stroke. Despite the agreement on the importance of adherence, there is still no clear definition of this concept in rehabilitation. The aim of this study was the concept analysis of the concept of adherence to rehabilitation regimens in stroke patients.

MATERIALS AND METHODS

This qualitative concept analysis was performed using Walker and Avant's method. English and Persian articles were searched using keywords such as "adherence", "compliance", "rehabilitation", "stroke", and other related keywords among articles published from 1997 to 2018 in PubMed, Scopus, Web of Science, Google Scholar, Iranmedex, Magiran, and Scientific Information Database (SID). Related textbooks were also searched and all articles containing definitions, attributes, antecedents, and consequences of the concept were included in the study.

RESULTS

The attributes of the concept included complex, multidimensional, and dynamic behavior in the treatment process, personal experience, and adaptive behavior in patients, changeable, situational, voluntary, and collaborative behavior, and active communication between the patient and the healthcare provider. Common antecedents of the concept of adherence to the rehabilitation regimen were classified into patient-related and environmental-related categories and the consequences were classified into the three categories of patient-related, healthcare professional-related, and healthcare system-related.

CONCLUSIONS

This concept analysis can be useful in eliminating any ambiguity of the concept of adherence to rehabilitation regimens. It helps clarify the vague concepts used in nursing rehabilitation instead of adherence. The results of this study can be helpful for researchers for further studies in this context.

Adherence-adjustment in placebo-controlled randomized trials: An application to the candesartan in heart failure randomized trial

BACKGROUND

The per-protocol effect provides important information in randomized trials with incomplete adherence. Yet, because valid estimation typically requires adjustment for prognostic factors that predict adherence, per-protocol effect estimates are often met with skepticism. In placebo-controlled trials, however, the validity of adjustment can be indirectly verified by demonstrating no association between adherence and the outcome among the placebo arm. Here, we describe a two-stage procedure in which we first adjust for time-varying adherence in the placebo arm and then use a similar procedure to estimate the per-protocol effect.

METHODS

We use the Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity (CHARM) randomized trial. First, we compare adherers versus non-adherers in the placebo arm, adjusting for pre- and post-randomization variables. Second, we use models validated in the placebo arm to estimate the per-protocol effect of adherence to candesartan versus placebo in the full trial.

FINDINGS

We successfully estimated no association between adherence and mortality in the placebo arm; hazard ratio: 0.91 (95% CI: 0.51, 2.52). We then estimated the per-protocol effect under two sets of protocol-defined stopping criteria after adjustment for post-randomization confounders. The mortality hazard ratio estimates ranged from 0.91 to 0.93 for the per-protocol effect estimates, similar to the intention-to-treat effect estimates.

INTERPRETATION

Adherence adjustment in the CHARM trial is feasible when appropriate assumptions about missing data and confounding are made. These assumptions cannot be verified but can be supported through the use of placebo-arm adherence assessment.

Medication adherence and survival among hospitalized heart failure patients in a tertiary hospital in Tanzania: a prospective cohort study

Objective

Management of heart failure is complex and multifaceted but adherence to medications remains the cornerstone of preventing avoidable readmissions, premature deaths, and unnecessary healthcare expenses. Despite of evidence-based efficacy on anti-failure drugs, poor adherence is pervasive and remains a significant barrier to improving clinical outcomes in heart failure population.

Results

We enrolled 459 patients with diagnosis of heart failure admitted at a tertiary cardiovascular hospital in Dar es Salaam, Tanzania. The mean age was 46.4 years, there was a female predominance (56.5%), 67.5% resided in urban areas and 74.2% had primary education. Of the 419 participants eligible for assessment of medication adherence, 313 (74.7%) had poor adherence and 106 (25.3%) had good adherence. Possession of a health insurance was found to be the strongest associated factor for adherence (adjusted OR 8.7, 95% CI 4.7–16.0, p < 0.001). Participants with poor adherence displayed a 70% increased risk for rehospitalization compared to their counterparts with good adherence (adjusted RR 1.7, 95% CI 1.2–2.9, p = 0.04). Poor adherence was found to be the strongest predictor of early mortality (HR 2.5, 95% CI 1.3–4.6, p < 0.01). In conclusion, Poor medication adherence in patients with heart failure is associated with increased readmissions and mortality.

Adherence in Hypertension

The global epidemic of hypertension is largely uncontrolled and hypertension remains the leading cause of noncommunicable disease deaths worldwide. Suboptimal adherence, which includes failure to initiate pharmacotherapy, to take medications as often as prescribed, and to persist on therapy long-term, is a well-recognized factor contributing to the poor control of blood pressure in hypertension. Several categories of factors including demographic, socioeconomic, concomitant medical-behavioral conditions, therapy-related, healthcare team and system-related factors, and patient factors are associated with nonadherence. Understanding the categories of factors contributing to nonadherence is useful in managing nonadherence. In patients at high risk for major adverse cardiovascular outcomes, electronic and biochemical monitoring are useful for detecting nonadherence and for improving adherence. Increasing the availability and affordability of these more precise measures of adherence represent a future opportunity to realize more of the proven benefits of evidence-based medications. In the absence of new antihypertensive drugs, it is important that healthcare providers focus their attention on how to do better with the drugs they have. This is the reason why recent guidelines have emphasize the important need to address drug adherence as a major issue in hypertension management.

Basal Insulin Initiation and Maintenance in Adults with Type 2 Diabetes Mellitus in the United States

OBJECTIVE

A survey of US adults with type 2 diabetes mellitus was conducted to better understand patients' insulin initiation experiences and treatment persistence behaviors.

RESEARCH DESIGN AND METHODS

Participants were recruited from consumer panels and grouped by basal insulin treatment pattern: continuers (no gap of ≥7 days within 6 months of initiation); interrupters (gap ≥7 days, resumed treatment); discontinuers (stopped for ≥7 days, not resumed). A quota of approximately 50 respondents per persistence category was set.

RESULTS

A total of 154 respondents (52 continuers, 52 interrupters, 50 discontinuers) completed the survey. Mean age was 51.4 years; 51.9% male. Continuers were more likely to report their views being considered during initiation, and less likely to report a sense of failure. Concerns included insulin dependence (64.3% agree/strongly agree), frequent blood glucose monitoring (55.2%), costs/ability to pay (53.9%), fears of or mistakes during self-injection (52.6%), and weight gain (52.6%). Continuers were motivated by benefits of insulin therapy; experienced or potential side effects were notable factors for interruption/discontinuation. Healthcare provider instruction was indicated as a reason for continuing, stopping, and restarting therapy.

CONCLUSION

Benefits of basal insulin therapy motivated continuers while side effects impacted interruption/discontinuation. Persistence on basal insulin is often influenced by provider actions. Earlier provider intervention upon signs of treatment discontinuation may promote persistence.

A Brief Metric Framework for Patient Adherence to Doctor's Advice Based on Behavioral Economics

PURPOSE

This study tried to establish a metric framework of patient adherence to doctor's advice based on the expected utility and prospect theories, and it explained why the key to patient adherence to doctor's advice is patients' perceptions.

METHODS

Our framework is primarily based on two mature theories: expected utility theory and prospect theory. We started with a basic assumption: the doctor is rational and cares for patient's health utility. We analyzed the expected utility of therapy with a definite diagnosis. Then, we considered the impacts of the accuracy of diagnostic techniques. After that, we explored the patient's response to the doctors' advices based on behavioral economics. In addition, we launched a discrete choice experiment to test our main point: perception is the key to patients' adherence. A total of 200 undergraduate students participated in the discrete choice experiment.

RESULTS

Three main factors might impact a rational clinical decision: the therapeutic and side effects of the treatment, patient's true disease risk, and diagnostic accuracy. However, another factor, patient's individual percepion, was crucial for patient's adherence since it may bias the patient's estimations regarding the above three factors. As a result, doctors and patients would have a cognitive gap in the estimation of the disease and the treatment.

CONCLUSION

The results indicate that without the necessary information, better clinical techniques may not help to improve patient adherence, which support our theoretical reasoning forcefully. Therefore, improving patient adherence should be more of a process of empathy and communication rather than a promotion of medical technology.

The Association Among Medication Beliefs, Perception of Illness and Medication Adherence in Ischemic Stroke Patients: A Cross-Sectional Study in China

PURPOSE

To examine the association and the mediating effect among medication beliefs, perception of illness, and medication adherence in ischemic stroke patients.

PATIENTS AND METHODS

This is a cross-sectional study, 306 ischemic stroke patients recruited from The Second Affiliated Hospital of Harbin Medical University, China between June 2018 and October 2018. The Beliefs about Medications Questionnaire (BMQ) was used to assess a patient's beliefs about medication. The Brief Illness Perceptions Questionnaire (BIPQ) was used to rapidly determine the cognitive and emotional representation of ischemic stroke. Self-reported adherence was assessed using the Medication Adherence Report Scale (MARS). Logistic regression analysis, Pearson correlations, and mediation analysis were used to evaluate the association and mediating effects among medication beliefs, perception of illness, and medication adherence.

RESULTS

Overall, 220 (65.48%) participants were non-adherent to their ischemic stroke medications. Non-adherent patients had greater stroke severity (p = 0.031) compared to adherent patients. After adjusting for demographic characteristics, specific concern (odds ratio [OR]: 0.652, 95% confidence interval [CI]: 0.431 to 0.987, p-value [P] = 0.043), and the perception of illness (overall score) (OR: 0.964, 95% CI: 0.944 to 0.985, P = 0.001) were significantly associated with medication adherence in ischemic stroke patients. The mediation analysis showed the significant indirect effects of specific concern, general overuse, and general harm. It suggested that some impacts of medication beliefs have been mediated on medication adherence.

CONCLUSION

Perceived concern about adverse effects of medicines and perception of illness have an influential impact on self-reported medication adherence in ischemic stroke patients. To enhance adherence, patients' beliefs about medication and perceptions of their disease should be reconsidered. Future work should investigate interventions to influence patient adherence by addressing concerns about their ischemic stroke medications and the perception of the disease.

Development of the NIH Patient-Reported Outcomes Measurement Information System (PROMIS) Medication Adherence Scale (PMAS)

Poor medication adherence is associated with reduced drug effectiveness, poor health-related quality of life, increased morbidity and mortality, and increased healthcare utilization and cost. Including the patient's voice is essential in understanding barriers to adherence. Useful patient-reported adherence measures are brief, inexpensive, non-invasive; can indicate barriers to adherence; and can be incorporated in electronic health records. The NIH Patient-Reported Outcomes Measurement Information System (PROMIS^®) includes high-quality, freely available patient-reported measures covering many important constructs in patient-centered research but does not include a medication adherence measure. To fill this gap, we developed the PROMIS Medication Adherence Scale (PMAS) using the rigorous PROMIS instrument development guidelines. To develop the PMAS, we first conducted a review of the reviews, which enabled us to identify content areas relevant to medication adherence behavior. Then, we conducted qualitative research to elicit patients' views of and experiences with medication adherence. This process identified the following important content areas to guide item writing: extent medication is taken, knowledge of medication regimen, beliefs about medication, remembering to take medication, skipping due to side effects, skipping due to feeling better, and cost of medications. Based on the results of these activities, we wrote items and aimed to retain 1-2 items per content area. The final item set included 9 total adherence items, which were then refined through intensive comprehension and translatability review, as well as cognitive interviews. Future steps include testing the PMAS's validity.

An expert opinion paper on statin adherence and implementation of new lipid-lowering medications by the ESC Working Group on Cardiovascular Pharmacotherapy: Barriers to be overcome

Benefits and safety on statins have been well-established over 20 years of research. Despite this, the vast majority of patients are not adequately treated and do not achieve the low-density lipoprotein cholesterol target levels. This is mainly due to poor adherence, which is associated with dangerous and sometimes fatal outcomes. To increase adherence and prevent worse outcomes, a combination therapy with lower dosage of statins and new lipid-lowering drugs may be used. However, the implementation of new lipid-lowering drugs in European countries is still at the beginning. For these reasons, the aim of this position paper is to give an up-to-date indication from the ESC Working Group on Cardiovascular Pharmacotherapy in order to discuss the barriers towards statins adherence and new lipid-lowering drugs implementation in Europe.

Cross-sectional evaluation of perceived health care provider engagement, self-efficacy, and ART adherence in people living with HIV/AIDS

Despite advancements in the treatment and prevention of HIV/AIDS, adherence to antiretroviral therapy (ART) remains suboptimal. Research indicates that health care provider (HCP) engagement is related to adherence, yet little is known about the specific pathways that underlie this relation. This cross-sectional study examined the relation between perceived HCP engagement and ART adherence in people living with HIV/AIDS (PLWHA), as well as the role of adherence self-efficacy in this relation. Participants (N = 207) completed self-report measures assessing monthly ART adherence, perceived ability to take ART as prescribed, and perceptions of HCP engagement. Results of a path analysis revealed a direct positive relation between perceived HCP engagement and ART adherence, and a significant indirect relation of perceived HCP engagement to ART adherence through adherence self-efficacy. Higher perceived HCP engagement was related to greater adherence self-efficacy, which, in turn was related to higher ART adherence. Findings are consistent with research demonstrating that HCP support leads to increased motivation to engage in treatment and extends past work on the importance of positive patient-provider relationships. Notably, results suggest that increasing patient perceptions of HCP engagement may be one way to boost adherence self-efficacy and improve ART adherence in PLWHA.

An Active Inference Approach to Dissecting Reasons for Nonadherence to Antidepressants

BACKGROUND

Antidepressant medication adherence is among the most important problems in health care worldwide. Interventions designed to increase adherence have largely failed, pointing toward a critical need to better understand the underlying decision-making processes that contribute to adherence. A computational decision-making model that integrates empirical data with a fundamental action selection principle could be pragmatically useful in 1) making individual-level predictions about adherence and 2) providing an explanatory framework that improves our understanding of nonadherence.

METHODS

Here we formulated a partially observable Markov decision process model based on the active inference framework that can simulate several processes that plausibly influence adherence decisions.

RESULTS

Using model simulations of the day-to-day decisions to take a prescribed selective serotonin reuptake inhibitor, we show that several distinct parameters in the model can influence adherence decisions in predictable ways. These parameters include differences in policy depth (i.e., how far into the future one considers when deciding), decision uncertainty, beliefs about the predictability (stochasticity) of symptoms, beliefs about the magnitude and time course of symptom reductions and side effects, and strength of medication-taking habits that one has acquired.

CONCLUSIONS

Clarifying these influential factors will be an important first step toward empirically determining which factors are contributing to nonadherence to antidepressants in individual patients. The model can also be seamlessly extended to simulate adherence to other medications (by incorporating the known symptom reduction and side effect trajectories of those medications), with the potential promise of identifying which treatments may be best suited for different patients.

Patient-Reported Satisfaction and Study Drug Discontinuation: Post-Hoc Analysis of Findings from ROCKET AF

INTRODUCTION

Patient-reported outcomes (PROs) and satisfaction endpoints are increasingly important in clinical trials and may be associated with treatment adherence. In this post hoc substudy from ROCKET AF, we examined whether patient-reported satisfaction was associated with study drug discontinuation.

METHODS

ROCKET AF (n = 14,264) compared rivaroxaban with warfarin for prevention of stroke and systemic embolism in patients with atrial fibrillation. We analyzed treatment satisfaction scores: the Anti-Clot Treatment Scale (ACTS) and Treatment Satisfaction Questionnaire for Medication version II (TSQM II). We compared satisfaction with study drug between the two treatment arms, and examined the association between satisfaction and patient-driven study drug discontinuation (stopping study drug due to withdrawal of consent, noncompliance, or loss to follow-up).

RESULTS

A total of 1577 (11%) patients participated in the Patient Satisfaction substudy; 1181 (8.3%) completed both the ACTS and TSQM II 4 weeks after starting study drug. Patients receiving rivaroxaban did not experience significant differences in satisfaction compared with those receiving warfarin. During a median follow-up of 1.6 years, 448 premature study drug discontinuations occurred (213 rivaroxaban group; 235 warfarin group), of which 116 (26%) were patient-driven (52 [24%] rivaroxaban group; 64 [27%] warfarin group). No significant differences were observed between satisfaction level and rates of patient-driven study drug discontinuation.

CONCLUSIONS

Study drug satisfaction did not predict rate of study drug discontinuation. No significant difference was observed between satisfaction with warfarin and rivaroxaban, as expected given the double-blind trial design. Although these results are negative, the importance of PRO data will only increase, and these analyses may inform future studies that explore the relationship between drug-satisfaction PROs, adherence, and clinical outcomes. CLINICALTRIALS.GOV: NCT00403767.

FUNDING

The ROCKET AF trial was funded by Johnson & Johnson and Bayer.

Community-Based Services by Pharmacists: A Systematic Review of Cost-Utility Analyses

OBJECTIVES

To conduct a systematic review of cost-utility studies of community-based services provided by pharmacists and to examine their reporting and methodological quality.

METHODS

A comprehensive literature search was performed in February 2019 using a replicable search strategy in bibliographic databases MEDLINE, EMBASE, and the NHS Economic Evaluations Database from their inception onwards. Two reviewers independently screened the literature, abstracted data from full-text articles, and assessed reporting and methodological quality using the Consolidated Health Economic Evaluation Reporting Standards and Quality of Health Economic Studies checklists.

RESULTS

Twenty studies were included in this review, representing the healthcare systems of the United Kingdom, Spain, France, The Netherlands, Belgium, Italy, Canada, the United States of America, and Brazil. Descriptions of the context in which the studies were done, justification of data sources on patient and process outcomes, choices of model, and generalizability of study findings were often inadequately reported. Seven studies (35%) were deemed of high methodological quality, 11 studies (55%) of fair quality, and 2 studies (10%) of poor quality. In addition, various methodological issues related to the randomized controlled trials and observational studies used to generate effectiveness estimates were identified.

CONCLUSIONS

In view of the lack of standardized definitions of expanded services, heterogeneity in study objectives, settings, comparators, methodology, outcomes, and the variable quality of these studies, the value of these services (in terms of costs) compared with quality-adjusted survival remains inconclusive.

Differential Patterns of Adherence to Opioid Therapy in Opioid Naïve and Opioid Existing Patients With Different Age Groups

Limited data are available on the adherence to opioid therapy and the influence of different patient groups on adherence. This study examined the patterns of adherence in opioid naïve and opioid existing patients with varying age and gender. This retrospective cohort study was conducted using the prescription databases in tertiary hospital settings in Malaysia from 2010 to 2016. Adult patients aged ≥18 years, receiving at least two opioid prescriptions, were included and stratified into the opioid naïve and existing patient groups. Adherence to opioid therapy was measured using the proportion of days covered (PDC), which was derived by dividing the total number of days covered with any opioids by the number of days in the follow-up period. Generalized linear modeling was used to assess factors associated with PDC. A total of 10,569 patients with 36,650 prescription episodes were included in the study. Of these, 91.7% (n = 9,696) were opioid naïve patients and 8.3% (n = 873) were opioid existing patients. The median PDC was 35.5% (interquartile range (IQR) 10.3–78.7%) and 26.8% (IQR 8.8–69.5%) for opioid naïve and opioid existing patients, respectively. A higher opioid daily dose (coefficient 0.010, confidence interval (CI) 0.009, 0.012 p < 0.0001) and increasing age (coefficient 0.002, CI 0.001, 0.003 p < 0.0001) were associated with higher levels of PDC, while lower PDC values were associated with male subjects (coefficient −0.0041, CI −0.072, −0.010 p = 0.009) and existing opioid patients (coefficient −0.134, CI −0.191, −0.077 p < 0.0001). The suboptimal adherence to opioid medications was commonly observed among patients with non-cancer pain, and the opioid existing patients were less adherent compared to opioid naïve patients. Increasing age and a higher daily opioid dose were factors associated with higher levels of adherence, while male and opioid existing patients were potential determinants for lower levels of adherence to opioid medications.

Influenza Vaccination of Pregnant Women and Serious Adverse Events in the Offspring

Pregnant women are increasingly considered a priority group for influenza vaccination, but the evidence in favor relies mainly on observational studies, subject to the "healthy-vaccinee bias". Propensity score methods-sometimes applied-reduce but cannot eliminate residual confounding. Meta-analyses of observational studies show relative risks far from the thresholds that would confirm the efficacy of universal vaccination for pregnant women without needing randomized controlled trials (RCTs). Critical articles have shown that in the four RCTs investigating the outcomes of this vaccination, there was a tendency towards higher offspring mortality. In the largest RCT, there was a significant excess of presumed/serious neonatal infections, and also significantly more serious adverse events. Many widely acknowledged observational results (about hormone replacing therapy, vitamin D, omega-3 fatty acids, etc.) were confuted by RCTs. Therefore the international drive to consider this vaccination a "standard of care" is not justified yet. Moreover, there is the risk of precluding further independent RCTs for "ethical considerations", so as "to not deny the benefits of influenza vaccinations to pregnant women of a control group". Instead, before promoting national campaigns for universal vaccination in pregnancy, further large, independent, and reassuring RCTs are needed, even braving challenging a current paradigm. Until then, influenza vaccination should be offered to pregnant women only once open information is available about the safety uncertainties, to allow truly informed choices, and promoting also other protective behaviors.

The Vietnamese Version of the Brief Illness Perception Questionnaire and the Beliefs about Medicines Questionnaire: Translation and Cross-cultural Adaptation

OBJECTIVE

To translate and cross-culturally adapt the Brief Illness Perception Questionnaire (BIPQ) and the Beliefs about Medicines Questionnaire (BMQ) into Vietnamese.

METHODS

We followed the guideline by Beaton et al. (2000 & 2007). Stage I: two translators (informed and uninformed) translated the questionnaires. Stage II: the translations were synthesised. Stage III: back translation was performed by two translators fluent in both Vietnamese and English but naïve to the outcome measurement. Stage IV: seven experts reached consensus on the pre-final Vietnamese version (BIPQ-V and BMQ-V). Stage V: field test of the questionnaires on 16 twelve-year-old students and 31 Vietnamese patients. In addition, we determined the internal consistency and test-retest reliability of the questionnaires in 34 Vietnamese patients with acute coronary syndrome.

RESULTS

All experts agreed that there was semantic, idiomatic, experiential and conceptual equivalence between the original and pre-final Vietnamese versions of the BIPQ and BMQ. Cronbach's alpha coefficients of the internal consistency were acceptable for the BMQ-V Specific-Necessity (0.64), BMQ-V Specific-Concerns (0.62) and BMQ-V General-Harm (0.60), with the exception of BMQ-V General-Overuse (0.27). Intra-class correlation coefficients of the test-retest reliability were acceptable for the subscales of BMQ-V (range: 0.77-0.86), and BIPQ-V items (range: 0.62-0.85) with the exception of BIPQ-V 1 (0.44, 95% CI -014 to 0.72) and BIPQ-V 4 (0.57, 95% CI 0.22-0.81).

CONCLUSIONS

The Vietnamese version of BIPQ and BMQ are reliable tools to assess illness perceptions and beliefs about medicines of patients with acute coronary syndrome. Psychometric properties of these questionnaires should be tested in different patient populations.

The association between medication non-adherence and adverse health outcomes in ageing populations: A systematic review and meta-analysis

AIMS

The aim of this systematic review and meta-analysis was to synthesise the evidence relating to medication non-adherence and its association with health outcomes in people aged ≥50 years.

METHODS

Seven databases were searched up to February 2019 for observational studies that measured medication (non-)adherence as a predictor of the following health outcomes in adults aged ≥50 years: healthcare utilisation (hospitalisation, emergency department visits, outpatient visits and general practitioner visits), mortality, adverse clinical events and quality of life. Screening and quality assessment using validated criteria were completed by 2 reviewers independently. Random effects models were used to generate pooled estimates of association using adjusted study results. The full methodological approach was published on PROSPERO (ID: CRD42017077264).

RESULTS

Sixty-six studies were identified for qualitative synthesis, with 11 of these studies eligible for meta-analyses. A meta-analysis including 3 studies measuring medication non-adherence in adults aged ≥55 years showed a significant association with all-cause hospitalisation (adjusted odds ratio 1.17, 95% confidence interval [CI] 1.12, 1.21). A meta-analysis including 2 studies showed that medication non-adherence was not significantly associated with an emergency department visit (adjusted odds ratio 1.05, 95% CI 0.90, 1.22). Good adherence was associated with a 21% reduction in long-term mortality risk in comparison to medication non-adherence (adjusted hazard ratio 0.79, 95% CI 0.63, 0.98).

CONCLUSION

Medication non-adherence may be significantly associated with all-cause hospitalisation and mortality in older people. Medication adherence should be monitored and addressed in this cohort to minimise hospitalisation, improve clinical outcomes and reduce healthcare costs.

Adherence to anti-osteoporosis medication associated with lower mortality following hip fracture in older adults: a nationwide propensity score-matched cohort study

Background

We investigated the association of anti-osteoporosis medication with mortality risk in older adults with hip fractures and evaluated the influence of medication adherence on mortality.

Methods

We conducted a population-based cohort study and identified a total of 13,123 patients aged 65 years or older with hip fracture from the Taiwan National Health Insurance Database during the period 2001–2010. Individuals with (n = 2092) and without (n = 2092) receiving anti-osteoporosis medication were matched using propensity score matching (1:1 ratio). The 1-, 3- and 5-year survival rates after the index fracture were compared between patients with and without treatment. In the treated group, survival rate was compared between those with good and non-adherence. Good adherence was defined as the medication possession ratio of ≥80% and non-adherence as a ratio < 80%.

Results

The 1-, 3- and 5-year mortality rates were significantly lower in the treated vs. the non-treated group (all p < 0.0001). In the treated group, the estimated 1-, 3- and 5-year survival rates were higher in those with good adherence than in those with non-adherence (all p < 0.0001). Regarding all-cause mortality, the adjusted hazard ratio in the treated vs. the non-treated group was 0.63 (95% confidence interval 0.58–0.68, p < 0.0001). The good adherence subgroup showed a significantly lower mortality risk than that in the non-adherence subgroup (hazard ratio 0.41, 95% confidence interval 0.32–0.51, p < 0.0001).

Conclusions

The 1-, 3- and 5-year survival rates were significantly higher in patients receiving anti-osteoporosis medication than in the untreated group. All-cause mortality rates were lower in patients with good adherence to anti-osteoporosis medication.

Validity Of The Self-Reported Domains Of Subjective Extent Of Nonadherence (DOSE-Nonadherence) Scale In Comparison With Electronically Monitored Adherence To Cardiovascular Medications

BACKGROUND

Self-report measures are important tools for assessing adherence to medication. Many of these scales, however, combine the extent of and reasons for nonadherence in one instrument, and have limited reliability and validity. The present study was the first to assess the convergent validity of the self-reported Domains of Subjective Extent of Nonadherence (DOSE-Nonadherence) scale with electronically measured adherence to a single cardiovascular medication.

METHODS

English- and Spanish-speaking patients evaluated for acute coronary syndrome (N=165; n=68 and n= 97, respectively) were recruited from an urban academic emergency department. Post-hospital discharge, participants were mailed a medication bottle with an electronic cap (eCAP) that recorded bottle openings. At 1 month, participants completed the 3-item DOSE-Nonadherence scale, which assessed the extent to which patients missed, skipped, or did not take the eCAP-monitored medication over the past 7 days. Correlations, sensitivity, and specificity were calculated using eCAP-monitored correct dosing adherence over the same 7-day time period as the reference standard.

RESULTS

The most commonly assessed medication was aspirin (70.91%). Correlations between self-reported and electronically monitored adherence were low-to-moderate: English-speaking participants (n=68), r=0.24, p=0.046; Spanish-speaking participants (n=97), r=0.18, p=0.071. Sensitivity was low (0.47 English, 0.28 Spanish) and specificity was moderate (0.77 English, 0.88 Spanish).

CONCLUSIONS

The DOSE-Nonadherence scale was associated with electronically monitored adherence to a single daily cardiovascular medication in English-speaking participants, but had weak diagnostic properties when using electronic adherence as the reference standard.

High burden of drug therapy in adult congenital heart disease: polypharmacy as marker of morbidity and mortality

AIMS

To assess medication use in adult congenital heart disease (ACHD) patients compared to the age- and sex-matched general population, identify patterns of pharmacotherapy, and analyse associations between pharmacotherapy and adverse outcomes in ACHD.

METHODS AND RESULTS

Data of 14 138 ACHD patients from the CONCOR registry [35 (24-48) years, 49% male] and age- and sex-matched referents (1:10 ratio) were extracted from the Dutch Dispensed Drug Register for the years 2006-14. Adult congenital heart disease patients had more cardiovascular and non-cardiovascular drugs than referents (median 3 vs. 1, P < 0.001). Polypharmacy, defined as ≥5 dispensed drug types yearly, was present in 30% of ACHD and 15% of referents {odds ratio [OR] = 2.47 [95% confidence interval (CI) 2.39-2.54]}. Polypharmacy was independently associated with female sex [OR = 1.92 (95% CI 1.88-1.96)], older age [for men: OR = 2.3/10 years (95% CI 2.2-2.4) and for women: OR = 1.6/10 years (95% CI 1.5-1.6); Pinteraction < 0.001], and ACHD severity [mild: OR = 2.51 (95% CI 2.40-2.61), moderate: OR = 3.22 (95% CI 3.06-3.40), severe: OR = 4.87 (95% CI 4.41-5.38)]. Cluster analysis identified three subgroups with distinct medication patterns; a low medication use group (8-year cumulative survival: 98%), and a cardiovascular and comorbidity group with lower survival (92% and 95%, respectively). Cox regression revealed a strong association between polypharmacy and mortality [hazard ratio (HR) = 3.94 (95% CI 3.22-4.81)], corrected for age, sex, and defect severity. Polypharmacy also increased the risk of hospitalization for adverse drug events [HR = 4.58 (95% CI 2.04-10.29)].

CONCLUSION

Both cardiovascular and non-cardiovascular medication use is high in ACHD with twice as much polypharmacy compared with the matched general population. Patients with polypharmacy had a four-fold increased risk of mortality and adverse drug events. Recognition of distinct medication patterns can help identify patients at highest risk. Drug regimens need repeating evaluation to assess the appropriateness of all prescriptions. More high-quality studies are needed to improve ACHD care with more evidence-based pharmacotherapy.

[Factors associated with medication non-adherence in patients with type 2 diabetes mellitus: The first Algerian survey]

BACKGROUND

Non-adherence in patients with type 2 diabetes is a frequent phenomenon with important impact in terms of management of this disease. The aim of this study was to assess the level of medication adherence and to identify the factors associated with non-adherence in type 2 diabetic patients.

METHODS

A cross-sectional study was conducted in type 2 diabetic patients at the endocrinology and diabetology department of University Medical Center of Sidi Bel Abbes (Algeria) in 2017. Medication adherence was determined using a morisky 8-Item medication adherence questionnaire. A logistic regression was used to identify factors associated with non-adherence.

RESULTS

The study enrolled 403 type 2 diabetic patients. The mean age was 60 years and sex-ratio was 0.8. Medication non-adherence rate was 31.3% (95% CI: 26.8-35.8%). The factors significantly associated with non-adherence in multivariate analysis were: health insurance status, self-monitoring of blood glucose, disease duration, education level and need for information on diabetes.

CONCLUSION

Our study had demonstrated a low adherence in patients with type 2 diabetes. The results suggest that implementation of a therapeutic education program could be important in management of diabetes.

Symptom Subtypes of Obstructive Sleep Apnea Predict Incidence of Cardiovascular Outcomes

Rationale: Symptom subtypes have been described in clinical and population samples of patients with obstructive sleep apnea (OSA). It is unclear whether these subtypes have different cardiovascular consequences.Objectives: To characterize OSA symptom subtypes and assess their association with prevalent and incident cardiovascular disease in the Sleep Heart Health Study.Methods: Data from 1,207 patients with OSA (apnea-hypopnea index ≥ 15 events/h) were used to evaluate the existence of symptom subtypes using latent class analysis. Associations between subtypes and prevalence of overall cardiovascular disease and its components (coronary heart disease, heart failure, and stroke) were assessed using logistic regression. Kaplan-Meier survival analysis and Cox proportional hazards models were used to evaluate whether subtypes were associated with incident events, including cardiovascular mortality.Measurements and Main Results: Four symptom subtypes were identified (disturbed sleep [12.2%], minimally symptomatic [32.6%], excessively sleepy [16.7%], and moderately sleepy [38.5%]), similar to prior studies. In adjusted models, although no significant associations with prevalent cardiovascular disease were found, the excessively sleepy subtype was associated with more than threefold increased risk of prevalent heart failure compared with each of the other subtypes. Symptom subtype was also associated with incident cardiovascular disease (P < 0.001), coronary heart disease (P = 0.015), and heart failure (P = 0.018), with the excessively sleepy again demonstrating increased risk (hazard ratios, 1.7-2.4) compared with other subtypes. When compared with individuals without OSA (apnea-hypopnea index < 5), significantly increased risk for prevalent and incident cardiovascular events was observed mostly for patients in the excessively sleepy subtype.Conclusions: OSA symptom subtypes are reproducible and associated with cardiovascular risk, providing important evidence of their clinical relevance.

Myocardial infarction patients referred to the primary care physician after 1‑year treatment according to a guideline-based protocol have a good prognosis

Introduction

Identifying ST-elevation myocardial infarction (STEMI) patients who can be referred back to the general practitioner (GP) can improve patient-tailored care. However, the long-term prognosis of patients who are returned to the care of their GP is unknown. Therefore, the aim of this study was to assess the long-term prognosis of patients referred back to the GP after treatment in accordance with a 1-year institutional guideline-based protocol.

Methods

All consecutive patients treated between February 2004 up to May 2013 who completed the 1‑year institutional MISSION! Myocardial Infarction (MI) follow-up and who were referred to the GP were evaluated. After 1 year of protocolised monitoring, asymptomatic patients with a left ventricular ejection fraction >45% on echocardiography were referred to the GP. Long-term prognosis was assessed with Kaplan-Meier curves and Cox proportional hazards analysis was used to identify independent predictors for 5‑year all-cause mortality and major adverse cardiovascular events (MACE).

Results

In total, 922 STEMI patients were included in this study. Mean age was 61.6 ± 11.7 years and 74.4% were male. Median follow-up duration after the 1‑year MISSION! MI follow-up was 4.55 years (interquartile range [IQR] 2.28–5.00). The event-free survival was 93.2%. After multivariable analysis, age, not using an angiotensin-converting enzyme (ACE) inhibitor/angiotensin-II (AT2) antagonist and impaired left ventricular function remained statistically significant predictors for 5‑year all-cause mortality. Kaplan-Meier curves revealed that 80.3% remained event-free for MACE after 5 years. Multivariable predictors for MACE were current smoking and a mitral regurgitation grade ≥2.

Conclusion

STEMI patients who are referred back to their GP have an excellent prognosis after being treated according to the 1‑year institutional MISSION! MI protocol.

Adherence in inflammatory bowel disease (IBD): a clinical review

Adherence to treatment can be challenging, especially in chronic diseases. In inflammatory bowel disease (IBD), maintenance therapy is common to prevent a disease relapse, and adherence becomes even more of a challenge during remission. Furthermore, practical problems with taking topical treatment can increase the likelihood of non-adherence. In IBD, the definition adherence can be expanded beyond taking medication to factors like leaving blood or stool samples, keeping appointments or adjusting behaviour regarding smoking or diet. This review provides a taxonomy of different types of non-adherence and indicates how these types call for different interventions. Furthermore, the article describes how IBD nurses can open up conversations with patients that will hopefully lead to improvements in their adherence.

The placebo and its effects: A psychoneuroendocrinological perspective

Placebos are usually employed deceptively in clinical trials in order to control for non-specific effects. However, since placebos themselves have been found to cause clinically relevant changes and in some cases are indistinguishable from the verum they are tested against, this theoretically inert, but practically effective intervention has become a scientific discipline in its own right. In this review, it is argued that placebos are generic and genuine biopsychosocial interventions and as such are highly interesting candidates for a psychoneuroendocrinological perspective. Yet, despite a considerable conceptual proximity between explanatory models of placebos and their effects with psychoneuroendocrine models and findings, placebos have thus far not been subject to systematic psychoneuroendocrine examination. Consequently, it would be highly interesting and informative to make placebos the target of psychoneuroendocrine scrutiny.

Developing Preliminary Steps in a Pharmacist Communication - Patient Outcome Pathway

BACKGROUND

Nonadherence to medication therapy has been associated with poor health outcomes and increased health care costs. The literature describes pharmacists as key health care professionals in identifying and addressing nonadherence issues but does not explain how and why effective pharmacist-patient communication affects patients' medication adherence. Previously published pathways used in linking effective physician-patient communication to patient outcomes are proposed for the context of pharmacist-patient communication.

OBJECTIVES

To develop preliminary steps in a pharmacist communication - patient outcome pathway, adapted from a physician-patient communication pathway.

METHODS

This longitudinal descriptive study, which took place in a large quaternary hospital, involved hospital pharmacists and patients. Patients' assessment of pharmacist communication behaviours and reporting of patient satisfaction occurred after the pharmacist-patient consultation. Medication-taking behaviour questionnaires were administered before the consultation and again 4 weeks after discharge. Developing the preliminary pathway (based on previously established physician communication pathways) involved 2 steps, with investigation of the following associations: (1) between patient-reported effective communication by pharmacists, as per the Communication Accommodation Theory (CAT), and patient satisfaction; and (2) between patient-reported pharmacist communication and satisfaction and patients' medication-taking behaviour.

RESULTS

Twelve pharmacists and 48 patients participated. For step 1, almost all patient-reported pharmacist communication behaviours were positively correlated with patient satisfaction statements. Strong associations between CAT-related pharmacist communication behaviours and patient satisfaction highlighted the pharmacists' behaviours that are important to patients and necessary for effective conversations to take place. In step 2, there were fewer correlations of medication-taking behaviour indices with pharmacist communication behaviours and patient satisfaction.

CONCLUSIONS

This study showed how a preliminary pharmacist communication - patient outcome pathway could be successfully adapted from existing physician communication pathways. Such pathways provide an initial platform upon which future pharmacist communication - patient outcome research can be built.

Epileptic patients' willingness to receive cell-phone based medication reminder in Northwest Ethiopia

Background

Poor adherence compromises medication treatment effectiveness which results in suboptimal illness control. This can lead to increased use of healthcare services, reduction in patients’ quality of life and increased healthcare costs. Reminding patients of their medication intake increases their adherence. Therefore, this study aimed to assess the willingness of epileptic patients to receive cell-phone based medication reminders and its associated factors in Northwest Ethiopia.

Methods

Institution based cross sectional study was conducted in the study period scheduled from March 1 to April 30, 2018 to interview 422 study participants at University of Gondar Comprehensive and Specialized Hospital, Northwest Ethiopia. Systematic random sampling was used to select 422 epileptic patients. A structured interviewer administered questionnaire was used to collect data and analyzed by using SPSS version 21. Binary and multivariate logistic regression analysis was performed to identify the determinant factors for willingness to receive cell-phone based medication reminders. P < 0.05 at 95% confidence interval was considered statistically significant.

Results

A total of 394 (93% response rate) respondents were interviewed. The majority of respondents 262 (66.5%) owned a cellphone. Among the participants 271 (68.8%) were willing to receive reminder messages. In the multivariate regression analysis; living in urban areas (AOR = 5.63, 95% CI; 3.18–9.96), experience of forgetting things (AOR = 2.63, 95% CI; 1.44–4.80), forgetting to take Long-term Antiepileptic Drugs (AEDs) (AOR = 2.17, 95% CI; 1.06–4.43) and average monthly income ≥2000 birr (AOR = 2.43, 95% CI; 1.03–5.75) were significantly associated with willingness to receive cell-phone medication reminders. Pertaining to marital status; being married (AOR = 5.75, 95% CI; 1.11–29.70) or divorced (AOR = 5.15, 95% CI; 1.29–20.49) participants were also more willing to receive cell-phone medication reminders as compared to singles.

Conclusion

Most respondents have a cellphone and were willing to use it as a medication reminder. Marital status, place of residence, average monthly income, experience of forgetting things since they started AED, forget to take AED are the most notable factors that are associated with the willingness of patients to receive cell phone drug reminder messages.

Effects of combination drugs on antihypertensive medication adherence in a real-world setting: a Korean Nationwide Study

OBJECTIVES

We tried to clarify, by using representative national data in a real-world setting, whether single-pill combinations (SPCs) of antihypertensives actually improve medication adherence.

DESIGN

A nationwide population-based study.

SETTING

We used a 2.2% cohort (n=1 048 061) of the total population (n=46 605 433) that was randomly extracted by National Health Insurance of Korea from 2008 to 2013.

PARTICIPANTS

We included patients (n=116 677) who were prescribed with the same antihypertensive drugs for at least 1 year and divided them into groups of angiotensin II receptor blocker (ARB)-only, calcium channel blocker (CCB)-only, multiple-pill combinations (MPCs) and SPCs of ARB/CCB.

PRIMARY OUTCOME MEASURES

Medication possession ratio (MPR), a frequently used indirect measurement method of medication adherence.

RESULTS

Adjusted MPR was higher in combination therapy (89.7% in SPC, 87.2% in MPC) than monotherapy (81.6% in ARB, 79.7% in CCB), and MPR of SPC (89.7%, 95% CI 89.3 to 90.0) was higher than MPR of MPC (87.2%, 95% CI 86.7 to 87.7) (p<0.05). In subgroup analysis, adherence of SPC and MPC was 92.3% (95% CI 91.5 to 93.0) vs 88.1% (95% CI 87.1 to 89.0) in those aged 65-74 years and 89.3% (95% CI 88.0 to 90.7) vs 84.8% (95% CI 83.3 to 92.0) in those ≥75 years (p<0.05). According to total pill numbers, adherence of SPC and MPC was 90.9% (CI 89.8 to 92.0) vs 85.3% (95% CI 84.1 to 86.5) in seven to eight pills and 91.2% (95% CI 89.3 to 93.1) vs 82.5% (95% CI 80.6 to 84.4) in nine or more (p<0.05). The adherence difference between SPC and MPC started to increase at five to six pills and at age 50-64 years (p<0.05). When analysed according to elderly status, the adherence difference started to increase at three to four pills in the elderly (≥65 years) and at five to six in the non-elderly group (20-64 years) (p<0.05). These differences all widened further with increasing age and the total medications.

CONCLUSION

SPC regimens demonstrated higher adherence than MPC, and this tendency is more pronounced with increasing age and the total number of medications.

Association between adherence to antihypertensive medications and health outcomes in middle and older aged community dwelling adults; results from the Irish longitudinal study on ageing

PURPOSE

To examine the association between antihypertensive medication (AHTM) implementation adherence and healthcare utilisation in community-dwelling adults aged ≥ 50 years in Ireland.

METHODS

This was a prospective cohort study. The Irish Longitudinal Study on Ageing (TILDA) was linked to pharmacy claims data for participants aged ≥ 50 years. Participants were included if they had ≥ 3 pharmacy claims for one or more AHTM (ATC codes 'C02', 'C03', 'C07', 'C08' or 'C09') within the year preceding the year of self-reported healthcare utilisation outcome occurrence. Outcomes included self-reported general practitioner (GP), emergency department (ED), outpatient department visits and hospital admissions. Implementation adherence was measured using proportion of days covered (PDC), with participants classified as adherent if the average PDC ≥ 0.8. Negative binomial models were used to analyse the association between AHTM adherence and number of GP, ED, outpatient visits and hospitalisations (adjusted IRR and 95% CI are presented).

RESULTS

One thousand four hundred thirty-one participants were included. The majority of participants (72.6%) were considered adherent. Good implementation adherence to AHTM was associated with a significant decrease in self-reported GP visits (adjusted IRR 0.91, 95% CI 0.83-0.99). Adherence had no significant impact on the number of ED visits, outpatient visits or hospitalisations reported by TILDA participants.

CONCLUSIONS

Good adherence to AHTM was associated with less self-reported GP visits in this population, suggesting improved overall health status. However, the impact of medication non-adherence on the other self-reported healthcare utilisation outcomes (ED, outpatient visits and hospitalisations) was not evident in this study.

Selection of interventions aimed at improving medication adherence in patients with multimorbidity

Objectives

To select interventions aimed at improving medication adherence in patients with multimorbidity by means of a standardised methodology.

Methods

A modified Delphi methodology was used to reach consensus. Interventions that had demonstrated their efficacy in improving medication adherence in patients with multimorbidity or in similar populations were identified from a literature search of several databases (PubMed, EMBASE, the Cochrane Library, Center for Reviews and Dissemination, and Web of Science). 11 experts in medication adherence and/or chronic disease scored the selected interventions for appropriateness according to three criteria: strength of the evidence that supported each intervention, usefulness in patients with multimorbidity, and feasibility of implementation in clinical practice. The final set of interventions was selected according to appropriateness and agreement based on the Delphi methodology.

Results

566 articles were retrieved in the literature search. Nine systematic reviews were included. 33 interventions were initially selected for evaluation by the panellists. Consensus after two Delphi rounds was reached on 16 interventions. Five interventions were categorized as educational, six as behavioural and five were related to other aspects of interest.

Conclusions

The interventions selected following a comprehensive and standardized methodology, could be used to improve medication adherence in patients with multimorbidity.

Behavioral economic insights to improve medication adherence in adults with chronic conditions: a scoping review protocol

OBJECTIVE

The objective of this review is to map the evidence on the use of behavioral economic insights to improve medication adherence in adults with chronic conditions.

INTRODUCTION

Medication non-adherence is a barrier to effectively managing chronic conditions, leading to poorer patient outcomes and placing an additional financial burden on healthcare systems. As the population ages and the prevalence of chronic disease increases, new ways to influence patient behavior are needed. Approaches that use insights from behavioral economics may help improve medication adherence, thus reducing morbidity, mortality and financial costs of unmanaged chronic diseases.

INCLUSION CRITERIA

Eligible studies will include adults taking medication for a chronic condition. All interventions relevant to high-income settings using insights from behavioral economics to improve medication adherence in adults will be considered. Contexts may include, but are not limited to, primary health care, corporate wellness programs and health insurance schemes. Any study design published in English will be considered. Studies in facilities where medication is administered to patients will be excluded.

METHODS

PubMed, Embase, Scopus, PsycINFO, EconLit and CINAHL will be searched from database inception to present. Gray literature will be searched using Google Scholar, OpenGrey and the Grey Literature Report. One reviewer will review titles, and then two reviewers will independently review abstracts to identify eligible studies. One reviewer will extract data on study characteristics, study design and study outcomes. A second reviewer will validate 25% of the extracted information. The results of the data extraction will be presented in a table, and a narrative summary will be presented.

A systematic review and meta-analysis on the effectiveness of education on medication adherence for patients with hypertension, hyperlipidaemia and diabetes

AIM

To evaluate the effectiveness of educational interventions in improving medication adherence among adult patients diagnosed with hypertension, hyperlipidaemia and/or diabetes.

DESIGN

This review was conducted with reference to methods set out in the Cochrane Handbook for Systematic Reviews of Interventions (PROSPERO registration number: CRD42016053402).

DATA SOURCES

A search from seven electronic databases (2003-2016).

REVIEW METHOD

The quality of evidence and strength of the studies was evaluated systematically, followed by an assessment of risks of bias by two reviewers with the Cochrane Collaboration's tool.

RESULTS

Eighteen randomized controlled trials demonstrated a low to moderate quality evidence on the improvements of medication adherence with educational interventions. Participants with type 2 diabetes benefited from education interventions but not those with hypertension. No randomized controlled trials (RCT) was found for participants with hyperlipidaemia. Education that was conducted at home showed better medication adherence than education conducted in clinics. Medication adherence was improved after two to three sessions but no significant differences found after three sessions.

CONCLUSION

Through education, health literacy is improved, thus improving medication adherence.

IMPACT

A plethora of educational interventions have been implemented in the clinical settings, but no reviews have hitherto been conducted on their effectiveness. This review suggested that education improves health literacy which is directly proportionate to optimal disease management including medication adherence. The suggestions proposed in this review may impact the individual in terms of their adherence to medication to tackle exacerbation and relapse of chronic diseases and also proposed suggestions for future implementation of an education intervention.

Physician and patient preferences for dosing options in migraine prevention

Background

Adherence to a therapy, though a key factor for successful treatment, is low among patients with chronic conditions such as migraine. Dose frequency plays a major role in adherence. This study evaluated the impact of having flexible dosing options on acceptance of and adherence to a new migraine preventive therapy class among adults with migraine.

Methods

In this observational study, two 20-min online surveys were completed: one by physicians currently treating adult patients with migraine and the other by adults with migraine. Both surveys presented the participants with three scenarios: 1) only monthly, 2) only quarterly, and 3) both dosing options of the new medication are available. Physicians estimated the proportion of their migraine patients who would receive the new medication in each scenario. Patients were asked about their dosing preference when either or both options are available. Respondents were asked to rate the likelihood of their acceptance of and adherence to the therapy.

Results

400 physicians and 417 US adults with migraine completed the surveys. The availability of both dosing options yielded a significant increase in the proportion of patients expected to receive the new medication. The overall proportion of patients favoring monthly dosing (35%) was similar to the proportion favoring quarterly dosing (40%). Among those who preferred monthly dosing (n = 147), a greater proportion indicated they are more likely to fill the prescription (77% vs 56%, P < 0.05) and remain adherent (80% vs 57%, P < 0.05) when only monthly is available versus when only quarterly is available. Similarly, among those who preferred quarterly dosing (n = 166), a greater proportion indicated they are likely to fill (63% vs 55%, P < 0.05) and remain adherent (62% vs 54%, P < 0.05) when only quarterly is available compared with when only monthly is available.

Conclusions

Physicians anticipated that the proportion of patients to receive the new medication would increase when both dosing options are available. Patients stated that they are more likely to fill the prescription and adhere to the new therapy when their preferred dosing regimen is available.

Adherence to Levothyroxine Tablet in Patients with Hypothyroidism

Introduction

Patients with hypothyroidism are managed with life-long levothyroxine (LT4) therapy. However, as with other chronic illnesses, drug adherence (DA) is a prominent issue in these patients. The aim of this study is to identify the extent of DA to LT4 in hypothyroidism patients and study the clinical factors contributing to DA in these patients.

Methods

This cross-sectional study assessed patient adherence to LT4 therapy by Modified Morisky Adherence Scale (MMAS). Factors predicting the pattern of medication adherence were also assessed in all patients. Data were entered and analyzed using SPSS v. 22.0.

Results

On MMAS, 79 (27.3%) participants indicated low adherence, 117 (40.48%) indicated medium adherence, and 93 (32.2%) participants indicated high adherence. Regular endocrinologist visits and knowledge about medication were highest in high adherent patients (p < 0.05). Need for assistance in taking medication, avoidance of medication with symptomatic relief and busy work schedule was highest in low adherent patients (p < 0.05).

Conclusion

Patients with hypothyroidism showed moderate adherence to their treatment.

Association Between Medication Adherence and 1-Year Major Cardiovascular Adverse Events After Acute Myocardial Infarction in China

Background Secondary prevention after acute myocardial infarction ( AMI ) requires long-term guideline-directed medical therapy. However, the level of medication adherence, factors associated with poor adherence, and extent to which good adherence can reduce adverse events after AMI in China remain uncertain. Methods and Results In 2013 to 2014, 4001 AMI patients aged ≥18 years were discharged alive from 53 hospitals across China (mean age 60.5±11.7 years; 22.7% female). Good adherence was defined as taking medications (aspirin, β-blockers, statins, clopidogrel, or angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers) ≥90% of the time as prescribed. Cox models assessed the association between good adherence (a time-varying covariate) and 1-year cardiovascular events after AMI . The most common medications were aspirin (82.2%) and statins (80.5%). There were 243 patients who were not prescribed any medications during follow-up; 1-year event rates were higher for these patients (25.1%, 95% CI 19.7-30.6%) versus those taking ≥1 medications (6.6%, 95% CI 5.76-7.34%). The overall rate of good adherence was 52.9%. Good adherence was associated with lower risk of 1-year events (adjusted hazard ratio 0.61, 95% CI 0.49-0.77). The most common reason for poor adherence was belief that one's condition had improved/no longer required medication. More comorbidities and lower education level were associated with poor adherence. Conclusions Good adherence reduced 1-year cardiovascular event risk after AMI . About half of our cohort did not have good adherence. National efforts to improve AMI outcomes in China should focus on medication adherence and educating patients on the importance of cardiovascular medications for reducing risk of recurrent events. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT01624909.

Pioglitazone Therapy in Patients With Stroke and Prediabetes: A Post Hoc Analysis of the IRIS Randomized Clinical Trial

Importance

In the Insulin Resistance Intervention After Stroke (IRIS) randomized clinical trial, pioglitazone, an insulin-sensitizing agent, reduced the risk for recurrent stroke or myocardial infarction (MI) among patients with insulin resistance. However, insulin resistance is not commonly measured in clinical practice.

Objective

To analyze the effects of pioglitazone in patients with good adherence as well as intention-to-treat effects of pioglitazone in patients with prediabetes in the IRIS trial.

Design, Setting, and Participants

The IRIS trial was a randomized multicenter clinical trial in patients with prior stroke or transient ischemic attack as well as insulin resistance but not diabetes. Patients were enrolled from February 2005 to January 2013, and the median follow-up was 4.8 years. The post hoc analyses reported here were performed from June to September 2018. Per American Diabetes Association criteria, prediabetes was defined as having a hemoglobin A1c level of 5.7% to 6.4% or fasting plasma glucose level of 100 mg/dL to 125 mg/dL (to convert to mmol/L, multiply by 0.0555). Good adherence was defined as taking 80% or more of the protocol dose. Fasting glucose and hemoglobin A1c, used to define prediabetes, and adherence of 80% or higher, stipulated in the protocol as defining good adherence, were prespecified subgroups in the analysis plan.

Interventions

Participants were randomized to 15 mg of pioglitazone, with dose titrated to target of 45 mg daily, or matching placebo.

Main Outcomes and Measures

The primary outcome was recurrent stroke or MI. Secondary outcomes included stroke, acute coronary syndrome, stroke/MI/hospitalization for heart failure, and progression to diabetes.

Results

Among 3876 participants analyzed in the IRIS trial, 2885 were included in this analysis (1456 in the pioglitazone cohort and 1429 in the placebo cohort). The mean (SD) age of patients was 64 (11) years, and 974 (66.9%) and 908 (63.5%) of patients were men in the pioglitazone and placebo cohort, respectively. In the prediabetic population with good adherence (644 of 1456 individuals [44.2%] in the pioglitazone group and 810 of 1429 [56.7%] in the placebo group), the hazard ratios (95% CI) were 0.57 (0.39-0.84) for stroke/MI, 0.64 (0.42-0.99) for stroke, 0.47 (0.26-0.85) for acute coronary syndrome, 0.61 (0.42-0.88) for stroke/MI/hospitalization for heart failure, and 0.18 (0.10-0.33) for progression to diabetes. There was a nonsignificant reduction in overall mortality, cancer, and hospitalization, a slight increase in serious bone fractures, and an increase in weight gain and edema. Intention-to-treat results also showed significant reduction of events but to a lesser degree. Hazard ratios (95% CI) were 0.70 (0.56-0.88) for stroke/MI, 0.72 (0.56-0.92) for stroke, 0.72 (0.52-1.00) for acute coronary syndrome, 0.78 (0.63-0.96), for stroke/MI/hospitalization for heart failure, and 0.46 (0.35 to 0.61) for progression to diabetes.

Conclusions and Relevance

Pioglitazone may be effective for secondary prevention in patients with stroke/transient ischemic attack and with prediabetes, particularly in those with good adherence.

Trial Registration

ClinicalTrials.gov identifier: NCT00091949.

The association between pharmacy refill-adherence metrics and healthcare utilisation: a prospective cohort study of older hypertensive adults

AIMS

Methods that enable targeting and tailoring of adherence interventions may facilitate implementation in clinical settings. We aimed to determine whether community pharmacy refill-adherence metrics are useful to identify patients at higher risk of healthcare utilisation due to low antihypertensive adherence, who may benefit from an adherence intervention.

METHODS

We conducted a prospective cohort study, recruiting participants (n = 905) from 106 community pharmacies across the Republic of Ireland. Participants completed a structured interview at baseline and 12 months. Antihypertensive medication adherence was evaluated from linked pharmacy records using group-based trajectory modelling (GBTM) and proportion of days covered (PDC). Healthcare utilisation included self-reported number of hospital visits (emergency department visits and inpatient admissions) and general practitioner (GP) visits, over a 6-month period. Separate regression models were used to estimate the association between adherence and number of hospital/GP visits. The relative statistical fit of each model using different adherence metrics was determined using the Bayesian information criterion (BIC).

RESULTS

For the number of hospital visits, significant associations were observed only for PDC but not for GBTM. Each 10% increase in refill-adherence by PDC was significantly associated with a 16% lower rate of hospital visits (adjusted incidence rate ratio 0.84, 95% CI 0.72-0.98, P = 0.036). Poorer adherence using both measures was associated with higher GP visits. Improvements in BIC favoured models using PDC.

CONCLUSIONS

Medication refill-adherence, measured using PDC in community pharmacy settings, could be used to recognise poor antihypertensive adherence to enable effective targeting of clinical interventions to improve hypertension management and outcomes.

The Importance of Inhaler Adherence to Prevent COPD Exacerbations

It has been shown that the better outcomes of chronic obstructive pulmonary disease (COPD) are closely associated with adherence to drug therapy, independent of the treatment administered. The clinical trial Towards a Revolution in COPD Health (TORCH) study clearly showed in a three year follow up that patients with good adherence to their inhaler treatment presented a longer time before the first exacerbation, a lower susceptibility to exacerbation and lower all-cause mortality. The Latin American Study of 24-hour Symptoms in Chronic Obstructive Pulmonary Disease (LASSYC), a real-life study, evaluated the self-reported inhaler adherence in COPD patients in seven countries in a cross-sectional non-interventional study and found that approximately 50% of the patients had good adherence, 30% moderate adherence and 20% poor adherence. Adherence to inhaler may be evaluated by the specific inhaler adherence questionnaire, the Test of Adherence to Inhalers (TAI). Several factors may predict the incorrect use of inhalers or adherence in COPD outpatient, including the number of devices and the daily dosing frequency. Ideally, patient education, simplicity of the device operation, the use of just one device for multiple medications and the best adaptation of the patient to the inhaler should guide the physician in prescribing the device.

Adherence, persistence, glycaemic control and costs among patients with type 2 diabetes initiating dulaglutide compared with liraglutide or exenatide once weekly at 12-month follow-up in a real-world setting in the United States

AIMS

To evaluate adherence, persistence, glycaemic control and costs at 12-month follow-up for patients initiating dulaglutide versus liraglutide or exenatide once weekly.

MATERIALS AND METHODS

The present retrospective observational claims study included patients with type 2 diabetes (T2D) and ≥ 1 pharmacy claim for dulaglutide, liraglutide or exenatide once weekly from the HealthCore Integrated Research Database. Adherence was defined as proportion of days covered ≥80%, and persistence was measured by time to discontinuation of index therapy. Change from baseline in glycated haemoglobin (HbA1c) concentration was assessed in a subset with pre- and post-index HbA1c results. Propensity scores were used to match the cohorts.

RESULTS

The baseline characteristics were balanced for the matched cohorts, dulaglutide versus liraglutide (n = 2471) and dulaglutide versus exenatide once weekly (n = 1891). Among those initiating dulaglutide there was a significantly higher proportion of adherent patients compared with the groups initiating liraglutide (51.2% vs. 38.2%; P < 0.001) and exenatide once weekly (50.7% vs. 31.9%; P < 0.001). At 12 months, 55% of patients in the dulaglutide group versus 43.8% in the liraglutide group (P < 0.001), and 54.9% in the dulaglutide versus 34.4% in the exenatide once-weekly group (P < 0.001) were persistent. The dulaglutide group had a significantly greater reduction in HbA1c than the liraglutide group (-34.24 vs. -31.94 mmol/mol; P = 0.032), and a greater, but nonsignificant, reduction in HbA1c than the exenatide once-weekly group (-34.46 vs. -31.94 mmol/mol; P = 0.056). The diabetes-related total costs were not significantly different between the dulaglutide and the liraglutide group ($16,174 vs. $16,694; P = 0.184), and were significantly higher for dulaglutide than for exenatide once weekly ($15,768 vs. $14,615; P = 0.005).

CONCLUSIONS

Adherence and persistence are important considerations in patient-centric treatment selection for patients with T2D. Higher adherence and persistence for dulaglutide compared with liraglutide or exenatide once weekly are relevant criteria when choosing glucagon-like peptide-1 receptor agonist treatment for patients with T2D.

Treatment adherence to pegvisomant in patients with acromegaly in Spain: PEGASO study

PURPOSE

The burden of chronic daily subcutaneous administration of pegvisomant on adherence has not been previously studied. This study was aimed to determine the adherence to pegvisomant treatment in acromegaly patients in the real-world clinical practice setting in Spain.

METHODS

Multicenter, observational, descriptive, cross-sectional study in patients with acromegaly treated with pegvisomant for at least 12 months. Patient adherence was indirectly determined by Batalla and Haynes-Sackett questionnaires and directly by prescription record review. Additionally, treatment satisfaction was assessed by the Treatment Satisfaction with Medicines Questionnaire (SATMED-Q) and treatment convenience by an ad-hoc Pegvisomant questionnaire. Errors in reconstitution and administration process were determined by direct observation.

RESULTS

108 patients were included in the analysis. Rates of adherence varied from 60.7 to 92.1% and did not correlate with disease control. Older patient age and alternative schedules other than daily pegvisomant dosing were associated with lower adherence. Treatment satisfaction and convenience was high, with a mean (SD) total SATMED-Q score of 74.6 ± 15.4 over 100 and a total ad-hoc Pegvisomant questionnaire score of 71.2 ± 15.2 over 100. 34.3% of patients made mistakes during the reconstitution /administration process.

CONCLUSIONS

Patient adherence to pegvisomant was high (60.7-92.1%), but more than a third of the patients in the study made mistakes during the administration process, with a potential impact on disease control. Besides dosing compliance, correct administration of medication should be carefully assessed in these patients.

The Association Between Medication Adherence for Chronic Conditions and Digital Health Activity Tracking: Retrospective Analysis

Background

Chronic diseases have a widespread impact on health outcomes and costs in the United States. Heart disease and diabetes are among the biggest cost burdens on the health care system. Adherence to medication is associated with better health outcomes and lower total health care costs for individuals with these conditions, but the relationship between medication adherence and health activity behavior has not been explored extensively.

Objective

The aim of this study was to examine the relationship between medication adherence and health behaviors among a large population of insured individuals with hypertension, diabetes, and dyslipidemia.

Methods

We conducted a retrospective analysis of health status, behaviors, and medication adherence from medical and pharmacy claims and health behavior data. Adherence was measured in terms of proportion of days covered (PDC), calculated from pharmacy claims using both a fixed and variable denominator methodology. Individuals were considered adherent if their PDC was at least 0.80. We used step counts, sleep, weight, and food log data that were transmitted through devices that individuals linked. We computed metrics on the frequency of tracking and the extent to which individuals engaged in each tracking activity. Finally, we used logistic regression to model the relationship between adherent status and the activity-tracking metrics, including age and sex as fixed effects.

Results

We identified 117,765 cases with diabetes, 317,340 with dyslipidemia, and 673,428 with hypertension between January 1, 2015 and June 1, 2016 in available data sources. Average fixed and variable PDC for all individuals ranged from 0.673 to 0.917 for diabetes, 0.756 to 0.921 for dyslipidemia, and 0.756 to 0.929 for hypertension. A subgroup of 8553 cases also had health behavior data (eg, activity-tracker data). On the basis of these data, individuals who tracked steps, sleep, weight, or diet were significantly more likely to be adherent to medication than those who did not track any activities in both the fixed methodology (odds ratio, OR 1.33, 95% CI 1.29-1.36) and variable methodology (OR 1.37, 95% CI 1.32-1.43), with age and sex as fixed effects. Furthermore, there was a positive association between frequency of activity tracking and medication adherence. In the logistic regression model, increasing the adjusted tracking ratio by 0.5 increased the fixed adherent status OR by a factor of 1.11 (95% CI 1.06-1.16). Finally, we found a positive association between number of steps and adherent status when controlling for age and sex.

Conclusions

Adopters of digital health activity trackers tend to be more adherent to hypertension, diabetes, and dyslipidemia medications, and adherence increases with tracking frequency. This suggests that there may be value in examining new ways to further promote medication adherence through programs that incentivize health tracking and leveraging insights derived from connected devices to improve health outcomes.