Economic impact of medication non-adherence by disease groups: a systematic review

Poor Adherence to Medical and Dietary Treatments in Adult Patients With Eosinophilic Esophagitis

INTRODUCTION

To investigate the adherence to prescribed medical and dietary maintenance treatments in a cohort of adult patients with eosinophilic esophagitis (EoE) and to identify associated factors.

METHODS

In this cross-sectional study, adult patients with EoE who were prescribed medical or dietary maintenance therapy were included. Patients were asked to complete questionnaires concerning treatment adherence (Medication Adherence Rating Scale), beliefs about treatment (Beliefs about Medicine Questionnaire), beliefs about disease (Illness Perception Questionnaire), and current symptoms (Straumann Dysphagia Index).

RESULTS

A total of 177 patients with EoE (71% males) were included, with a median age of 43 years. The overall prevalence of poor adherence to prescribed treatments (Medication Adherence Rating Scale < 21 or Diet Adherence Rating Scale < 21) in this cohort was high, being 41.8%. Medically treated patients seemed less adherent to prescribed treatment compared with patients prescribed a diet (35.1% vs 41.8%, P = 0.320). Multivariate logistic regression analyses identified the following independent factors associated with poor treatment adherence: age <40 years (odds ratio [OR] 2.571, 95% CI 1.195-5.532, P = 0.016), longer disease duration in years (OR 1.130, 95% CI 1.014-1.258, P = 0.027), severe symptoms (Straumann Dysphagia Index) (OR 1.167, 95% CI 1.012-1.345, P = 0.034), and low necessity beliefs (OR 4.423, 95% CI 2.169-9.016, P < 0.001).

DISCUSSION

Adherence to maintenance treatment is poor in many adult patients with EoE. Clinicians should pay more attention to treatment adherence, particularly in younger patients, and discuss the necessity of treatment.

Digital Pills with Ingestible Sensors: Patent Landscape Analysis

The modern healthcare system is directly related to the development of digital health tools and solutions. Pills with digital sensors represent a highly innovative class of new pharmaceuticals. The aim of this work was to analyze the patent landscape and to systematize the main trends in patent protection of digital pills with ingestible sensors worldwide; accordingly, to identify the patenting leaders as well as the main prevailing areas of therapy for patent protection, and the future perspectives in the field. In July 2022, a search was conducted using Internet databases, such as the EPO, USPTO, FDA and the Lens database. The patent landscape analysis shows an increase in the number of patents related to digital pills with ingestible sensors for mobile clinical monitoring, smart drug delivery, and endoscopy diagnostics. The leaders in the number of patents issued are the United States, the European Patent Office, Canada, Australia, and China. The following main areas of patenting digital pills with ingestible sensors were identified: treatment in the field of mental health; HIV/AIDS; pain control; cardiovascular diseases; diabetes; gastroenterology (including hepatitis C); oncology; tuberculosis; and transplantology. The development of scientific and practical approaches towards the implementation of effective and safe digital pills will improve treatment outcomes, increase compliance, reduce hospital stays, provide mobile clinical monitoring, have a positive impact on treatment costs and will contribute to increased patient safety.

Treatment compliance in amblyopia: A mini-review and description of a novel online platform for compliance tracking

Patient compliance with amblyopia therapies, including eye patching and atropine drops, is crucial for optimal visual acuity outcomes. Studies utilizing objective measures of compliance measurement have consistently shown that a majority of patients receive significantly less treatment than prescribed. We review the subjective and objective compliance rates reported in the literature, assess possible explanations for poor compliance and describe studies of interventions to improve compliance. Additionally, we report our experience implementing Inside Out Care, a novel online platform designed to improve monitoring of amblyopia patient compliance, in our clinics. We have found that this platform, which is accessible via both computer and smartphone, has improved monitoring of amblyopia patient patching compliance, as well as allowed for enhanced doctor-patient communication.

Reimbursed medication adherence enhancing interventions in 12 european countries: Current state of the art and future challenges

Background: Medication non-adherence jeopardises the effectiveness of chronic therapies and negatively affects financial sustainability of healthcare systems. Available medication adherence-enhancing interventions (MAEIs) are utilised infrequently, and even more rarely reimbursed. The aim of this paper was to review reimbursed MAEIs across selected European countries.

Methods: Data on reimbursed MAEIs were collected from European countries at the ENABLE Cost Action expert meeting in September 2021. The identified MAEIs were analysed and clustered according to their characteristics, direct vs. indirect relation to adherence, and the targeted adherence phase.

Results: Out of 12 contributing countries, 10 reported reimbursed MAEIs, 28 in total, of which 20 were identified as MAEIs targeting adherence directly. Reimbursed MAEIs were most often performed by either doctors (n = 6), nurses (n = 6), or pharmacists (n = 3). The most common types of MAEIs were education (n = 6), medication regimen management (n = 5), and adherence monitoring feedback (n = 4). Only seven reimbursed MAEIs were technology-mediated, whereas 11 addressed two interlinked phases of medication adherence, i.e., implementation and persistence.

Conclusion: Our review highlights the scarcity of reimbursed MAEIs across the selected European countries, and calls for their more frequent use and reimbursement.

Cost-Related Medication Nonadherence and Patient Cost Responsibility for Rural and Urban Cancer Survivors

PURPOSE

The relationship between out-of-pocket spending and cost-related medication nonadherence among older rural- and urban-dwelling cancer survivors is not well understood.

METHODS

This retrospective cohort study used the Surveillance, Epidemiology, and End Results Program, Medicare claims, and the Consumer Assessment of Healthcare Providers and Systems survey linked data resource linked data (2007-2015) to investigate the relationship between cancer survivors' cost responsibility in the year before and after report of delaying or not filling a prescription medication because of cost in the past 6 months (cost-related medication nonadherence). Secondary exposures and outcomes included Medicare spending and utilization. Generalized linear models assessed bidirectional relationships between cost-related medication nonadherence, spending, and utilization. Effects of residence were assessed via interaction terms.

RESULTS

Of 6,591 older cancer survivors, 13% reported cost-related medication nonadherence. Survivors were a median 8 years (interquartile range, 4.5-12.5 years) from their cancer diagnosis, 15% were dually Medicare/Medicaid-eligible, and prostate (40%) and breast (32%) cancer survivors were most prevalent. With every $500 USD increase in patient cost responsibility, risk of cost-related medication nonadherence increased by 3% (risk ratio, 1.03; 95% CI, 1.02 to 1.04). After report of cost-related medication nonadherence, patient cost responsibility was 22% higher (95% CI, 1.11 to 1.32) compared with those not reporting nonadherence, amounting to $523 USD (95% CI, $430 USD to $630 USD). Medicare spending and utilization were also higher before and after report of cost-related nonadherence versus none. For survivors residing in rural (18%) and urban (82%) areas, residence did not modify adherence or cost outcomes.

CONCLUSION

A bidirectional relationship exists between patient cost responsibility and cost-related medication nonadherence. Interventions reducing urban- and rural-dwelling survivor health care costs and cost-related adherence barriers are needed.

Relationship Among Treatment Adherence, Family Functioning, and Self-Care Agency in Colombian Patients With Cardiovascular Disease

BACKGROUND

Multiple factors affect treatment adherence in individuals with cardiovascular disease. However, information on the relationships among treatment adherence, family functioning, and self-care agency in these patients and their families is limited.

PURPOSE

This study was developed to determine the relationships among treatment adherence, family functioning, self-care agency, and sociodemographic variables in patients with cardiovascular disease. Self-care agency, as defined by Orem, is the dynamic process patients use to engage in their own healthcare that involves discerning and addressing factors that allow their making decisions that improve self-care abilities.

METHODS

This cross-sectional, observational-analytical study enrolled 151 adult patients with cardiovascular diseases who had undergone pharmacological and nonpharmacological treatments and 108 family members of these patients who had consented to participate. Measurements were performed using the "Questionnaire for measuring treatment adherence in patients with cardiovascular disease," the "Family Functioning Assessment Scale," and the "Self-care Agency Scale."

RESULTS

Of the 151 patients, 119 (78.8%) were assessed as having a low risk of nonadherence, 60 (39.7%) as having low family functioning, and 131 (86.8%) as having high self-care agency. Treatment adherence and self-care agency showed a moderate and significant correlation ( r = .66, p < .001). Similarly, treatment adherence and family functioning showed a low but significant correlation ( r = .35, p < .001). Moreover, significant multivariate associations were found among the variables of interest. Patients with a low risk of nonadherence were found to be more likely to have a secondary or postsecondary education, not to have vision or hearing problems, and to have a contributory affiliation mode with the health system or private health insurance. In addition, participants with moderate or high levels of family functioning were less likely to be workers or to not have hearing or vision problems. Finally, significant differences were noted between patients with low self-care agency and those with high self-care agency in terms of kinship relationship with family members and affiliation mode with the health system.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

The results of this research help clarify the issue of treatment adherence in patients with cardiovascular disease. Although family functioning and self-care agency were found to be low to moderately correlated with treatment adherence, relevant information regarding these variables and sociodemographic variables is presented in this study. Nurses may use these results as a reference to design nursing care plans and interventions to address the conditions of their patients more appropriately.

High non-adherence rates to secondary prevention by chemical adherence testing in patients with TIA

INTRODUCTION

Transient ischaemic attack (TIA) clinics are important for secondary prevention of fatal or disabling stroke. Non-adherence to prescribed medications is an important reason for treatment failure but difficult to diagnose. This study ascertained the utility of a novel biochemical tool in the objective biochemical diagnosis of non-adherence.

METHODS

One-hundred consecutive urine samples collected from patients attending the TIA clinic, at a tertiary centre, were analysed for presence or absence of prescribed cardiovascular medications using liquid chromatography-mass spectrometry (LC-MS/MS). Patients were classified as adherent or non-adherent, respectively. Demographic and clinical characteristics were compared between the two cohorts. Univariate regression analyses were performed for individual variables and model fitting was undertaken for significant variables.

RESULTS

The mean duration of follow-up from the index event was 31 days [standard deviation (SD): 18.9]. The overall rate of non-adherence for at least one medication was 24%. In univariate analysis, the number of comorbidities [3.4 (SD: 1.9) vs. 2.5 (1.9), P = 0.032] and total number of all prescribed medications [6.0 (3.3) vs 4.4 (2.1), P = 0.032] were higher in the non-adherent group. On multivariate analysis, the total number of medications prescribed correlated with increased non-adherence (odds ratio: 1.27, 95% Confidence Intervals: 1.1-1.5, P = 0.01).

CONCLUSIONS

LC-MS/MS is a clinically useful tool for the diagnosis of non-adherence. Nearly a quarter of TIA patients were non-adherent to their cardiovascular medications Addressing non-adherence early may reduce the risk of future disabling cardiovascular events.

Effectiveness and cost-effectiveness of an intervention to improve Initial Medication Adherence to treatments for cardiovascular diseases and diabetes in primary care: study protocol for a pragmatic cluster randomised controlled trial and economic model (the IMA-cRCT study)

BACKGROUND

Between 2 and 43% of patients who receive a new prescription in PC do not initiate their treatments. Non-initiation is associated with poorer clinical outcomes, more sick leave and higher costs to the healthcare system. Existing evidence suggests that shared decision-making positively impacts medication initiation. The IMA-cRCT assesses the effectiveness of the IMA intervention in improving adherence and clinical parameters compared to usual care in patients with a new treatment for cardiovascular disease and diabetes prescribed in PC, and its cost-effectiveness, through a cRCT and economic modelling.

METHODS

The IMA intervention is a shared decision-making intervention based on the Theoretical Model of Non-initiation. A cRCT will be conducted in 24 PC teams in Catalonia (Spain), randomly assigned to the intervention group (1:1), and community pharmacies in the catchment areas of the intervention PC teams. Healthcare professionals in the intervention group will apply the intervention to all patients who receive a new prescription for cardiovascular disease or diabetes treatment (no other prescription from the same pharmacological group in the previous 6 months). All the study variables will be collected from real-world databases for the 12 months before and after receiving a new prescription. Effectiveness analyses will assess impact on initiation, secondary adherence, cardiovascular risk, clinical parameters and cardiovascular events. Cost-effectiveness analyses will be conducted as part of the cRCT from a healthcare and societal perspective in terms of extra cost per cardiovascular risk reduction and improved adherence; all analyses will be clustered. Economic models will be built to assess the long-term cost-effectiveness of the IMA intervention, in terms of extra cost for gains in QALY and life expectancy, using clinical trial data and data from previous studies.

DISCUSSION

The IMA-cRCT represents an innovative approach to the design and evaluation of behavioural interventions that use the principles of complex interventions, pragmatic trials and implementation research. This study will provide evidence on the IMA intervention and on a new methodology for developing and evaluating complex interventions. The results of the study will be disseminated among stakeholders to facilitate its transferability to clinical practice.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05026775 . Registered 30th August 2021.

Clinical standards for drug-susceptible pulmonary TB

BACKGROUND: The aim of these clinical standards is to provide guidance on 'best practice´ for diagnosis, treatment and management of drug-susceptible pulmonary TB (PTB).METHODS: A panel of 54 global experts in the field of TB care, public health, microbiology, and pharmacology were identified; 46 participated in a Delphi process. A 5-point Likert scale was used to score draft standards. The final document represents the broad consensus and was approved by all 46 participants.RESULTS: Seven clinical standards were defined: Standard 1, all patients (adult or child) who have symptoms and signs compatible with PTB should undergo investigations to reach a diagnosis; Standard 2, adequate bacteriological tests should be conducted to exclude drug-resistant TB; Standard 3, an appropriate regimen recommended by WHO and national guidelines for the treatment of PTB should be identified; Standard 4, health education and counselling should be provided for each patient starting treatment; Standard 5, treatment monitoring should be conducted to assess adherence, follow patient progress, identify and manage adverse events, and detect development of resistance; Standard 6, a recommended series of patient examinations should be performed at the end of treatment; Standard 7, necessary public health actions should be conducted for each patient. We also identified priorities for future research into PTB.CONCLUSION: These consensus-based clinical standards will help to improve patient care by guiding clinicians and programme managers in planning and implementation of locally appropriate measures for optimal person-centred treatment for PTB.

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

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

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

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

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

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

A systematic review and meta-analysis on impact of suboptimal use of antidepressants, bisphosphonates, and statins on healthcare resource utilisation and healthcare cost

BACKGROUND

Depression, osteoporosis, and cardiovascular disease impose a heavy economic burden on society. Understanding economic impacts of suboptimal use of medication due to nonadherence and non-persistence (non-MAP) for these conditions is important for clinical practice and health policy-making.

OBJECTIVE

This systematic literature review aims to assess the impact of non-MAP to antidepressants, bisphosphonates and statins on healthcare resource utilisation and healthcare cost (HRUHC), and to assess how these impacts differ across medication classes.

METHODS

A systematic literature review and an aggregate meta-analysis were performed. Using the search protocol developed, PubMed, Cochrane Library, ClinicalTrials.gov, JSTOR and EconLit were searched for articles that explored the relationship between non-MAP and HRUHC (i.e., use of hospital, visit to healthcare service providers other than hospital, and healthcare cost components including medical cost and pharmacy cost) published from November 2004 to April 2021. Inverse-variance meta-analysis was used to assess the relationship between non-MAP and HRUHC when reported for at least two different populations.

RESULTS

Screening 1,123 articles left 10, seven and 13 articles on antidepressants, bisphosphonates, and statins, respectively. Of those, 27 were rated of good quality, three fair and none poor using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. In general, non-MAP was positively associated with HRUHC for all three medication classes and most prominently for bisphosphonates, although the relationships differed across HRUHC components and medication classes. The meta-analysis found that non-MAP was associated with increased hospital cost (26%, p = 0.02), outpatient cost (10%, p = 0.01), and total medical cost excluding pharmacy cost (12%, p<0.00001) for antidepressants, and increased total healthcare cost (3%, p = 0.07) for bisphosphonates.

CONCLUSIONS

This systematic literature review is the first to compare the impact of non-MAP on HRUHC across medications for three prevalent conditions, depression, osteoporosis and cardiovascular disease. Positive relationships between non-MAP and HRUHC highlight inefficiencies within the healthcare system related to non-MAP, suggesting a need to reduce non-MAP in a cost-effective way.

Reimbursed Medication Adherence Enhancing Interventions in European Countries: Results of the EUREcA Study

Introduction: Current literature lacks detailed understanding of the reimbursement framework of medication adherence enhancing interventions (MAEIs). As part of the ENABLE COST Action, the EUREcA (“EUropen REimbursement strategies for interventions targeting medication Adherence”) study aimed to provide an in-depth overview of reimbursed MAEIs currently available in European countries at national and regional levels and to pave the way for further MAEIs to be implemented in the future.

Methods: A web-based, cross-sectional survey was performed across 38 European countries and Israel. The survey questionnaire was developed as a result of an iterative process of discussion informed by a desk review. The survey was performed among invited ENABLE collaborators from June to July 2021. Besides descriptive analysis, association between country income and health care expenditure, and the availability of reimbursed MAEIs were also assessed.

Results: The survey identified 13 reimbursed MAEIs in nine countries: multi-dose drug dispensing (n = 5), medication review (n = 4), smart device (n = 2), mobile application (n = 1), and patient education (n = 1). The median GDP per capita of countries having ≥1 reimbursed MAEI was significantly higher compared to countries having no reimbursed adherence intervention (33,888 EUR vs 16,620 EUR, respectively; p = 0.05).

Conclusions: Our findings highlight that to date only a small number of MAEIs have been reimbursed in European countries. Comprehensive health technology assessment recommendations and multi-stakeholder collaboration could help removing barriers related to the implementation and reimbursement of MAEIs.

Cost-effectiveness of Ezetimibe plus statin lipid-lowering therapy: A systematic review and meta-analysis of cost-utility studies

In addition to statin therapy, Ezetimibe, a non-statin lipid-modifying agent, is increasingly used to reduce low-density lipoprotein cholesterol and atherosclerotic cardiovascular disease risk. Literature suggests the clinical effectiveness of Ezetimibe plus statin (EPS) therapy; however, primary evidence on its economic effectiveness is inconsistent. Hence, we pooled incremental net benefit to synthesise the cost-effectiveness of EPS therapy. We identified economic evaluation studies reporting outcomes of EPS therapy compared with other lipid-lowering therapeutic agents or placebo by searching PubMed, Embase, Scopus, and Tufts Cost-Effective Analysis registry. Using random-effects meta-analysis, we pooled Incremental Net Benefit (INB) in the US $ with a 95% confidence interval (CI). We used the modified economic evaluations bias checklist and GRADE quality assessment for quality appraisal. The pooled INB from twenty-one eligible studies showed that EPS therapy was significantly cost-effective compared to other lipid-lowering therapeutic agents or placebo. The pooled INB (95% CI) was $4,274 (621 to 7,927), but there was considerable heterogeneity (I² = 84.21). On subgroup analysis EPS therapy is significantly cost-effective in high-income countries [$4,356 (621 to 8,092)], for primary prevention [$4,814 (2,523 to 7,106)], and for payers’ perspective [$3,255 (571 to 5,939)], and from lifetime horizon [$4,571 (746 to 8,395)]. EPS therapy is cost-effective compared to other lipid-lowering therapeutic agents or placebo in high-income countries and for primary prevention. However, there is a dearth of evidence from lower-middle-income countries and the societal perspective.

Evaluation of antipsychotic medication adherence and its relation to negative and positive psychiatric symptoms

Objectives

The aim of this study was to assess antipsychotic medication adherence and its relation to Psychiatric symptoms in a sample of patients with schizophrenia in Palestine.

Methods

Patients were recruited from the governmental psychiatry clinic in Ramallah in a cross-sectional study. The self-reported Morisky–Green–Levine (MGL) scale was used to measure patients’ adherence. Psychiatric symptoms were measured using the expanded Brief Psychiatric Rating Scale (BPRS-E).

Key findings

Of the 130 participants in the study, 78 (60%) were men and mean age was 41.8 ± 9.8 years 70 (53.8%). of the sample participants were classified as low-adherent while 60 (46.2%) of patients classified as high adherent. That negative symptom scores of high adherence group are significantly lower than low adherence group (12.5 vs. 15.0, P = 0.002) and lower depression anxiety scores (18.3 vs. 22.1, P &lt; 0.001) indicated that high adherence group had lower depression, anxiety, social isolation, anxiety and suicidal ideation symptoms than low-adherence group. The multivariate regression model demonstrated that four variables remain significant and associated with nonadherence; no formal education (OR = 2.11; CI: 0.8–3.8; P = 0.04), age (OR = 2.88; CI: 1.2–4.4; P = 0.01), having comorbidity (OR = 3.2; CI: 1.9–4.3; P = 0.01) and having higher negative symptoms scores (OR = 2.5; CI: 1.2–3.9; P = 0.03); as they are positively correlated to nonadherence.

Conclusion

Medication nonadherence was significant, and it was linked to poor psychiatric outcomes and adherence scores were unaffected by medication-related variables.

Barriers to following imaging guidelines for the treatment and management of patients with low-back pain in primary care: a qualitative assessment guided by the Theoretical Domains Framework

Background

Low back pain (LBP) is a leading cause of disability and is among the top five reasons that patients visit their family doctors. Over-imaging for non-specific low back pain remains a problem in primary care. To inform a larger study to develop and evaluate a theory-based intervention to reduce inappropriate imaging, we completed an assessment of the barriers and facilitators to reducing unnecessary imaging for NSLBP among family doctors in Newfoundland and Labrador (NL).

Methods

This was an exploratory, qualitative study describing family doctors’ experiences and practices related to diagnostic imaging for non-specific LBP in NL, guided by the Theoretical Domains Framework (TDF). Data were collected using in-depth, semi-structured interviews. Transcripts were analyzed deductively (assigning text to one or more domains) and inductively (generating themes at each of the domains) before the results were examined to determine which domains should be targeted to reduce imaging.

Results

Nine family doctors (four males; five females) working in community (n = 4) and academic (n = 5) clinics in both rural (n = 6) and urban (n = 3) settings participated in this study. We found five barriers to reducing imaging for patients with NSLBP: 1) negative consequences, 2) patient demand 3) health system organization, 4) time, and 5) access to resources. These were related to the following domains: 1) beliefs about consequences, 2) beliefs about capabilities, 3) emotion, 4) reinforcement, 5) environmental context and resources, 6) social influences, and 7) behavioural regulation.

Conclusions

Family physicians a) fear that if they do not image they may miss something serious, b) face significant patient demand for imaging, c) are working in a system that encourages unnecessary imaging, d) don’t have enough time to counsel patients about why they don’t need imaging, and e) lack access to appropriate practitioners, community programs, and treatment modalities to prescribe to their patients. These barriers were related to seven TDF domains. Successfully reducing inappropriate imaging requires a comprehensive intervention that addresses these barriers using established behaviour change techniques. These techniques should be matched directly to relevant TDF domains. The results of our study represent the important first step of this process – identifying the contextual barriers and the domains to which they are related.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01751-6.

Prevalence and correlates of medication reminder app ‘use and use intention’ among older adults

Background

Medication adherence is relatively poor among older adults. Although there exist medication reminder apps, data on the prevalence and correlates of their ‘use and use intention’ by older adults are limited.

Objective

To examine the prevalence, and socio-demographic and health correlates of medication reminder app use and use intention among older adults in Singapore.

Methods

Data from a nationally representative survey of 2228 adults aged 62 years and above, who were taking at least one prescription medication, were analysed. Medication reminder app use (in the past one month) and use intention (in the next one month) were self-reported. Bivariate and multivariable logistic regression models were used to identify the correlates of medication reminder app use and use intention.

Results

The prevalence of medication reminder app use and use intention was low at 2.6% (comprising 0.5% for use and 2.1% for use intention). Age, ethnicity, education level, previous participation in information technology/computer-related courses, comorbidity, health literacy, medication adherence and polypharmacy were correlated with app use and use intention in multivariable analyses.

Conclusion

The very low prevalence of medication reminder app use and use intention among older adults in Singapore and identified correlates point to opportunities to increase the use of such apps.

Direct oral anticoagulants and therapeutic adherence: do not let your guard down

BACKGROUND

Direct oral anticoagulants (DOAC) and vitamin K antagonist drugs (VKA) are recommended for stroke prevention in atrial fibrillation and for treatment of venous thromboembolism. Undoubtedly, DOAC have contributed to improve quality of life of these patients, but unfortunately, available 'real world' data show a very high variable compliance to DOAC.

AIMS AND OBJECTIVES

to evaluate predictors that adversely affect therapeutic adherence in patients naive naïve  to DOAC.

METHODS AND POPULATION

this study was conducted on an outpatient population in oral anticoagulant therapy in a period between January 2019 and February 2020. Patients naiveto DOAC and treated for at least 6 months were enrolled. Non-Italian-speaking patients, cognitive or psychiatric disorders, refusal to participate or non-consent to the interview were exclusion criteria. A socio-demographic scale and the 8-item Morisky scale (MMAS-8) questionnaire assessed therapeutic adherence.

RESULTS

One hundred two DOAC-naïve patients were selected from a population of 407 patients on the first visit at our centre. The population was homogeneously represented for gender (males 48%). The mean age was 79.5 years. Atrial fibrillation (65.7%) resulted the main reason for DOAC prescription and a polypharmacy was detected in 47.1% of the patients. Moreover, an optimal adherence to DOAC therapy was assessed in less than 30% of patients.

CONCLUSIONS

Polypharmacy, patient's isolation, such as a low education level were statistically associated with a low therapeutic adherence. Therapeutic adherence remains an unsolved problem for anticoagulated patient. To identify patients at higher risk of poor compliance and therapeutic failure and establish targeted care pathways is a priority.

Associations of Chronic Medication Adherence with Emergency Room Visits and Hospitalizations

INTRODUCTION

Good medication adherence is associated with decreased healthcare expenditure; however, adherence is usually assessed for single medication. We aim to explore the associations of adherence levels to 23 chronic medications with emergency room (ER) visits and hospitalizations. The primary endpoints are ER visits and hospitalizations in internal medicine and surgical wards.

METHODS

Individuals aged 50-74 years, with a diagnosis of diabetes mellitus or hypertension, treated with at least one antihypertensive or antidiabetic medication during 2017 were included. We determined personal adherence rates by calculating the mean adherence rates of the medications prescribed to each individual. Adherence rates were stratified into categories. We retrieved information about all the ER visits, and hospitalizations in internal medicine and surgical wards during 2016-2018.

RESULTS

Of 268,792 persons included in the study, 50.6% were men. The mean age was 63.7 years. Hypertension was recorded for 217,953 (81.1%), diabetes for 160,082 (59.5%), and both diabetes and hypertension for 109,225 (40.6%). The mean number of antihypertensive and antidiabetic medications used was 2.2 ± 1.1. In total, 51,301 (19.1%) of the cohort visited the ER at least once during 2017, 21,740 (8.1%) were hospitalized in internal medicine wards, and 10,167 (3.8%) in surgical wards during 2017. Comparing the highest adherence category to the lowest, adjusted odds ratios were 0.64 (0.61, 0.67) for ER visits, 0.56 (0.52, 0.60) for hospitalization in internal wards, and 0.63 (0.57, 0.70) for hospitalization in surgical wards. Odds ratios were similar for the three consecutive years 2016-2018.

CONCLUSION

Better medication adherence was associated with fewer ER visits and hospitalizations among persons with diabetes and hypertension. Investing in improving medication adherence may reduce health costs and improve patients' health.

Exploring a New Theoretical Model to Explain the Behavior of Medication Adherence

Medication adherence is essential for optimal therapeutic outcomes. However, non-adherence with long-term therapy is at 50%. Several theoretical models have identified several key factors that could explain medication adherence. Though numerous interventions have been developed based on these theoretical models, the success rates with interventions are not the best. This paper proposes a new Hierarchical Model for Medication Adherence. In this model, we propose medication adherence as a five-tier model with medication adherence as the desirable behavior on the top of the pyramid. From the bottom of the hierarchy upwards, the skills/beliefs/behaviors to be achieved are: health literacy, belief in illness (impacted by perceived susceptibility and severity of illness), belief in medicines (impacted by treatment satisfaction), and self-efficacy (impacted by social support). The model further proposes that each individual will achieve or already have these skills/beliefs/behaviors at various levels. Screening patients for these benchmarks will enable providers to decide where to target interventions.

Content validation of a new measure of patient-reported barriers to antiretroviral therapy adherence, the I-Score: results from a Delphi study

Background

Over a third of people living with HIV (PLHIV) have suboptimal adherence to antiretroviral therapy (ART). Measures of barriers to ART adherence often lack comprehensiveness. To help manage ART adherence barriers in HIV care, we are developing a new patient-reported outcome measure (PROM) of these barriers (the I-Score).

Methods

We assessed the content validity of 100 items (distinct barriers) to retain only those most relevant to both PLHIV and HIV health/social service providers. A web-based Delphi was conducted in Canada and France, collecting data from December 2018 to October 2019. Items were evaluated on relevance (the combined rated importance and actionability for HIV care of items among both PLHIV and providers); comprehensibility (rated item clarity); comprehensiveness (examined against our conceptual framework); cross-cultural equivalence (based on comparisons by questionnaire language (English, French) and country of residence). Pearson’s chi-square tests were used for comparisons by language, country, gender, and stakeholder group (PLHIV, providers).

Results

Panelists included 40 PLHIV and 57 providers (66% response rate). Thirty-one items were retained based on consensus thresholds for relevance (minimum: 50% for PLHIV, 60% for providers) and showed good comprehensibility and comprehensiveness, when compared to our conceptual framework (representation of: 6/6 domains, 15/20 subdomains). No significant difference in relevance based on language or country was found among retained items, suggestive of cross-cultural equivalence. Among all 100 items, only 6 significant differences on relevance were observed for gender. For 62 items, the relevance ratings of PLHIV and providers differed significantly, with providers showing greater endorsement of all items but one.

Discussion

The Delphi led to a much-needed item reduction. Remaining items highlight the panel’s multidimensional priorities for the PROM on ART adherence barriers, with few, if any, differences by language, country, and gender. While the analyses may lack generalizability and power, the sample size is considered adequate for a PROM validation study.

Conclusion

Retained items showed good content validity. The different patterns of item endorsement observed underscore the utility of engaging multiple stakeholder groups in PROM development for use in clinical practice. The greater endorsement of items by providers versus patients merits further investigation, including the implications of such differentials for measure development.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-022-00435-0.

Integrating Pharmacy and Registry Data Strengthens Clinical Assessments of Patient Adherence

Background: Accurate clinical assessment of patient adherence using reliable and valid measures is essential in establishing the presence of adherence issues and support practices for pharmacists.

Objective: This investigation aims to conduct a novel assessment of patient adherence to asthma controller therapy by combining 1) patient-specific dosage data found in pharmacy dispensing data with 2) centrally collected administrative claims records, to determine the added value of using both sources of data.

Methods: A total of 381 clinically uncontrolled asthma patients, from 95 community pharmacies across three Australian States were recruited and provided consent for the retrieval of their claims records and pharmacy dispensing data. Patients were stratified as multiple or single pharmacy users and adherence scores were calculated via the proportion of days covered (PDC) method using 1) patient claims records, 2) patient pharmacy dispensing data, and 3) combined claims records and pharmacy dispensing data. Cohort and subgroup adherence estimates were then compared.

Results: Low levels of adherence were evident amongst the cohort irrespective of the data source used. PDC estimates based on claims records alone or combined claims records and pharmacy dispensing data were significantly higher than estimates based on pharmacy dispensing data for the total cohort (56%, 52%, 42% respectively, p &lt; 0.001) and more noticeably for multiple pharmacy users (67%, 64%, 35% respectively, p &lt; 0.001). PDC estimates based on combined claims records and pharmacy dispensing data were significantly lower than estimates based on claims records alone, indicating that perhaps standard daily dose is not a robust proxy for prescribed dosage to inhaled respiratory devices in adherence approximations. Poorer adherence was found amongst single pharmacy users than multiple pharmacy users when combined claims records and pharmacy dispensing data (46% compared to 64% respectively, p &lt; 0.001) or claims records alone (51% compared to 67% respectively, p &lt; 0.001) were compared.

Conclusion: Access to routine collected data increases clinical acuity over patient adherence to asthma controller medications and is a valuable resource for health care professionals. A policy of secure accessibility of such data at the patient-pharmacist or patient-GP interface may allow real-time intervention and assist in decision making across numerous therapeutic areas.

Enhancement in medication adherence amidst COVID-19 using active reminders

The aim of this study is to enhance medication adherence amidst COVID-19 with the help of active reminders. Effect of: patients' perception of side effect, importance of physicians' instructions, and their beliefs, on medication adherence were measured. Sample size was 583. The study was conducted in the state of Sikkim in India. Responses were analyzed and a structural equation model was framed to test the paths. It was found that reminders had a significant impact on patients' perception about importance given to physician instruction ( β = 0.433 ) and their beliefs ( β = 0.224 ). These mediators helped to increase the adherence rate of patients.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1140/epjs/s11734-022-00532-7.

Identifying temporal patterns of adherence to antidepressants, bisphosphonates and statins, and associated patient factors

Background

Group-based trajectory modelling (GBTM) has recently been explored internationally as an improved approach to measuring medication adherence (MA) by differentiating between alternative temporal patterns of nonadherence. To build on this international research, we use the method to identify temporal patterns of medication adherence to antidepressants, bisphosphonates or statins, and their associations with patient characteristics.

Objectives

The objectives include identification of MA types using GBTM, exploration of features and associated patient characteristics of each MA type, and identification of the advantages of GBTM compared to the traditional proportion of days covered (PDC) measure.

Data and methods

We used 45 and Up Study survey data which contains information about demographics, family, health, diet, work and lifestyle of 267,153 participants aged at least 45 years across New South Wales, Australia. This data was linked to participant records of medication use, outpatient and inpatient care, and death. Our study participants initiated use of antidepressants (9287 participants), bisphosphonates (1660 participants) or statins (10,242 participants) during 2012–2016. MA types were identified from 180-day patterns of medication use for antidepressants and 360-day patterns for bisphosphonates and statins. Multinomial and binomial logistic regressions were performed to estimate participant characteristics associated with GBTM MA and PDC MA, respectively.

Results

Three GBTM MA types were identified for antidepressants and six for bisphosphonates and statins. For all three medications, MA types included: almost fully adherent; decreasing adherence and early discontinuation. The additional nonadherent types for bisphosphonates and statins were improved adherence, low adherence and later discontinuation. Participant characteristics impacting GBTM MA and PDC MA were consistent. However, several associations were uniquely found for GBTM MA as compared to PDC MA.

Conclusion

GBTM permits clinicians, policy-makers and researchers to differentiate between alternative nonadherence patterns, allowing them to better identify patients at risk of poor adherence and tailor interventions accordingly.

•

Medication adherence was categorised using group-based trajectory modelling (GBTM).

•

GBTM categories include adherence, early discontinuation and decreasing adherence.

•

Demographic, economic, health and other factors determined GBTM categories.

•

GBTM provides additional information to better target adherence interventions.

Pharmacist Interventions for Medication Adherence: Community Guide Economic Reviews for Cardiovascular Disease

INTRODUCTION

Adherence to medications for cardiovascular disease and its risk factors is less than optimal, although greater adherence to medication has been shown to reduce the risk factors for cardiovascular disease. This paper examines the economics of tailored pharmacy interventions to improve medication adherence for cardiovascular disease prevention and management.

METHODS

Literature from inception of databases to May 2019 was searched, yielding 29 studies for cardiovascular disease prevention and 9 studies for cardiovascular disease management. Analyses were done from June 2019 through May 2020. All monetary values are in 2019 U.S. dollars.

RESULTS

The median intervention cost per patient per year was $246 for cardiovascular disease prevention and $292 for cardiovascular disease management. The median change in healthcare cost per person per year due to the intervention was -$355 for cardiovascular disease prevention and -$2,430 for cardiovascular disease management. The median total cost per person per year was -$89 for cardiovascular disease prevention, with a median return on investment of 0.01. The median total cost per person per year for cardiovascular disease management was -$1,080, with a median return on investment of 7.52, and 6 of 7 estimates indicating reduced healthcare cost averted exceeded intervention cost. For cardiovascular disease prevention, the median cost per quality-adjusted life year gained was $11,298. There were no cost effectiveness studies for cardiovascular disease management.

DISCUSSION

The evidence shows that tailored pharmacy-based interventions to improve medication adherence are cost effective for cardiovascular disease prevention. For cardiovascular disease management, healthcare cost averted exceeds the cost of implementation for a favorable return on investment from a healthcare systems perspective.

Development and testing of a framework for defining a strategy to address medication adherence during patient encounters in community pharmacies

Background

Counseling patients on medication adherence could be ameliorated in pharmacy practice. There is a lack of simple and practical strategies to address medication adherence with patients in daily practice. The goal was to develop and test a framework that allows pharmacy teams to define and apply a strategy to address medication adherence in community pharmacies.

Methods

A framework based on the principles of social marketing was developed. It consisted of 3 items: the target patient (“Who”), the target plan (“How”), and the target goal (“How many”). To test the framework, each participating pharmacy team developed their strategy by defining the 3 items and applied them during one pilot day. A master student observed the encounters between patients and pharmacy team members and used a structured checklist to document the patient's characteristics, counseling content, and strategy use. Pharmacy teams answered a feedback questionnaire at the end of the pilot day.

Results

Ten pharmacy teams were included. During a brainstorming session that lasted on average 31 ± 8 min, unique strategies comprised 18 different target patients and 20 different target plans. The planned target goal was a mean of 31 patients (range: 1 to “all”). A total of 325 encounters were observed, of which 208 patients (64%) corresponded to the predefined target patients. Medication adherence was addressed with 73 patients (22.5%), and adherence counseling was performed with 50 patients (15%). The pharmacy teams accepted the framework and judged it feasible and adaptable to their needs.

Conclusion

The proposed framework represents a simple tool that enables pharmacy teams to develop a strategy for addressing medication adherence in community pharmacies. Its adoption by pharmacy teams occurred without additional training and its integration into daily practice without difficulties. A further study is now needed to investigate if pharmacy teams can successfully engage patients in discussion on medication adherence and ultimately propose targeted adherence interventions.

•

A 3-item framework to address medication adherence in pharmacies was introduced.

•

The three framework was well received by the pharmacy teams.

•

The adoption of the 3-item framework by the pharmacy teams was simple and quick.

•

The teams chose target patient not according to known factors for poor adherence

•

Patients reacted mainly positively when asked about medication adherence

The Use of Gamification and Incentives in Mobile Health Apps to Improve Medication Adherence: Scoping Review

Background

Emerging health care strategies addressing medication adherence include the use of direct-to-patient incentives or elements adapted from computer games. However, there is currently no published evidence synthesis on the use of gamification or financial incentives in mobile apps to improve medication adherence.

Objective

The aim of this scoping review is to synthesize and appraise the literature pertaining to the use of mobile apps containing gamification or financial incentives for medication adherence. There were two objectives: to explore the reported effectiveness of these features and to describe and appraise the design and development process, including patient involvement.

Methods

The following databases were searched for relevant articles published in English from database inception to September 24, 2020: Embase, MEDLINE, PsycINFO, CINAHL, and Web of Science. The framework by Arksey and O’Malley and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist guided this scoping review. Using a systematic screening process, studies were included if incentives or game features were used within mobile apps to specifically address medication adherence. An appraisal using risk of bias tools was also applied to their respective study design.

Results

A total of 11 studies from the initial 691 retrieved articles were included in this review. Across the studies, gamification alone (9/11, 82%) was used more than financial incentives (1/11, 9%) alone or a combination of the two (1/11, 9%). The studies generally reported improved or sustained optimal medication adherence outcomes; however, there was significant heterogeneity in the patient population, methodology such as outcome measures, and reporting of these studies. There was considerable variability in the development process and evaluation of the apps, with authors opting for either the waterfall or agile methodology. App development was often guided by a theory, but across the reviewed studies, there were no common theories used. Patient involvement was not commonly evident in predevelopment phases but were generally reserved for evaluations of feasibility, acceptance, and effectiveness. Patient perspectives on gamified app features indicated a potential to motivate positive health behaviors such as medication adherence along with critical themes of repetitiveness and irrelevance of certain features. The appraisal indicated a low risk of bias in most studies, although concerns were identified in potential confounding.

Conclusions

To effectively address medication adherence via gamified and incentivized mobile apps, an evidence-based co-design approach and agile methodology should be used. This review indicates some adoption of an agile approach in app development; however, patient involvement is lacking in earlier stages. Further research in a generalized cohort of patients living with chronic conditions would facilitate the identification of barriers, potential opportunities, and the justification for the use of gamification and financial incentives in mobile apps for medication adherence.

Acceptability of and Willingness to Take Digital Pills by Patients, the Public, and Health Care Professionals: Qualitative Content Analysis of a Large Online Survey

BACKGROUND

Digital pills are pills combined with a sensor, which sends a signal to a patch connected to a smartphone when the pills are ingested. Health care professionals can access patient data from digital pills online via their own interface, thus allowing them to check whether a patient took the drug. Digital pills were developed for the stated goal of improving treatment adherence. The US Food and Drug Administration approved the first digital pills in November 2017, but the manufacturer withdrew its application to the European Medicines Agency in July 2020 because of insufficient evaluation.

OBJECTIVE

As recommended for the evaluation of health technologies, this study assesses the prospective acceptability of and willingness to take digital pills among patients, the public, and health care professionals.

METHODS

Participants were patients who were receiving long-term treatment for a chronic condition, public participants (both groups recruited from a representative sample), and health care professionals. Participants answered 5 open-ended questions regarding the acceptability of digital pills and 1 close-ended question regarding the willingness to take digital pills, which were developed in a preliminary qualitative study. We explored the 5 theoretical dimensions of acceptability by performing an abductive qualitative content analysis of all free-text responses. We assessed data saturation with mathematical models. We fitted a multivariate logistic regression model to identify the sociodemographic and health characteristics associated with the willingness to take digital pills.

RESULTS

Between January 29, 2020, and April 18, 2020, 767 patients, 1238 public participants, and 246 health care professionals provided 11,451 free-text responses. We identified 98 codes related to the acceptability of digital pills: 29 codes on perceived clinical effectiveness (eg, sensor safety cited by 66/2251 participants, 29.5%), 6 on perceived burden (eg, increased doctors' workload, 164/2251 participants, 7.3%), 25 on perceived ethicality (eg, policing, 345/2251 participants, 15.3%), 30 codes on perceived opportunity (eg, exclusively negative perception, 690/2251 participants, 30.7%), and 8 on affective attitude (eg, anger, 541/2251, 24%). Overall, 271/767 (35.3%) patients, 376/1238 (30.4%) public participants, and 39/246 (15.8%) health care professionals reported willingness to take digital pills. This willingness was associated with male sex (odds ratio 1.98, 95% CI 1.62-2.43) and current use of a connected device to record health settings (with a dose-response relationship).

CONCLUSIONS

The prospective acceptability of and willingness to take digital pills were limited by clinical and ethical concerns both at the individual and societal level. Our results suggest that digital pills should not be considered a mere change in the form of drug administration but a complex intervention requiring specific evaluation before extended use in clinical routine practice as well as an ethical and legal framework to ensure safe and ethical collection and use of health data through a patient-centered approach.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION NUMBER

ACTRN12618000410257.

Integration of a smart multidose blister package for medication intake: A mixed method ethnographic informed study of older adults with chronic diseases

Smart adherence products are marketed to assist with medication management. However, little is known about their in-home integration by older adults. It is necessary to investigate the facilitators and barriers older adults face when integrating these products into their medication taking routines before effectiveness can be examined. The aim of this study was to (a) examine the integration of a smart multidose blister package and (b) understand medication intake behaviour of adults with chronic diseases using an integrated theoretical model comprised of the Technology Acceptance Model (TAM), Theory of Planned Behaviour (TPB) and Capacity, Opportunity, Motivation and Behaviour (COM-B) Model. An ethnographic-informed study was conducted with older adults using the smart multidose blister package to manage their medications for eight weeks. Data was collected quantitatively and qualitatively using in-home observations, photo-elicitation, field notes, semi-structured interviews, system usability scale (SUS) and net promoter scale (NPS). The interview guide was developed with constructs from the TAM, TPB and COM-B Model. Data were analyzed using the Qualitative Analysis Guide of Leuven (QUAGOL) framework to generate themes and sub-themes which were mapped back to TAM, TBP and COM-B Model. Ten older adults with an average age of 76 years, of which 80% were female, participated in the study. On average, participants reported five medical conditions, while the average number of medications was 11.1. The mean SUS was 75.50 and overall NPS score was 0. Qualitative analysis identified three themes; (1) factors influencing medication intake behaviour (2) facilitators to the product use and, (3) barriers to the product use. The smart blister package was found to be easy to use and acceptable by older adults. Clinicians should assess an older adult’s medication intake behavior as well as barriers and facilitators to product use prior to recommending an adherence product for managing medications.

Racial Disparities in Medication Adherence Barriers: Pediatric Epilepsy as an Exemplar

OBJECTIVE

To evaluate how racial disparities in medication adherence barriers relate to key clinical outcomes (i.e., seizure control and adherence) in pediatric epilepsy and to identify the most critical barriers in determining health outcomes in Black youth and White youth.

METHODS

This observational study included a sample of youth aged 2-17 years with epilepsy obtained by combining data from four different studies. A total of 226 caregivers and 43 adolescents reported on adherence barriers. An electronic monitor was used to measure adherence to the primary antiepileptic drug. Racial disparities in individual barriers were examined. The relative importance of different types of barriers in determining clinical outcomes was evaluated in both Black and White youth.

RESULTS

Adherence barriers, including running out of medications, access to pharmacies, competing demands, and difficulty swallowing, disproportionally affected Black children with epilepsy compared to White children. System- and community-level barriers emerged as the most important in determining seizure outcomes among Black youth. Both system- and individual-level barriers, on the other hand, were important for adherence outcomes.

CONCLUSIONS

System- and community-level barriers, as opposed to individual-level barriers, are more highly endorsed by Black families compared to White families. These barriers are also the most critical in driving seizure outcomes among Black youth. There is a critical need to shift from a primary focus on individual-level barriers to an approach that deliberately targets larger systemic barriers to reduce the existing adherence and health disparities that affect Black children with pediatric conditions.

Attitudes and Beliefs of Primary Care Physicians Working in Saudi Arabia Regarding the Management of Low Back Pain: A Cross-Sectional Study

Introduction

Healthcare professionals’ beliefs and attitudes towards low back pain management play a significant role during treatment. This is a crucial aspect of primary care physicians working as a first point of contact for people seeking healthcare for low back pain.

Aim

To identify the beliefs and behaviors of frontline healthcare professionals (primary care physicians) working in the Riyadh region with regard to low back pain management.

Methods

A cross-sectional design was implemented, in which the Pain Attitude and Beliefs Scale (PABS) questionnaire was used along with a low back pain clinical vignette with some questions. The PABS assesses healthcare provider orientations toward low back pain with two subscales: biomedical and behavioral. In total, 400 primary care physicians working in the Riyadh region of Saudi Arabia were invited to participate.

Results

The responding primary care physicians (n = 72, response rate = 18%) provided an average score on the behavioral subscale (mean = 31.5±7.1) that was lower than that on the biomedical subscale (36.5±7.8) of the PABS. The lower scores in the biomedical subscale are associated with the using of clinical guidelines for low back pain management (χ² (1) = 4.7, p = 0.03). Moreover, providing guideline-based advices regarding activity and work was more likely to come from those scoring above the mean in the behavioral subscale.

Conclusion

The results of this study show that Saudi Arabian primary care physicians manage their patients within a biomedical framework; there is some compliance to the current low back pain clinical guidelines among these physicians, with under/post-graduate education being needed for these professionals to adopt a more biopsychosocial framework during low back pain management.

Optimizing Social Support in Oncology with Digital Platforms (Preprint)

Increased cancer prevalence and survival rates coupled with earlier patient discharges from hospitals have created a greater need for social support. Cancer care is both short term and long term, requiring acute treatments, treatments for remission, and long-term screenings and treatment regimens. Health care systems are already overwhelmed and often struggle to provide social support systems for everyone. Caregivers are limited in number, and even when they are available, they often lack necessary information, skills, or resources to meet the needs of patients with cancer. The act of caregiving presents various challenges, and caregivers themselves often need social support as well. Despite these needs, most social support programs are targeted toward patients alone. Given the prevalence of cancer and known needs of these patients and their caregivers, the ability to identify those who need social support is crucial. Further, the scalability and overall availability of social support programs is vital for successful patient care. This paper establishes the benefits of social support for both patients and caregivers coping with cancer treatments, explores innovative ways of identifying patients who may need social support using digital tools, and reviews potential advantages of digital social support programs.

Ingestible electronic sensors to measure instantaneous medication adherence: A narrative review

Objective

Medication nonadherence contributes to significant morbidity and mortality worldwide. While many techniques to measure adherence exist, digital pill systems represent a novel, direct method of measuring adherence and a means of providing instantaneous adherence supports. In this narrative review, we discuss digital pill system research based on clinical trials and qualitative investigations conducted to date and potential future applications of digital pill system in medication adherence measurement.

Methods

We conducted a literature search in PubMed of English language peer-reviewed articles describing the use of digital pill system for medication adherence measurement between 2000 and 2021. We included all articles that described the deployment of ingestible sensors and those involving qualitative investigations of digital pill system with human subjects.

Results

A total of 95 articles were found on initial search; 75 were removed based on exclusion criteria. Included articles were categorized as investigations that deployed an ingestible sensor in human populations (n = 18), or those that conducted qualitative work (n = 3). For pilot studies, the mean accuracy of the sensor to successfully detect a medication ingestion event ranged from 68% to 100%. When digital pill systems were deployed in real-world clinical settings, accuracy ranged from 68% to 90% with lower accuracy due to nonadherence to digital pill system technology. Qualitative studies demonstrated that providers and patients perceive the digital pill system as a facilitator for improving adherence and as a potential platform for delivering adherence interventions. Additionally, ingestion data from digital pill system was viewed as useful in facilitating adherence discussions between clinicians and patients.

Conclusions

This narrative review demonstrates that the use of digital pill system is broadly feasible across multiple disease states including human immunodeficiency virus, hepatitis C infection, solid organ transplants, tuberculosis, schizophrenia, cardiovascular disease, and acute fractures, where adherence is closely linked to significant morbidity and mortality. It also highlights key areas of research that are still needed prior to broad-scale clinical deployment of such systems.

Medication Adherence Among Hypertensive Patients Attending Different Primary Health Centers in Abha, Saudi Arabia: A Cross-Sectional Study

BACKGROUND AND OBJECTIVES

Optimal blood pressure control is achieved by medication adherence. This will reduce the risk of associated morbidities and mortalities. The present study aimed to determine medication adherence and its associated factors among hypertensive patients attending different primary health centers (PHC) in Abha, Saudi Arabia (KSA).

METHODS

A cross-sectional study was conducted among ten different PHCs in Abha, KSA. Simple random sampling procedure was utilized to choose 400 participants. A structured anonymous questionnaire was used in the present study. Analysis of the data was done using the SPSS program, version 23. A logistic regression statistical test was applied to identify the independent associated factors of medication adherence. Furthermore, we have applied Spearman's test to find the correlation between overall B-IPQ score and medication adherence score.

RESULTS

A total of 400 hypertensive patients responded in the present survey. More than one-third of the participants (36.3%) were in the high adherence category group, while the remaining participants (63.7%) were either low or medium adherence category. The binary logistic regression analysis revealed that low and medium adherence category is significantly associated with age (adjusted odds ratio [AOR] = 0.96, 95% CI =0.93-0.99, p = 0.021), married participants (AOR = 0.42, 95% CI =0.33-0.58, p = 0.001), residing at village (AOR = 1.49, 95% CI =1.14-1.73, p = 0.038), and participants with monthly family income of 5000 to 7000 SAR (AOR = 3.06, 95% CI =1.62-5.79, p = 0.001). A negligible positive correlation was revealed between illness perception and medication adherence.

CONCLUSION

The present study revealed that hypertensive patients poorly adhere to their antihypertensive medications. This low adherence is significantly associated with the age, monthly income, people living in rural areas, and married participants. The present study results recommend sustained efforts to implement health education programs and awareness-raising interventions targeted at hypertensive patients.

A Critical Review of Medication Adherence in Hypertension: Barriers and Facilitators Clinicians Should Consider

Hypertension is a global public health problem, and its prevalence is increasing worldwide. Impacting all human societies and socioeconomic strata, it remains the major modifiable risk factor for global burden of cardiovascular disease all-cause mortality and the leading cause of loss of disability-adjusted life years. Despite increased awareness, the rate of blood pressure control remains unsatisfactory, particularly in low- to middle-income countries. Apparent treatment-resistant hypertension is associated with worse adverse health outcomes. It includes both true resistant and pseudo-resistant hypertension, which requires out-of-office blood pressure monitoring to exclude white-coat effect and confirmation of adherence to the agreed recommended antihypertensive therapy. The depth of medication non-adherence remains poorly recognized among medical practitioners, thus presenting an underestimated modifiable risk factor. Medication non-adherence is a complex and multidimensional variable with three quantifiable phases: initiation, implementation, and discontinuation, collectively called persistence. Non-adherence can be both intentional and non-intentional and usually involves several interconnected factors. Persistence declines over time in the treatment of chronic diseases like hypertension. The risk is higher in patients with new diagnosis, poor insurance status, polypharmacy, and multiple comorbidities, particularly psychiatric disorders. The World Health Organization divides the contributing factors impacting adherence into five categories. Screening and detection for medication non-adherence are challenging due to its dynamic nature and potential white-coat effect. Easy-to-conduct screening methods have low reliability and validity, whereas more reliable and valid methods are costly and difficult to perform. Medication non-adherence is associated with poor clinical outcome and potential negative impact on health-care costs. Evaluation of adherence should become an integral part of assessment of patients treated for hypertension. Medication adherence can significantly improve with a patient-centered approach, non-judgmental communication skills, and collaborative multidisciplinary management, including engagement of the patients in their care by self-blood pressure monitoring.

Nonadherence in Hypertension: How to Develop and Implement Chemical Adherence Testing

Nonadherence to antihypertensive medication is common, especially in those with apparent treatment-resistant hypertension (true treatment-resistant hypertension requires exclusion of nonadherence), and its routine detection is supported by clinical guidelines. Chemical adherence testing is a reliable and valid method to detect adherence, yet methods are unstandardized and are not ubiquitous. This article describes the principles of chemical adherence testing for hypertensive patients and provides a set of recommendations for centers wishing to develop the test. We recommend testing should be done in either of two instances: (1) in those who have resistant hypertension or (2) in those on 2 antihypertensives who have a less than 10 mm Hg drop in systolic blood pressure on addition of the second antihypertensive medication. Furthermore, we recommend that verbal consent is secured before undertaking the test, and the results should be discussed with the patient. Based on medications prescribed in United Kingdom, European Union, and United States, we list top 20 to 24 drugs that cover >95% of hypertension prescriptions which may be included in the testing panel. Information required to identify these medications on mass spectrometry platforms is likewise provided. We discuss issues related to ethics, sample collection, transport, stability, urine versus blood samples, qualitative versus quantitative testing, pharmacokinetics, instrumentation, validation, quality assurance, and gaps in knowledge. We consider how to best present, interpret, and discuss chemical adherence test results with the patient. In summary, this guidance should help clinicians and their laboratories in the development of chemical adherence testing of prescribed antihypertensive drugs.

Electronic Smart Blister Packages to Monitor and Support Medication Adherence: A Usability Study

PURPOSE

An electronic version of the Dosepak^® (EDP) which records date and time of dosing events has been developed to monitor adherence to medication packaged in blisters. This study aimed to evaluate its usability and acceptance and to monitor dose-taking adherence for optimal implementation in future clinical trials and practice.

METHODS

Healthy volunteers aged over 18 years were asked to dispense placebo tablets twice daily from EDPs equipped with a re-usable electronic module for a total duration of four weeks. Afterwards, subjects were asked to complete an online questionnaire and partake in a short one-on-one interview. The usability of the EDP was assessed using the System Usability Scale (SUS), while dose-taking adherence was monitored by EDP records, pill counting, and self-report. The short interview explored user experiences in more detail.

RESULTS

Twenty subjects with median [IQR] age 41.5 [32-49.8] years, 55% female, 45% healthcare professionals, and 20% chronic medication users completed the study and found the EDP easy to use, with a mean [SD] SUS score of 78.0 [11.2]. Median [IQR] dose-taking adherence was 89% [82-95%] based on EDP records, 96.5% [89-100%] based on pill counting, 92% [91-96%] based on self-report, and the levels differed significantly (p < 0.05). Four themes emerged from the interviews: user preference, experience, patient burden, and ideas for improvement. Most participants preferred smaller sized blisters. They found the EDP simple to use and did not see any patient burden for its use in trials or clinical practice. Some reported forgetfulness and suggested reminders built into the blister or sent to their mobile phones. Adequate information or instruction should also be provided for older people and polypharmacy patients.

CONCLUSION

EDP had good perceived usability, was well accepted, and differed significantly from other adherence measurement methods. This study provides input to further guide scale-up of the blister packages.

A Systematic Analysis of Reviews Exploring the Scope, Validity, and Reporting of Patient-Reported Outcomes Measures of Medication Adherence in Type 2 Diabetes

INTRODUCTION

Non-adherence to medicines is estimated to cost billions to healthcare providers across the US and Europe each year. Addressing medication adherence (MA) can be challenging. Patient-reported outcome measures (PROMs) have been developed to collect self-reported data on MA, among other behaviours. Despite the myriad PROMs available and their widespread implementation in research, there is little commentary or standardization on the way they are reported, or their validity assessed. This review aims to provide a comprehensive analysis of systematic reviews (SRs) that report PROMs of MA with a focus on type 2 diabetes to explore PROM reporting and validity.

MATERIALS AND METHODS

A literature search was conducted using the following databases: PubMed, EMBASE, CINAHL, Cochrane, and Web of Science. SRs reporting on PROMs related to MA behaviour in patients living with type 2 diabetes were included. Any SR published in English prior to December 2021 was included. Abstract and title screening were performed prior to full-text review by two independent researchers with discrepancies managed by a third. Protocols and SRs reporting on paediatric populations were excluded.

RESULTS

A total of 19 eligible SRs that included 241 unique PROM studies were captured from the initial 2074 records that were identified. Data were captured across a 30-year scope, with roughly half (47.4%, n=9/19) of the SRs published in the last 5 years. In total, 104 unique PROMs were identified. Inclusion of non-validated PROMs was identified in 63.2% (n=12/19) of the included SRs, and reporting issues were identified in 47.3% of studies (n=114/241). A lower journal impact factor was significantly associated with a higher prevalence of validity issues (r=0.44, p=0.04).

CONCLUSION

There are a broad range of available PROMs; however, they have been reported inconsistently in the literature, often lacking significant evidence with respect to validity criteria. Standardization of reporting and assessments of validity may help to address this.

Fracture rates and economic outcomes in patients with osteoporosis prescribed risedronate gastro-resistant versus other oral bisphosphonates: a claims data analysis

Patients with osteoporosis prescribed risedronate gastro-resistant had a lower incidence of fractures versus those prescribed other oral bisphosphonates. Administration of risedronate gastric-resistant does not require fasting, and this more convenient dosing administration may explain its improved efficacy.

PURPOSE

Up to half of patients do not follow complex dosing instructions of immediate-release bisphosphonates used for the prevention of osteoporotic fractures, which can result in suboptimal effectiveness. Risedronate gastro-resistant (GR) offers a more convenient dosing option by eliminating the need for fasting. This study compares fracture rates and outcomes between osteoporosis women treated with risedronate GR (GR cohort) versus other oral bisphosphonates (other cohort).

METHODS

Claims from women with osteoporosis in the USA were analyzed. Patients were classified into the two cohorts based on the first oral bisphosphonate observed (index date) and matched 1:1 based on patient characteristics. Patients were observed for ≥ 2 years following the index date. Fracture rates, health care resource utilization and costs, and treatment persistence were compared.

RESULTS

In total, 2,726 patients were selected in each cohort (median age: 60.0 years). The incidence of fractures was lower in the GR versus the other cohort for any fracture sites (incidence rate ratio, 95% CI: 0.83, 0.70-0.97) and spine fractures (0.71, 0.54-0.95), although the respective rate of medication discontinuation at 2 years was 80.5% and 74.4%. Time to first fracture was delayed for the GR cohort, reaching statistical significance after 36 months. The GR cohort incurred fewer hospitalizations (incidence rate per 1,000 patient-years: GR = 106.74; other = 124.20, p < 0.05) translating into lower hospitalization costs per patient per year (GR = $3,611; other = $4,603, p < 0.05).

CONCLUSIONS

Patients prescribed risedronate GR versus other bisphosphonates had a lower incidence of fractures, which may be explained by the fact that the GR formulation is absorbed even when taken with food.

Estimating proportion of days covered (PDC) using real-world online medicine suppliers' datasets

BACKGROUND

The proportion of days covered (PDC) is used to estimate medication adherence by looking at the proportion of days in which a person has access to the medication, over a given period of interest. This study aimed to adapt the PDC algorithm to allow for plausible assumptions about prescription refill behaviour when applied to data from online pharmacy suppliers.

METHODS

Three PDC algorithms, the conventional approach (PDC1) and two alternative approaches (PDC2 and PDC3), were used to estimate adherence in a real-world dataset from an online pharmacy. Each algorithm has different denominators and increasing levels of complexity. PDC1, the conventional approach, is the total number of days between first dispensation and a defined end date. PDC2 counts the days until the end of supply date. PDC3 removes from the denominator specifically defined large gaps between refills, which could indicate legitimate reasons for treatment discontinuation. The distribution of the three PDCs across four different follow-up lengths was compared.

RESULTS

The dataset included people taking ACE inhibitors (n = 65,905), statins (n = 100,362), and/or thyroid hormones (n = 30,637). The proportion of people taking ACE inhibitors with PDC ≥ 0.8 was 50-74% for PDC1, 81-91% for PDC2, and 86-100% for PDC3 with values depending on drug and length of follow-up. Similar ranges were identified in people taking statins and thyroid hormones.

CONCLUSION

These algorithms enable researchers and healthcare providers to assess pharmacy services and individual levels of adherence in real-world databases, particularly in settings where people may switch between different suppliers of medicines, meaning an individual supplier's data may show temporary but legitimate gaps in access to medication. Accurately identifying problems with adherence provides the foundation for opportunities to improve experience, adherence and outcomes and to reduce medicines wastage. Research with people taking medications and prescribers is required to validate the algorithms' assumptions.

Reevaluating medication adherence in the era of digital health

INTRODUCTION

Medication adherence is a worldwide issue impacting more than half the population. The cost associated with nonadherence is tremendous and has spurred the growth of novel technologies to address this growing problem.

AREAS COVERED

This perspective covers the different digital health medication adherence tools that have come to market in the past decade and their clinical impact. These digital interventions and their applicability to medication adherence across different stakeholders are then evaluated.

EXPERT OPINION

Digital health will play a significant role in creating new pathways to care in the 2020s. However, the current design of medication adherence tools has not demonstrated a clinical impact that will be relevant for the digital health space without a change in redesign factoring in relevant stakeholders' incentives to address adherence issues. A focus on only adherence has not yielded the economic or clinical benefit as expected, which is likely due to a lack of focus on broader drug-related problems (DRPs) that are causative factors beyond adherence alone. As such, adherence tools will see disparate uptake, likely due to condition-specific interventions rather than adherence issues as a whole, and future endeavors will need to address the larger DRP considerations to actualize clinical outcomes.

Interventions for improving medication adherence in community-dwelling older people with multimorbidity: A systematic review and meta-analysis

BACKGROUND

Multimorbidity is highly prevalent amongst older people. Compared with those with a single disease, older people with multimorbidity are more susceptible to medication nonadherence, which causes adverse health outcomes and increased health care costs. The effectiveness of interventions for improving medication adherence in this population is still unclear.

OBJECTIVE

To evaluate the effectiveness of interventions to improve medication adherence for community-dwelling older people with multimorbidity.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Ten databases: Airiti Library, China National Knowledge Infrastructure, Cochrane CENTRAL, EBSCO CINAHL, OVID EMBASE, OVID MEDLINE, Proquest Central, PsycINFO, Wanfang Database and Web of Science Core Collection.

REVIEW METHODS

Studies evaluating the effects of interventions on medication adherence in community-dwelling older people with multimorbidity were included. Two researchers independently performed the study selection, data extraction and risk assessment. Intervention effects were pooled by random-effects meta-analysis.

RESULTS

A total of nine studies with 3,292 participants were included. Studies on self-management interventions revealed a significant and modest improvement in medication adherence (n = 3 studies; SMD 0.52; 95% CI 0.04 to 0.99; p = 0.03, I² = 43%). Studies using electronic health interventions demonstrated a small yet significant benefit for medication adherence (n = 2 studies; SMD 0.22; 95% CI 0.02 to 0.42; p = 0.03, I² = 0%). There was no pooled significant effect of medication review on medication adherence (n = 4 studies; SMD -0.03; 95% CI -0.21 to 0.15; p = 0.74, I² = 68%). Most of the studies failed to yield a significant improvement in patients' health outcomes.

CONCLUSIONS

Self-management interventions and electronic health interventions might be effective in improving medication adherence for older people with multimorbidity. Future adherence interventions are needed to demonstrate improvements in medication adherence and health outcomes.

PROSPERO REGISTRATION NUMBER

CRD42020150500.

Prevalence and predictors of cost-related medication nonadherence in individuals with cardiovascular disease: Results from the Behavioral Risk Factor Surveillance System (BRFSS) survey

Medication nonadherence is highly prevalent among patients with chronic cardiovascular disease. Poor adherence has been associated with increased morbidity and mortality. Medication cost is a major driver for medication nonadherence. Utilizing data from the 2016 to 2018 Behavioral Risk Factor Surveillance System (BRFSS) survey, we estimated the prevalence of cost-related medication nonadherence (CRMNA) among the overall population and among individuals who reported a history of diabetes, atherosclerotic cardiovascular disease (ASCVD), or hypertension. We then performed multivariable logistic regression to analyze sociodemographic factors associated with CRMNA. Our study population consisted of 142,577 individuals of whom 24% were older than 65 years, 47% were men, 66% were White, 17% Black, 35% had hypertension, 13% had diabetes mellitus, and 10% had ASCVD. CRMNA was reported in 10% of the overall population, 12% among those with hypertension, 17% among those with diabetes, and 17% among those with ASCVD. Age below 65 years, female gender, unemployment, lower income, lower educational attainment, having at least 1 comorbidity, and living in a state that did not expand Medicaid were independently associated with CRMNA. The prevalence of CRMNA increased with greater number of these high-risk sociodemographic factors. We conclude that the prevalence of CRMNA is 10% among U.S. adults overall and is higher among those with common chronic diseases. Risk factors associated with CRMNA should be addressed in order to improve adherence rates and health outcomes among high-risk individuals.