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

Mismatching Among Guidelines, Providers, and Parents on Controller Medication Use in Children with Asthma

BACKGROUND

Underuse of controller medicines among children with asthma remains widespread despite national guidelines.

OBJECTIVES

To (1) assess provider prescribing patterns for asthma controller medications; (2) assess how frequently parents' reports of their child's asthma controller medicine use were mismatched with their provider's recommendations; and (3) evaluate parent attitudes and demographic characteristics associated with these mismatches.

METHODS

In this cross-sectional study, we conducted linked surveys of parents and providers of children with probable persistent asthma in a Medicaid program and 4 commercial health plans in 2011. Probable persistent asthma was defined as a diagnosis of asthma and 1 or more controller medication dispensing.

RESULTS

This study included 740 children (mean age, 8.6 years). Providers for 50% of the children reported prescribing controller medications for daily year-round use, 41% for daily use during active asthma months, and 9% for intermittent use for relief. Among parents, 72% knew which class of controller medication the provider prescribed and 49% knew the administration frequency and the medication class. Parents were less likely to report the same controller medication type as the provider, irrespective of dose and frequency, if they were Latino (odds ratio [OR], 0.23; CI, 0.057-0.90), had a household smoker (OR, 2.87; CI, 0.42-19.6), or believed the controller medicine was not helping (OR, 0.15; CI, 0.048-0.45).

CONCLUSIONS

Mismatches between parent reports and providers intentions regarding how the child was supposed to use inhaled steroids occurred for half of the children. Efforts should focus on ways to reduce mismatches between parent and provider intentions regarding controller medication use.

Defining and Measuring Primary Medication Nonadherence: Development of a Quality Measure

Poor medication adherence has been increasingly recognized as a major public health issue and a priority for health care reform. Primary medication nonadherence (PMN) is a subset of this broader subject and occurs when a new medication is prescribed for a patient, but the patient does not obtain the medication, or an appropriate alternative, within an acceptable period of time after it was prescribed. It is increasingly evident that the public health problem of PMN is widespread. However, the lack of standardized definitions and measures inhibits the ability to establish the true incidence of this problem or to track changes in PMN rates over time. Given the limitations of current measures, the Pharmacy Quality Alliance (PQA) convened an expert working group to set parameters for a new industry measure. That new measure, which links electronic prescribing and pharmacy dispensing databases and was developed and approved by the PQA, is described here. PMN literature from 1990 to June 2015 is also reviewed, and existing PMN measures are summarized.

DISCLOSURES

No funding was received for this article, and the authors declare no conflicts of interest. The views expressed in this article are those of the authors alone and do not necessarily reflect those of their respective employers. Adams has received grant support from Pfizer for adherence research. Adams and Stolpe were equally involved in all aspects of study design, data collection and interpretation, and manuscript preparation.

Missing clinical and behavioral health data in a large electronic health record (EHR) system

OBJECTIVE

Recent massive investment in electronic health records (EHRs) was predicated on the assumption of improved patient safety, research capacity, and cost savings. However, most US health systems and health records are fragmented and do not share patient information. Our study compared information available in a typical EHR with more complete data from insurance claims, focusing on diagnoses, visits, and hospital care for depression and bipolar disorder.

METHODS

We included insurance plan members aged 12 and over, assigned throughout 2009 to a large multispecialty medical practice in Massachusetts, with diagnoses of depression (N = 5140) or bipolar disorder (N = 462). We extracted insurance claims and EHR data from the primary care site and compared diagnoses of interest, outpatient visits, and acute hospital events (overall and behavioral) between the 2 sources.

RESULTS

Patients with depression and bipolar disorder, respectively, averaged 8.4 and 14.0 days of outpatient behavioral care per year; 60% and 54% of these, respectively, were missing from the EHR because they occurred offsite. Total outpatient care days were 20.5 for those with depression and 25.0 for those with bipolar disorder, with 45% and 46% missing, respectively, from the EHR. The EHR missed 89% of acute psychiatric services. Study diagnoses were missing from the EHR's structured event data for 27.3% and 27.7% of patients.

CONCLUSION

EHRs inadequately capture mental health diagnoses, visits, specialty care, hospitalizations, and medications. Missing clinical information raises concerns about medical errors and research integrity. Given the fragmentation of health care and poor EHR interoperability, information exchange, and usability, priorities for further investment in health IT will need thoughtful reconsideration.

Physician Perception of Patient Medication Adherence in a Cohort of Medicare Advantage Plans in Texas

BACKGROUND

Prescription medication adherence is a known health-related barrier for elderly patients, leading to insufficient disease control and negative health outcomes. The Centers for Medicare & Medicaid Services (CMS) have placed significant emphasis on medication adherence, through the Part D star measures, revolving around treatment for chronic disease states such as hypertension, diabetes, and hyperlipidemia. However, it is unclear if physicians fully grasp the extent of nonadherence within their patient populations with regard to these medications, specifically those patients enrolled in Medicare Advantage Prescription Drug (MA-PD) plans.

OBJECTIVES

To (a) determine physicians' perceptions of medication adherence among their patients enrolled in MA-PD plans and (b) compare those perceptions with actual adherence rates obtained from claims data.

METHODS

A survey was developed and administered to primary care physicians (PCPs) contracted within a Texas MA-PD plan. The previously validated questionnaire was distributed during an all-PCP quarterly meeting and was collected prior to the meeting's conclusion to increase completion and return rates. PCPs were requested to indicate what percentage of their patients they believed to be adherent to each of the CMS Part D star medication classes, which includes statins, oral antidiabetic drugs (OADs), and reninangiotensin system (RAS) antagonists; what financial category they believe the majority of their patients fall under; and what percentage of their patients receive samples. The PCPs' perceived percentage of adherent patients were compared with the calculated percentage of patients, using a chi-square test at an a priori alpha level of 0.05. The calculated adherence was obtained from pharmacy claims data, meeting the CMS targeted adherence threshold (≥ 80%). This adherence rate was calculated using proportion of days covered (PDC) for all 3 medication categories in each PCP's patient population.

RESULTS

To compare PCP perception of patient adherence and actual adherence, 226 PCPs were used. The sample population shared similar sex and age distribution with the national physician average; however, there was more racial diversity represented. PCP perception of patient adherence, as well as the actual percentage of adherent patients, were significantly (P < 0.05) different across statins, OADs, and RAS antagonists; lowest perceived percentage, as well as actual percentage, were reported for statins. PCP perception of patient adherence and actual percentage of adherent patients were significantly different in the 3 medication categories. PCPs' correct estimations were significantly (P < 0.0001) lower than expected values, while over- and underestimations were significantly (P < 0.0001) higher than the expected values.

CONCLUSIONS

PCPs were almost equally likely to over- or underestimate percentage of adherent patients in their patient pools.

Adherence to Medication Regimens is an Effective Indicator of Cognitive Dysfunction in Elderly Individuals

BACKGROUND

Cognitive abilities strongly influence medication adherence among elderly individuals. We aimed to evaluate the relationship between medication adherence and cognitive decline using Lawton's instrumental activities of daily living (IADL) scoring system and the Mini-Mental State Examination (MMSE).

METHODS

Receiver-operating characteristic (ROC) curves were used to evaluate the IADL scores and MMSE results.

RESULTS

The ROC curve analysis of the IADL and MMSE results revealed that the shopping (MMSE cutoff = 22 points, sensitivity = 0.726, and specificity = 0.683) and responsibility for own medications (MMSE cutoff = 22 points, sensitivity = 0.759, and specificity = 0.720) categories were associated with declining IADL scores during early stage cognitive dysfunction.

CONCLUSION

Declining IADL scores in the shopping and responsibility for own medications categories may be effective indices for predicting early-stage cognitive dysfunction in elderly individuals. Cognitive dysfunction screening at pharmacy counters may be useful.

Field studies versus database studies on the risks and benefits of medication use during pregnancy: Distinct pieces of the same puzzle

Over the past two decades, findings on medication use during pregnancy have been accumulating from observational data. Generally, field studies with prospective recruitment of subjects have better outcome ascertainment, and more control on the longitudinal collection of data, but have lower sample sizes and thus they often lack statistical power to detect increased risks for rare events such as major congenital malformations. In addition, given the rarity of specific drug exposures in a population, even relatively common outcomes, such as low birth weight, may become rare in combination with the specific exposure. On the other hand, administrative databases usually provide larger samples and thus increased statistical power, decrease the probability of selection and recall bias, but often have missing data on potential confounders. Hence, debate amongst researchers, regulators and public health officials has been ongoing with regard to the most appropriate study populations for perinatal epidemiologic research. With this commentary, we aim to highlight the importance of both study populations, which can make complementary and crucial contributions to the iterative determination of causality as well as discuss basic epidemiologic principles that need to be applied in the field of perinatal pharmacoepidemiology for the purpose of causality assessment. This is relevant at present given that the United States Food and Drug Administration (US FDA) has modified their medication label requirements, especially given the international importance of these modifications.

Influence of exercise training on proangiogenic TIE-2 monocytes and circulating angiogenic cells in patients with peripheral arterial disease

BACKGROUND

Inflammation is the driving force in atherosclerosis. One central strategy in the treatment of peripheral arterial disease (PAD) is the promotion of angiogenesis. Here, proangiogenic Tie-2 expressing monocytes (TEM) and circulating angiogenic cells (CAC) play a crucial role. Exercise training (ET) is recommended in PAD patients at Fontaine stage II to promote angiogenesis.

METHODS

40 patients with intermittend claudication (IC) [2 groups: supervised ET (SET) vs. non-supervised ET (nSET), each n = 20] and 20 healthy controls were included in the study. Analysis of TEM and CAC was performed from whole blood by flow-cytometry. TEM were identified via CD45, CD86, CD14, CD16 and analysed for the expression of Tie-2. CAC were identified via their expression of CD45 (CD45dim), CD34 and VEGF-R2 (CD309/KDR). Follow up was performed after mean of 7.65 ± 1.62 months.

RESULTS

In comparison to healthy controls, we found increased proportions of CAC (p < 0.0001) and similar TEM numbers in both ET groups. At follow-up (FU) TEM poroportions increased (p < 0.001) and CAC proportions decreased (p < 0.01), but both more significantly in SET (p < 0.001) than nSET (p = 0.01). Only in SET fibrinogen levels decreased and VEGF-A increased (both p < 0.05). Finally, we found in both ET groups a significant increase in absolute walking distance but with a higher individual increase in SET (p < 0.01). TEM and CAC proportions correlated inversely with the absolute walking distance (CAC: r = -0.296, p = 0.02; TEM: r = -0.270, p = 0.04) as well as with ABI (CAC: r = -0.394, p < 0.01; TEM: r = -0.382, p < 0.01).

CONCLUSIONS

ET influences the distribution of CAC and TEM proportions. nSET, although still effective in regard to an improved walking distance, is less effective in the influence of proangiogenic cells and inflammatory burden than SET. Our results indicate SET to be a more preferential exercise form, supporting the necessity to establish more SET programs.

A Pilot Study Using a Web Survey to Identify Characteristics That Influence Hypogonadal Men to Initiate Testosterone Replacement Therapy

Men with hypogonadism (HG) who choose testosterone replacement therapy (TRT) may have distinct characteristics that provide insight as to why they may/may not initiate therapy. The aim of the current study was to identify trends in patient characteristics and attitudes in men diagnosed with HG who initiated TRT (TRT+) compared with men who were diagnosed with HG but did not initiate TRT (TRT-). The market research-based online survey conducted between 2012 and 2013 included patients from a Federated Sample, a commercially available panel of patients with diverse medical conditions. The current analysis was composed of two groups: TRT+ ( n = 155) and TRT- ( n = 157). Patient demographics, clinical characteristics, and attitudes toward HG and TRT were examined as potential predictors of primary adherence in men with HG; cohorts were compared by using Fisher's exact test. Significant associations among sexual orientation, relationship status, educational level, presence of comorbid erectile dysfunction, area of residence, and TRT initiation were present ( p ≤ .05). College-educated, heterosexual, married men with comorbid erectile dysfunction living in suburban and urban areas were more likely to initiate treatment. The most bothersome symptoms reported were lack of energy (90% vs. 81%, p = .075), decreased strength and endurance (86% vs. 76%, p = .077), and deterioration in work performance (52% vs. 31%, p = .004); lack of energy prompted men to seek help. Patients (48%) in the TRT+ group were more knowledgeable regarding HG as compared with TRT- respondents (14%, p < .001), and most men obtained their information from a health care professional (89% vs. 82%, p = .074). The current analysis identified distinct demographic and clinical characteristics and attitudes among TRT users compared with men who were diagnosed with HG yet remained untreated.

Adherence to medication and drug monitoring in apparent treatment-resistant hypertension

Poor drug adherence is one of the main reasons for the failure to achieve treatment targets in hypertensive patients. In patients who receive pharmacological treatment, assessment of drug adherence is of the utmost importance. The aim of this review is to present an update of the methods available to reveal and monitor non-adherence in patients with apparent treatment-resistant hypertension. Methods for monitoring adherence are divided into indirect and direct methods. The indirect methods are mainly based on self-reported adherence and can easily be manipulated by the patient. Directly observed therapy and therapeutic drug monitoring are examples of direct methods. There are limitations and advantages to all of the methods, and because of the patient's ability to manipulate the outcome of indirect methods, direct methods should be preferred. Therapeutic drug monitoring and directly observed therapy with subsequent ambulatory blood pressure measurement are considered to be reliable methods and should be used more in the routine assessment of patients with apparent treatment-resistant hypertension.

Persistence and compliance with newly initiated antihypertensive drug treatment in patients with chronic kidney disease

BACKGROUND

Patients with chronic kidney disease initiating an antihypertensive drug (AH) treatment must persist and comply with it to slow disease progression and benefit from the reduction of cardiovascular morbidity and mortality.

OBJECTIVES

This study evaluates the persistence and compliance with AH treatment and identifies the associated factors among chronic kidney disease patients who initiated AH treatment.

METHODS

A population-based cohort study using Quebec administrative data was conducted. Patients who still take any AH 1 year after initiation were considered persistent. Of these patients, those who had ≥80% of days covered with an AH in the year after initiation were considered compliant. Factors associated with persistence and compliance were identified using a modified Poisson regression.

RESULTS

Of the 7,119 eligible patients, 78.8% were persistent, 87.7% of whom were compliant with their AH treatment. Compared with patients on diuretic monotherapy, those who initially used angiotensin-converting enzyme inhibitor monotherapy, angiotensin II receptor blocker monotherapy, calcium channel blocker monotherapy, β-blocker monotherapy, or multidrug therapy were more likely to be persistent. In contrast, individuals who visited their physicians ≥17 times were less likely to be persistent than those who visited between 0 and 8 times. The patients who were more likely to be compliant had initially used an angiotensin-converting enzyme inhibitor, β-blocker, calcium channel blocker, or multitherapy as opposed to a diuretic.

CONCLUSION

A year after initiating AH treatment, nearly a third of chronic kidney disease patients were either not taking an AH or had not been compliant. Factors associated with persistence and compliance could help identify patients who need help in managing their AH treatment.

Poor medication adherence in type 2 diabetes: recognizing the scope of the problem and its key contributors

At least 45% of patients with type 2 diabetes (T2D) fail to achieve adequate glycemic control (HbA1c <7%). One of the major contributing factors is poor medication adherence. Poor medication adherence in T2D is well documented to be very common and is associated with inadequate glycemic control; increased morbidity and mortality; and increased costs of outpatient care, emergency room visits, hospitalization, and managing complications of diabetes. Poor medication adherence is linked to key nonpatient factors (eg, lack of integrated care in many health care systems and clinical inertia among health care professionals), patient demographic factors (eg, young age, low education level, and low income level), critical patient beliefs about their medications (eg, perceived treatment inefficacy), and perceived patient burden regarding obtaining and taking their medications (eg, treatment complexity, out-of-pocket costs, and hypoglycemia). Specific barriers to medication adherence in T2D, especially those that are potentially modifiable, need to be more clearly identified; strategies that target poor adherence should focus on reducing medication burden and addressing negative medication beliefs of patients. Solutions to these problems would require behavioral innovations as well as new methods and modes of drug delivery.

Primary adherence to antidepressant prescriptions in primary health care: a population-based study in Sweden

BACKGROUND

Medical adherence is important in the treatment of depression. Primary medical adherence, i.e. patients collecting their newly prescribed medications from pharmacies, is very different depending on the drug prescribed

OBJECTIVE

To assess the rate of primary medical adherence in patients prescribed antidepressants and to identify characteristics that make patients less likely to pick up prescriptions.

METHODS

An observational study was performed using primary health care data from Sweden on patients who were prescribed antidepressants. Univariate and multivariate logistic regression was used to determine differences in pick-up rate according to patient characteristics.

MAIN OUTCOME

Pick-up rate, defined as collection of a prescription within 30 days.

RESULTS

A total of 11 624 patients received an antidepressant prescription during the study period, and the overall pick-up rate was 85.1%. The pick-up rate differed according to country of birth: individuals born in the Middle East and other countries outside Europe had lower primary medical adherence than Swedes, with adjusted odds ratios (ORs) of 0.58 and 0.67, respectively. Patients at ages 64-79 years had a higher pick-up rate compared with those aged 25-44 years (OR 1.71). Divorced patients had a lower rate compared with married patients (OR 0.80).

CONCLUSION

Immigrants from the Middle East and other countries outside Europe and younger and divorced patients had lower primary medical adherence, which calls for clinical attention and preventive measures. KEY POINTS Primary medical adherence is important in the treatment of depression. Are patient characteristics associated with primary medical adherence? The overall primary medical adherence rate was 85%. The rate differed by country of birth, age at diagnosis of depression, and marital status. Clinical attention is needed in patients who do not pick up their antidepressants.

Adherence to Medical Cannabis Among Licensed Patients in Israel

Objectives: To evaluate adherence among Israeli patients who are licensed to use medical cannabis and to identify factors associated with adherence to medical cannabis. Methods: Ninety-five novice licensed patients were interviewed for this cross-sectional study. The questionnaire measured demographics, the perceived patient-physician relationship, and the level of patients' active involvement in their healthcare. In addition, patients were queried about adverse effect(s) and about their overall satisfaction from this medical treatment. Results: Eighty percent (n=76) has been identified as adherent to medical cannabis use. Variables found associated with adherence were "country of origin" (immigrant status), "type of illness" (cancer vs. non-cancer), and "experiencing adverse effect(s)." Three predictors of adherence were found significant in a logistic regression model: "type of illness" (odds ratio [OR] 0.101), patient-physician relationship (OR 1.406), and level of patient activation (OR 1.132). 71.5% rated themselves being "completely satisfied" or "satisfied" from medical cannabis use. Conclusions: Our findings show a relatively high adherence rate for medical cannabis, as well as relative safety and high satisfaction among licensed patients. Additionally indicated is the need to develop and implement standardized education about this evolving field-to both patients and physicians.

Adherence to Treatment in Hypertension

The lack of adherence to treatment in hypertension affects approximately 30 % of patients. The elderly, those with several co-morbidities, social isolation, low incomes or depressive symptoms are the most vulnerable to this problem. There is no ideal method to quantify the adherence to the treatment. Indirect methods are recommended in clinical practice. Any intervention strategy should not blame the patient and try a collaborative approach. It is recommended to involve the patient in decision-making. The clinical interview style must be patient-centered including motivational techniques. The improvement strategies that showed greater effectiveness in the compliance of hypertension treatment were: treatment simplification, appointment reminders systems, blood pressure self-monitoring, organizational improvements and nurse and pharmacists care. The combination of different interventions are recommended against isolated interventions.

Primary adherence to controller medications for asthma is poor

RATIONALE

Few previous studies have evaluated primary adherence (whether a new prescription is filled within 30 d) to controller medications in individuals with persistent asthma.

OBJECTIVE

To compare adherence to the major controller medication regimens for asthma.

METHODS

This was a retrospective cohort study of enrollees from five large health plans. We used electronic medical data on patients of all ages with asthma who had experienced an asthma-related exacerbation in the prior 12 months. We studied adherence measures including proportion of days covered and primary adherence (first prescription filled within 30 d).

MEASUREMENTS AND MAIN RESULTS

Our population included 69,652 subjects who had probable persistent asthma and were prescribed inhaled corticosteroids (ICSs), leukotriene antagonists (LTRAs), or ICS/long-acting β-agonists (ICS/LABAs). The mean age was 37 years and 58% were female. We found that 14-20% of subjects who were prescribed controller medicines for the first time did not fill their prescriptions. The mean proportion of days covered was 19% for ICS, 30% for LTRA, and 25% for ICS/LABA over 12 months. Using multivariate logistic regression, subjects prescribed LTRA were less likely to be primary adherent than subjects prescribed ICS (odds ratio, 0.82; 95% confidence interval, 0.74-0.92) or ICS/LABA (odds ratio, 0.88; 95% confidence interval, 0.80-0.97). Black and Latino patients were less likely to fill the prescription compared with white patients.

CONCLUSIONS

Adherence to controller medications for asthma is poor. In this insured population, primary adherence to ICSs was better than to LTRAs and ICS/LABAs. Adherence as measured by proportion of days covered was better for LTRAs and ICS/LABAs than for ICSs.

Counterpoint: the treatment decision design

The comparative new-user design is a principled approach to learning about the relative risks and benefits of starting different treatments in patients who have no history of use of the treatments being studied. Vandenbroucke and Pearce (Am J Epidemiol. 2015;182(10):826-833) discuss some problems inherent in incident exposure designs and argue that epidemiology may be harmed by a rigid requirement that follow-up can only begin at first exposure. In the present counterpoint article, a range of problems in pharmacoepidemiology that do not necessarily require that observation begin at first exposure are discussed. For example, among patients who are past or current users of a medication, we might want to know whether treatment should be augmented, switched, restarted, or discontinued. To answer these questions, a generalization of the new-user design, the treatment decision design, which identifies cohorts anchored at times when treatment decisions are being made, such as the evaluation of laboratory parameters, is discussed. The design aims to provide estimates that are directly relevant to physicians and patients, helping them to better understand the risks and benefits of the different treatment choices that they are considering.

Individualized Risk Communication and Outreach for Primary Cardiovascular Disease Prevention in Community Health Centers: Randomized Trial

BACKGROUND

Many eligible primary cardiovascular disease prevention candidates are not treated with statins. Electronic health record data can identify patients with increased cardiovascular disease risk.

METHODS AND RESULTS

We performed a pragmatic randomized controlled trial at community health centers in 2 states. Participants were men aged ≥35 years and women ≥45 years, without cardiovascular disease or diabetes mellitus, and with a 10-year risk of coronary heart disease of at least 10%. The intervention group received telephone and mailed outreach, individualized based on patients' cardiovascular disease risk and uncontrolled risk factors, provided by lay health workers. Main outcomes included: documented discussion of medication treatment for cholesterol with a primary care clinician, receipt of statin prescription within 6 months, and low-density lipoprotein (LDL)-cholesterol repeated and at least 30 mg/dL lower than baseline within 1 year. Six hundred forty-six participants (328 and 318 in the intervention and control groups, respectively) were included. At 6 months, 26.8% of intervention and 11.6% of control patients had discussed cholesterol treatment with a primary care clinician (odds ratio, 2.79; [95% confidence interval, 2.25-3.46]). Statin prescribing occurred for 10.1% in the intervention group and 6.0% in the control group (odds ratio, 1.76; [95% confidence interval, 0.90-3.45]). The cholesterol outcome did not differ, and the majority of patients did not repeat lipid levels during follow-up.

CONCLUSIONS

Risk communication and lay outreach increased cholesterol treatment discussions with primary care clinicians. However, most discussions did not result in statin prescribing. For outreach to be successful, it should be combined with interventions to encourage clinicians to follow contemporary risk-based cholesterol treatment guidelines.

CLINICAL TRIAL REGISTRATION

URL: http://www.clincialtrials.gov. Unique identifier: NCT01610609.

Medication Adherence Measures: An Overview

WHO reported that adherence among patients with chronic diseases averages only 50% in developed countries. This is recognized as a significant public health issue, since medication nonadherence leads to poor health outcomes and increased healthcare costs. Improving medication adherence is, therefore, crucial and revealed on many studies, suggesting interventions can improve medication adherence. One significant aspect of the strategies to improve medication adherence is to understand its magnitude. However, there is a lack of general guidance for researchers and healthcare professionals to choose the appropriate tools that can explore the extent of medication adherence and the reasons behind this problem in order to orchestrate subsequent interventions. This paper reviews both subjective and objective medication adherence measures, including direct measures, those involving secondary database analysis, electronic medication packaging (EMP) devices, pill count, and clinician assessments and self-report. Subjective measures generally provide explanations for patient's nonadherence whereas objective measures contribute to a more precise record of patient's medication-taking behavior. While choosing a suitable approach, researchers and healthcare professionals should balance the reliability and practicality, especially cost effectiveness, for their purpose. Meanwhile, because a perfect measure does not exist, a multimeasure approach seems to be the best solution currently.

Improving Patient's Primary Medication Adherence: The Value of Pharmaceutical Counseling

Quality of transitions of care is one of the first concerns in patient safety. Redesigning the discharge process to incorporate clinical pharmacy activities could reduce the incidence of postdischarge adverse events by improving medication adherence. The present study investigated the value of pharmacist counseling sessions on primary medication adherence after hospital discharge.This study was conducted in a 1844-bed hospital in France. It was divided in an observational period and an interventional period of 3 months each. In both periods, ward-based clinical pharmacists performed medication reconciliation and inpatient follow-up. In interventional period, initial counseling and discharge counseling sessions were added to pharmaceutical care. The primary medication adherence was assessed by calling community pharmacists 7 days after patient discharge.We compared the measure of adherence between the patients from the observational period (n = 201) and the interventional period (n = 193). The rate of patients who were adherent increased from 51.0% to 66.7% between both periods (P < 0.01). When discharge counseling was performed (n = 78), this rate rose to 79.7% (P < 0.001). The multivariate regression performed on data from both periods showed that age of at least 78 years old, and 3 or less new medications on discharge order were predictive factors of adherence. New medications ordered at discharge represented 42.0% (n = 1018/2426) of all medications on discharge order. The rate of unfilled new medications decreased from 50.2% in the observational period to 32.5% in the interventional period (P < 10). However, patients included in the observational period were not significantly more often readmitted or visited the emergency department than the patients who experienced discharge counseling during the interventional period (45.3% vs. 46.2%; P = 0.89).This study highlights that discharge counseling sessions are essential to improve outpatients' primary medication adherence. We identified predictive factors of primary nonadherence in order to target the most eligible patients for discharge counseling sessions. Moreover, implementation of discharge counseling could be facilitated by using Health Information Technology to adapt human resources and select patients at risk of nonadherence.

The Effect of Self-Monitoring of Blood Pressure on Medication Adherence and Lifestyle Factors: A Systematic Review and Meta-Analysis

BACKGROUND

Self-monitoring of blood pressure (SMBP) can contribute to reduced blood pressure in people with hypertension. Potential mediators include increased medication, improved adherence, and changes in lifestyle factors including dietary change and increased physical activity. The objective of this review was to determine the effect of SMBP on medication adherence, medication persistence, and lifestyle factors in people with hypertension.

METHODS

Electronic bibliographic databases were searched through February 2014 to identify randomized controlled trials that compared SMBP to control/usual care in ambulatory hypertensive patients and reported medication or nonpharmacologic treatment adherence measures.

RESULTS

Twenty-eight trials with 7,021 participants fulfilled the inclusion criteria. Medication adherence was assessed in 25 trials (89%), dietary outcomes in 8 (29%), physical activity in 6 (21%), and medication persistence in 1 (4%). Blood pressure was assessed in 26 studies (93%). Follow-up ranged from 2 weeks to 12 months. Pooled results of 13 studies demonstrated a small but significant overall effect on medication adherence in favor of SMBP interventions (standardized mean difference 0.21, 95% CI 0.08, 0.34), with moderate heterogeneity (I2 = 43%). Standardized mean difference was used to express the size of intervention effect in each study relative to the variability observed, and was used to combine the results of studies where different measures of medication adherence were used. Where SMBP interventions had a significant effect on lifestyle factor change, the effect was unlikely to be clinically significant. Pooled results of 11 studies demonstrate a significant overall effect on diastolic blood pressure in favor of SMBP (weighted mean difference -2.02, 95% CI -2.93, -1.11), with low heterogeneity (I2 = 0%). A test for subgroup differences showed no difference when studies were grouped according to whether medication adherence was significantly improved or not.

CONCLUSIONS

SMBP may contribute to improvements in medication adherence in hypertensives. However, evidence for the effect of SMBP on lifestyle change and medication persistence is scarce, of poor quality, and suggests little clinically relevant benefit.

Adherence to Antihypertensive Therapy and Elevated Blood Pressure: Should We Consider the Use of Multiple Medications?

Background

Although a majority of patients with hypertension require a multidrug therapy, this is rarely considered when measuring adherence from refill data. Moreover, investigating the association between refill non-adherence to antihypertensive therapy (AHT) and elevated blood pressure (BP) has been advocated.

Objective

Identify factors associated with non-adherence to AHT, considering the multidrug therapy, and investigate the association between non-adherence to AHT and elevated BP.

Methods

A retrospective cohort study including patients with hypertension, identified from a random sample of 5025 Swedish adults. Two measures of adherence were estimated by the proportion of days covered method (PDC≥80%): (1) Adherence to any antihypertensive medication and, (2) adherence to the full AHT regimen. Multiple logistic regressions were performed to investigate the association between sociodemographic factors (age, sex, education, income), clinical factors (user profile, number of antihypertensive medications, healthcare use, cardiovascular comorbidities) and non-adherence. Moreover, the association between non-adherence (long-term and a month prior to BP measurement) and elevated BP was investigated.

Results

Non-adherence to any antihypertensive medication was higher among persons < 65 years (Odds Ratio, OR 2.75 [95% CI, 1.18–6.43]) and with the lowest income (OR 2.05 [95% CI, 1.01–4.16]). Non-adherence to the full AHT regimen was higher among new users (OR 2.04 [95% CI, 1.32–3.15]), persons using specialized healthcare (OR 1.63, [95% CI, 1.14–2.32]), and having multiple antihypertensive medications (OR 1.85 [95% CI, 1.25–2.75] and OR 5.22 [95% CI, 3.48–7.83], for 2 and ≥3 antihypertensive medications, respectively). Non-adherence to any antihypertensive medication a month prior to healthcare visit was associated with elevated BP.

Conclusion

Sociodemographic factors were associated with non-adherence to any antihypertensive medication while clinical factors with non-adherence to the full AHT regimen. These differing findings support considering the use of multiple antihypertensive medications when measuring refill adherence. Monitoring patients' refill adherence prior to healthcare visit may facilitate interpreting elevated BP.

Clinical use of amyloid-positron emission tomography neuroimaging: Practical and bioethical considerations

Until recently, estimation of β-amyloid plaque density as a key element for identifying Alzheimer's disease (AD) pathology as the cause of cognitive impairment was only possible at autopsy. Now with amyloid-positron emission tomography (amyloid-PET) neuroimaging, this AD hallmark can be detected antemortem. Practitioners and patients need to better understand potential diagnostic benefits and limitations of amyloid-PET and the complex practical, ethical, and social implications surrounding this new technology. To complement the practical considerations, Eli Lilly and Company sponsored a Bioethics Advisory Board to discuss ethical issues that might arise from clinical use of amyloid-PET neuroimaging with patients being evaluated for causes of cognitive decline. To best address the multifaceted issues associated with amyloid-PET neuroimaging, we recommend this technology be used only by experienced imaging and treating physicians in appropriately selected patients and only in the context of a comprehensive clinical evaluation with adequate explanations before and after the scan.

When compliance is an issue-how to enhance statin adherence and address adverse effects

Cardiovascular disease is prevalent and costly. Interventions and therapies that reduce morbidity and mortality associated with cardiovascular disease could have an enormous impact on clinical and economic outcomes. Statins reduce atherosclerotic cardiovascular disease-related morbidity and mortality; however, adherence to statins is less than optimal. It is important for clinicians as well as health plan managers to be aware of the patient- and insurance plan-specific factors that have been shown to influence adherence. Perceived statin-related side effects may also decrease adherence. Statin-related myalgia may be difficult to distinguish from myalgia caused by other conditions, and statin therapy may be discontinued unnecessarily in patients who would otherwise benefit. It is imperative that clinicians work closely with patients to improve adherence to statin therapy and be knowledgable in managing potential statin-related side effects.

Impact of Employer-Sponsored Onsite Pharmacy and Condition Management Programs on Medication Adherence

BACKGROUND

Poor medication adherence is associated with worsened health outcomes and higher health care expenditures. An increasing number of employers are sponsoring wellness initiatives designed to support healthy lifestyles, improve productivity, and offer a return on investment. Onsite pharmacies may facilitate higher medication adherence rates by providing employees a convenient, low-cost option for filling prescriptions that is integrated with other onsite health services.

OBJECTIVES

To (a) assess the impact of an employer's onsite pharmacy on health plan members' medication adherence using multiple measures of medication adherence and persistence, including medication possession ratio (MPR), average number of days until discontinuation (60-day gap in coverage), and percentage of members without a 30-day gap in coverage, and (b) evaluate these outcomes between those members who participated in condition management programs and those who did not.

METHODS

A retrospective analysis of a self-insured employer's claims data was undertaken. Medication adherence was assessed among the self-insured employer's health plan members, which included subscribers and their dependents who filled an asthma, depression, diabetes, hypertension, or hyperlipidemia medication at an onsite pharmacy, compared with those who used a community pharmacy. Multiple standard measures of medication adherence were considered. These measures included MPR, which was assessed for 1- and 2-year time periods. MPR was chosen because it is one of the most commonly referenced formulas in the literature and represents adherence over a fixed period of time. In addition, medication persistence was estimated by 30-day gaps in coverage and discontinuation of treatment. To assess the impact of onsite pharmacy use and account for covariate effects, the linear mixed model approach was applied with the logit transformed MPR as the response variable. An analysis of MPR among condition management participants was also performed.

RESULTS

In total, 2,498 subscribers and their dependents were included in the analysis. The average MPR at 365 days was significantly higher (P  <  0.0001) among onsite pharmacy users for all medication types, ranging from 13% higher for depression medications to 20% higher for hypertension medications. This trend persisted at 730 days (P  <  0.001), with average MPRs ranging from 6% higher for hyperlipidemia medications to 11% higher for hypertension medications. A mixed model analysis indicated that members who used the onsite pharmacy were 3.44 times more likely to demonstrate medication adherence (95% CI = 2.84-4.16; P  <  0.0001) at 365 days. Likewise, at 180 and 365 days, onsite pharmacy users were less likely to have 30-day gaps in treatment. The average number of days until discontinuation (defined as a 60-day gap) was also significantly longer (P  <  0.0001) among onsite pharmacy users, ranging from an average of 56 additional days for depression medications to 105 additional days for hypertension medications. While the average MPR tended to be higher among those subscribers and their dependents who participated in condition management programs, this trend was not statistically significant for all medication types.

CONCLUSIONS

Based on multiple measures, onsite pharmacy use was associated with higher medication adherence, while the results were inconclusive for condition management participation.

Initial Medication Adherence-Review and Recommendations for Good Practices in Outcomes Research: An ISPOR Medication Adherence and Persistence Special Interest Group Report

BACKGROUND

Positive associations between medication adherence and beneficial outcomes primarily come from studying filling/consumption behaviors after therapy initiation. Few studies have focused on what happens before initiation, the point from prescribing to dispensing of an initial prescription.

OBJECTIVE

Our objective was to provide guidance and encourage high-quality research on the relationship between beneficial outcomes and initial medication adherence (IMA), the rate initially prescribed medication is dispensed.

METHODS

Using generic adherence terms, an international research panel identified IMA publications from 1966 to 2014. Their data sources were classified as to whether the primary source reflected the perspective of a prescriber, patient, or pharmacist or a combined perspective. Terminology and methodological differences were documented among core (essential elements of presented and unpresented prescribing events and claimed and unclaimed dispensing events regardless of setting), supplemental (refined for accuracy), and contextual (setting-specific) design parameters. Recommendations were made to encourage and guide future research.

RESULTS

The 45 IMA studies identified used multiple terms for IMA and operationalized measurements differently. Primary data sources reflecting a prescriber's and pharmacist's perspective potentially misclassified core parameters more often with shorter/nonexistent pre- and postperiods (1-14 days) than did a combined perspective. Only a few studies addressed supplemental issues, and minimal contextual information was provided.

CONCLUSIONS

General recommendations are to use IMA as the standard nomenclature, rigorously identify all data sources, and delineate all design parameters. Specific methodological recommendations include providing convincing evidence that initial prescribing and dispensing events are identified, supplemental parameters incorporating perspective and substitution biases are addressed, and contextual parameters are included.

The pharmacy-level asthma medication ratio and population health

BACKGROUND AND OBJECTIVES

Community pharmacies may be positioned for an increased role in population health. We sought to develop a population-level measure of asthma medication fills and assess its relationship to asthma-related utilization.

METHODS

We conducted a retrospective, ecological study (2010-2012). Medication data from a chain of pharmacies (n = 27) within 1 county were used to calculate a Pharmacy-level Asthma Medication Ratio (Ph-AMR), defined as controller fills divided by controller plus rescue fills. Higher values are superior because they indicate more controller compared with rescue fills. The outcome was the asthma-related utilization rate among children in the same census tract as the pharmacy, calculated by dividing all emergency visits and hospitalizations by the number of children in that tract. Covariates, including ecological measures of poverty and access to care, were used in multivariable linear regression.

RESULTS

Overall, 35 467 medications were filled. The median Ph-AMR was 0.53 (range 0.38-0.66). The median utilization rate across included census tracts was 22.4 visits per 1000 child-years (range 1.3-60.9). Tracts with Ph-AMR <0.5 had significantly higher utilization rates than those with Ph-AMR ≥0.5 (26.1 vs 9.9; P = .001). For every 0.1 increase in Ph-AMR, utilization rates decreased by 9.5 (P = .03), after adjustment for underlying poverty and access. Seasonal variation in fills was evident, but pharmacies in high-utilizing tracts filled more rescue than controller medications at nearly every point during the study period.

CONCLUSIONS

Ph-AMR was independently associated with ecological childhood asthma morbidity. Pharmacies may be a community-based leverage point for improving population-level asthma control through targeted interventions.

Compliance of medications prescribed from a pediatric emergency department

OBJECTIVES

Studies regarding compliance of medications prescribed from emergency departments (EDs) have primarily been adult-based or based on self-reported data. Most pediatric studies have shown that patients with private insurance tend to be more compliant. This study aims to determine the rate of medication compliance from a pediatric ED, which medications are most likely to be filled, if there are differences in compliance based on insurance status and age, and if noncompliant patients are more likely to have unintended return visits to the ED.

METHODS

In this retrospective chart review, a sample of consecutive pediatric patients discharged from the ED was obtained. Pharmacies were contacted to ensure prescriptions were filled. Medication compliance was inferred if a prescription was filled.

RESULTS

The 152 patients included had a total of 229 prescriptions that were used for data analysis. The overall medication compliance rate was 72.5%. There was no statistically significant difference in medication compliance between age (P = 0.9), diagnosis (P = 0.26), insurance status (P = 0.3), or type of medication (P = 0.3). No difference was demonstrated for unintended return visits based on compliance (P = 0.79).

CONCLUSIONS

Over a quarter of patients prescribed medications were noncompliant. However, there was no statistically significant difference in compliance between age, diagnosis, insurance status, or type of medication. Unlike most previous studies, privately insured patients were just as unlikely to fill their medications as publicly insured patients, and cost did not appear to be a contributing factor to noncompliance. Therefore efforts to educate patients and their families should be widespread and unbiased.

Causes and consequences of e-prescribing errors in community pharmacies

Major national policy forces are promoting the adoption and use of health information technology (health IT) to improve the quality, safety, and efficiency of health care delivery. One such health IT is electronic prescribing (e-prescribing), which is the direct transmission of prescription information from a provider to a pharmacy. Given research showing that handwritten prescriptions are unsafe and associated errors can lead to tremendous inefficiency for patients and pharmacists, e-prescribing has many potential benefits. However, as with the introduction of any new technology, unintended, adverse consequences may result. The purpose of this review is to explore the causes and consequences of e-prescribing errors in community pharmacies, which are pharmacies not affiliated with a hospital or clinic. Many new types of errors - including provider order entry errors, transcription errors, and dispensing errors - appear to result from e-prescribing. These lead to important consequences for pharmacies, including safety threats to patients, reduced efficiency for pharmacists, processing delays, and increased pharmacy cost. Increased attention to system design and pharmacist training, as well as additional research in this area, will be critical to realize the full benefits of e-prescribing.

Do patients initiate therapy? Primary non-adherence to statins and antidepressants in Iceland

BACKGROUND

Primary non-adherence occurs when a drug has been prescribed but the patient fails to have it dispensed at the pharmacy.

AIMS

To assess primary non-adherence to statins and antidepressants in Iceland, the association of demographic factors with primary non-adherence, and the time from when a prescription is issued until it is dispensed.

METHODS

Data on patients receiving a new prescription for a statin or an antidepressant from the Primary Health Care database were linked with dispensing histories from The Icelandic Prescription Database. The proportion of patients who did not have their prescription dispensed within a year from issuing (primary non-adherent) was assessed, as well as the time from issue until dispensing. Associations between demographic factors and primary non-adherence were estimated using logistic regression.

RESULTS

The overall primary non-adherence was 6.3% and 8.0% for statins and antidepressants, respectively. The majority of patients had their prescription dispensed within 7 days (85% for statins, 87% for antidepressants). Being disabled and receiving a prescription for an expensive drug was associated with higher rates of primary non-adherence.

CONCLUSION

The rate of primary non-adherence to statins and antidepressants in Iceland is low. Vulnerable groups such as the disabled should be given special attention when new drugs are prescribed.

The Malaysian Medication Adherence Scale (MALMAS): Concurrent Validity Using a Clinical Measure among People with Type 2 Diabetes in Malaysia

Medication non-adherence is a prevalent problem worldwide but up to today, no gold standard is available to assess such behavior. This study was to evaluate the psychometric properties, particularly the concurrent validity of the English version of the Malaysian Medication Adherence Scale (MALMAS) among people with type 2 diabetes in Malaysia. Individuals with type 2 diabetes, aged 21 years and above, using at least one anti-diabetes agent and could communicate in English were recruited. The MALMAS was compared with the 8-item Morisky Medication Adherence Scale (MMAS-8) to assess its convergent validity while concurrent validity was evaluated based on the levels of glycated hemoglobin (HbA1C). Participants answered the MALMAS twice: at baseline and 4 weeks later. The study involved 136 participants. The MALMAS achieved acceptable internal consistency (Cronbach’s alpha=0.565) and stable reliability as the test-retest scores showed fair correlation (Spearman’s rho=0.412). The MALMAS has good correlation with the MMAS-8 (Spearman’s rho=0.715). Participants who were adherent to their anti-diabetes medications had significantly lower median HbA1C values than those who were non-adherence (7.90 versus 8.55%, p=0.032). The odds of participants who were adherent to their medications achieving good glycemic control was 3.36 times (95% confidence interval: 1.09-10.37) of those who were non-adherence. This confirms the concurrent validity of the MALMAS. The sensitivity of the MALMAS was 88.9% while its specificity was 29.6%. The findings of this study further substantiates the reliability and validity of the MALMAS, in particular its concurrent validity and sensitivity for assessing medication adherence of people with type 2 diabetes in Malaysia.

Improving adherence with medication: a selective literature review based on the example of hypertension treatment

BACKGROUND

A common problem among patients with chronic diseases is poor adherence with prescribed medication. Studies have shown that certain interventions can improve adherence and clinical outcomes.

METHOD

We selectively searched the PubMed database for publications on the treatment of hypertension that contained the terms "adherence," "drug," "treatment, "outcome," "hypertension," and "randomized controlled trial."

RESULTS

The interventions studied were highly varied, ranging from the use of calendar blister packs to complex patient education programs. 62% of the studies that we identified documented an improvement in adherence after an intervention (median Cohen's d = 0.52). In 92% of cases, improved adherence was associated with a significant improvement in clinical end points (median Cohen's d = 0.34).

CONCLUSION

The promotion of adherence to prescribed medication is clearly desirable. Studies on the treatment of hypertension have shown that attempts to improve adherence often fail. In most studies, however, improved adherence led to better clinical outcomes. Simplification of drug regimens (e.g., reducing the number of pills taken per day) is the single most effective way to promote adherence. Moreover, the findings of studies on the treatment of hypertension and other diseases suggest that shared decision-making should be the basis of physicianpatient discussions about medication. Suitable medications can also be chosen in order to maximize safety and efficacy even if adherence is incomplete. It would also be desirable for studies on the promotion of adherence to be carried out in Germany, under the specific conditions that prevail in our national health-care system.

Primary non-adherence in Portugal: findings and implications

BACKGROUND

Portugal is currently facing a serious economic and financial crisis, which is dictating some important changes in the health care sector. Some of these measures may potentially influence patients' access to medication and consequently adherence, which will ultimately impact on health status, especially in chronic patients.

AIMS

This study aimed at providing a snapshot of adherence in patients with chronic conditions in Portugal between March and April 2012.

SETTING

Community pharmacy in Portugal.

METHOD

A cross-sectional pilot study was undertaken, where patients were recruited via community pharmacies to a questionnaire study evaluating the number of prescribed and purchased drugs and, when these figures were inconsistent, the reasons for this.

MAIN OUTCOME MEASURES

Primary and secondary adherence measures. Failing to purchase prescription items was categorized as primary nonadherence. Secondary nonadherence was attributed to purchasing prescription items, but not taking medicines as prescribed.

RESULTS

Data were collected from 375 patients. Primary nonadherence was identified in 22.8 % of patients. Regardless of the underlying condition, the most commonly reported reason for primary non-adherence was having spare medicines at home ("leftovers"), followed by financial problems. The latter appeared to be related to the class of medicines prescribed. Primary non-adherence was associated with low income (<475 <euro>/month; p = 0.026). Secondary non-adherence, assessed by the 7-MMAS was detected in over 50 % of all patients, where unintentional nonadherence was higher than intentional nonadherence across all disease conditions.

CONCLUSION

This study revealed that more than one fifth of chronic medication users report primary nonadherence (22.8 %) and more than 50 % report secondary nonadherence. Data indicates that the existence of spare medicines and financial constraints occurred were the two most frequent reasons cited for nonadherence (47, 6-64, 8 and 19-45.5 %, depending on the major underlying condition, respectively).

Longitudinal persistence with secondary prevention therapies relative to patient risk after myocardial infarction

BACKGROUND

Prior studies have demonstrated that patients with high-risk acute myocardial infarction (AMI) are less likely to receive guideline-directed medications during hospitalisation. It is unknown if this paradox persists following discharge. We aimed to assess if persistence with guideline-directed medications post discharge varies by patients' risk following AMI.

METHODS

Data were analysed from two prospective, multicentre US AMI registries. The primary outcome was persistence with all prescribed guideline-directed medications (aspirin, β-blockers, statins, angiotensin-antagonists) at 1, 6 and 12 months post discharge. The association between risk and medication persistence post discharge was assessed using multivariable mixed-effect models.

RESULTS

Among 6434 patients with AMI discharged home, 2824 were considered low-risk, 2014 intermediate-risk and 1596 high-risk for death based upon their Global Registry of Acute Coronary Event (GRACE) 6-month risk score. High-risk was associated with a lower likelihood of receiving all appropriate therapies at discharge compared with low-risk patients (relative risk (RR) 0.90; 95% CI 0.87 to 0.94). At 12 months, the rate of persistence with all prescribed therapies was 61.5%, 57.9% and 45.9% among low-risk, intermediate-risk and high-risk patients, respectively. After multivariable adjustment, high-risk was associated with lower persistence with all prescribed medications (RR 0.87; 95% CI 0.82 to 0.92) over follow-up. Similar associations were seen for individual medications. Over the 5 years of the study, persistence with prescribed therapies post discharge improved modestly among high-risk patients (RR 1.05; 95% CI 1.03 to 1.08 per year).

CONCLUSIONS

High-risk patients with AMI have a lower likelihood of persistently taking prescribed medications post discharge as compared with low-risk patients. Continued efforts are needed to improve the use of guideline-directed medications in high-risk patients.

Change of walking distance in intermittent claudication: impact on inflammation, oxidative stress and mononuclear cells: a pilot study

BACKGROUND

Atherosclerosis is a chronic inflammatory process involving the immune system and formation of reactive oxygen species (ROS). We investigated changes of mononuclear blood cells and ROS production in relation to the walking distance of patients with intermittent claudication during home-based exercise training.

METHODS

Forty patients with intermittent claudication were asked to perform a home-based exercise training for a mean time of 12 months. ROS formation was measured using the luminol analogue L-012. Peripheral blood leucocytes [monocytes, polymorphonuclear neutrophils (PMN) and dendritic cells (DC)] were analysed by flow cytometry and analysed for the expression of major inflammatory surface molecules.

RESULTS

At follow-up, patients showed an increased walking distance and reduced ROS production upon stimulation with a phorbol ester derivative (PDBu) (p < 0.01). Monocytes changed their inflammatory phenotype towards an increased anti-inflammatory CD14(++)CD16(-) subpopulation (p < 0.0001). Adhesion molecules CD11b, CD11c and TREM-1 on monocytes and PMN decreased (all p < 0.01). On DC expression of HLA-DR, CD86 or CD40 decreased at follow-up. Inflammatory markers like fibrinogen, C-reactive protein or soluble TREM-1 (sTREM-1) decreased over the observation period. Finally, we found a close relation of sTREM-1 with the walking distance, fibrinogen and ROS production.

CONCLUSIONS

We observed an amelioration of the proinflammatory phenotype on monocytes, DC and PMN, as well as a reduced ROS production in PAD patients under home-based exercise, paralleled by an increased walking distance. Our data suggest that a reduced inflammatory state might be achieved by regular walking exercise, possibly in a dimension proportionately to changes in walking distance.

Adherence to therapy and adverse drug reactions: is there a link?

INTRODUCTION

Advances in biomedical technology and access to effective medications have resulted in significant improvements in patient survival and quality of life. Patient adherence is crucial to quality healthcare outcomes; however, achievement of consistent adherence remains difficult. Patient non-adherence represents an important health problem, from a clinical/economic viewpoint, being associated with reduced treatment benefits and significant financial burden. Non-adherence potentially leads to adverse drug events (ADEs), which are generally responsible for poorer health outcomes and avoidable resource misuse. Further, adverse drug reactions (ADRs) exemplify one of the most significant barriers to patients' medication-taking behavior with further detrimental clinical/economic outcomes.

AREAS COVERED

The authors review adherence definitions and its measurement, emphasizing the consequences of the New European Pharmacovigilance Legislation on ADR definition. They analyzed the causes and the clinical/economic consequences of non-adherence and ADEs/ADRs in order to highlight a possible causal link.

EXPERT OPINION

Careful assessment of this harmful relationship is crucial in planning for the interventions needed to improve effectiveness of pharmacological care and to safeguard the sustainability of healthcare systems. Finally, through the 'deactivation' of this link, there will be more chance that advances in healthcare technologies will realize their potential to reduce the burden of chronic illness.

Age-related medication adherence in patients with chronic heart failure: A systematic literature review

BACKGROUND

Chronic heart failure (CHF) is prevalent among the elderly and is characterized by high mortality and hospitalization rates. Non-adherence to medications is frequent and related to poor clinical outcomes. It is often assumed that older age is related to poorer medication adherence compared with younger age. We analyzed the existing evidence of age as a determinant of medication adherence in patients with CHF.

METHODS

A systematic search of the bibliographic database MEDLINE and all Cochrane databases was performed. Studies were included if they examined medication adherence in adult patients with CHF, evaluated factors contributing to medication adherence, and analyzed the relationship between age and medication adherence. Articles classified as studies with poor quality were excluded.

RESULTS

A total of 1565 titles were found, and ultimately, 17 studies, which provide data for a total of 162,727 patients, were analyzed. Seven studies showed a statistically significant relationship between age and medication adherence: six articles demonstrated that increased age is correlated with higher medication adherence, and one study showed that patients in the age range of 57 to 64 years are affected by non-adherence to angiotensin-converting enzyme inhibitors. Ten studies found no significant relationship.

CONCLUSIONS

The results suggest that older age alone is not related to poorer medication adherence compared with younger patients with CHF. More attention should be paid to younger newly-diagnosed patients with CHF. Future studies are required to explore medication adherence in CHF in different, standardized, and specific age groups and should be sufficiently powered to assess clinical endpoints.

Use of statins by medicare beneficiaries post myocardial infarction: poor physician quality or patient-centered care?

Even though guidelines strongly recommend that patients receive a statin for secondary prevention after an acute myocardial infarction (MI), many elderly patients do not fill a statin prescription within 30 days of discharge. This paper assesses whether patterns of statin use by Medicare beneficiaries post-discharge may be due to a mix of high-quality and low-quality physicians. Our data come from the Centers for Medicare & Medicaid Services (CMS) Chronic Condition Data Warehouse (CCW) and include 100% of Medicare beneficiaries hospitalized for an acute myocardial infarction in 2008 or 2009. Our study sample included physicians treating at least 10 Medicare fee-for-service beneficiaries during their MI institutional stay. Physician-specific statin fill rates (the proportion of each physician’s patients with a statin within 30 days post-discharge) were calculated to assess physician quality. We hypothesized that if the observed statin rates reflected a mix of high-quality and low-quality physicians, then physician-specific statin fill rates should follow a u-shaped or bimodal distribution. In our sample, 62% of patients filled a statin prescription within 30 days of discharge. We found that the distribution of statin fill rates across physicians was normal, with no clear distinctions in physician quality. Physicians, especially cardiologists, with relatively younger and healthier patient populations had higher rates of statin use. Our results suggest that physicians were engaging in patient-centered care, tailoring treatments to patient characteristics.

Pharmacy-based interventions to reduce primary medication nonadherence to cardiovascular medications

BACKGROUND

Primary medication nonadherence (PMN) occurs when patients do not fill new prescriptions. Interventions to reduce PMN have not been well described.

OBJECTIVES

To determine whether 2 pharmacy-based interventions could decrease PMN.

DESIGN

Two sequential interventions with a control group were evaluated after completion. The automated intervention began in 2007 and consisted of phone calls to patients on the third and seventh days after a prescription was processed but remained unpurchased. The live intervention began in 2009 and used calls from a pharmacist or technician to patients who still had not picked up their prescriptions after 8 days.

SUBJECTS

Patients with newly prescribed cardiovascular medications received at CVS community pharmacies. Patients with randomly selected birthdays served as the control population.

MEASURES

Patient abandonment of new prescription, defined as not picking up medications within 30 days of initial processing at the pharmacy.

RESULTS

The automated intervention included 852,612 patients and 1.2 million prescriptions, with a control group of 9282 patients and 13,178 prescriptions. The live intervention included 121,155 patients and 139,502 prescriptions with a control group of 2976 patients and 3407 prescriptions. The groups were balanced by age, sex, and patterns of prior prescription use. For the automated intervention, 4.2% of prescriptions were abandoned in the intervention group and 4.5% in the control group (P>0.1), with no significant differences for any individual classes of medications. The live intervention was used in a group that had not purchased prescriptions after 8 days and thus had much higher PMN. In this setting 36.9% of prescriptions were abandoned in the intervention group and 41.7% in the control group, a difference of 4.8% (P<0.0001). The difference in abandoned prescriptions for antihypertensives was 6.9% (P<0.0001) but for antihyperlipidemics was only 1.4% (P>0.1).

CONCLUSIONS

Automated reminder calls had no effect on PMN. Live calls from pharmacists decreased antihypertensive PMN significantly, although many patients still abandoned their prescriptions.

Impact of a Clinical Pharmacist–Managed Medication Refill Clinic

Objective: To evaluate the impact of a clinical pharmacist managed medication refill clinic on physician workload. Methods: A retrospective case study was conducted for patients receiving refill authorizations or denials from the clinical pharmacist from 2008 to 2010. Data related to refill request volume and interventions undertaken were collected. Results: A total of 5706 refill requests were processed by the clinical pharmacist during the study period. The collaboration decreased physician refill request volume up to 60%. Of the total amount of refill requests processed, 42% required the pharmacist to make an intervention. The most common interventions were reminders for follow-up. Conclusion: The collaboration between a clinical pharmacist and family physicians to develop a clinical pharmacist managed medication refill clinic decreased physician workload and improved patient care.

A randomized telephone intervention trial to reduce primary medication nonadherence

BACKGROUND

Primary medication nonadherence (PMN), defined as patients not picking up an initial prescription, can limit the effectiveness of therapy for chronic conditions. Effective interventions to reduce PMN have not been widely studied or implemented.

OBJECTIVE

To evaluate the ability of an additional nurse-directed telephone intervention to reduce PMN in a cohort of patients with persistent nonadherence after repeated pharmacy-based outreach.

METHODS

Patients in the Geisinger Health System receiving new (i.e., initially prescribed) prescriptions sent to CVS pharmacies for medications treating asthma, hypertension, diabetes, or hyperlipidemia were identified. As part of existing programs, all patients received 2 automated and 1 live call from CVS pharmacies encouraging them to pick up their prescriptions; those who had canceled their prescriptions or had not picked them up after the 3 pharmacy interventions were eligible for this study. Patients were then randomized, and the intervention group received telephone outreach from a nursing call center to assess reasons for PMN and encourage pickup of prescriptions, with up to 3 attempts to reach each patient. Medication pickup rates were compared across the intervention and control groups.

RESULTS

Initial PMN rates in the overall population were 6%, lower than previously observed in other studies. A total of 290 patients had not picked up their prescriptions after 3 calls from the pharmacy and were enrolled in the study: 142 in the intervention group and 148 controls. The intervention did not change the rate at which patients picked up their prescriptions: 25% of intervention patients did so compared with 24% of control patients. Multivariate models adjusting for patient characteristics and medication classes did not change the results.

CONCLUSIONS

In a population of patients who had not picked up new prescriptions after 3 calls from the pharmacy, additional nurse-directed outreach did not improve primary medication adherence. Re-engagement with the prescribing clinician may be needed to improve adherence in this patient population. The low rate of PMN in the overall population differed from prior studies in this setting and others and should be assessed in future research.

Effectiveness of a computerized drug-monitoring program to detect and prevent adverse drug events and medication non-adherence in outpatient ambulatory care: study protocol of a randomized controlled trial

BACKGROUND

Medications are an effective intervention for managing and preventing health problems but their benefit can be undermined by non-adherence or adverse drug events (ADEs). Since these issues may be interconnected, efforts to improve non-adherence should also include reduction of ADEs. We have developed the ISTOP-ADE system (Information Systems-enabled Outreach for Preventing Adverse Drug Events), which enables timely monitoring and managing of ADEs. The objectives of this study are to determine whether the ISTOP-ADE system, compared to routine care, will reduce: a) the probability of discontinuing the use of prognosis-altering medications; b) the probability of a patient experiencing a severe ADE; c) the proportion of patients experiencing ADEs, preventable ADEs and ameliorable ADEs; and d) health services utilization.

METHODS/DESIGN

We will randomly assign 2,200 adult ambulatory patients in the province of Québec who have been prescribed an incident medication for the management or prevention of a chronic health condition, to routine care or the ISTOP-ADE system. The ISTOP-ADE system consists of an interactive voice response system (IVRS) paired with pharmacist support. The IVRS will call patients at 3 and 17 days post-prescription to determine if they are experiencing any problems and connect them with a pharmacist when required or desired by the patient. We will evaluate medication persistence at 180 days and health-care utilization using provincial administrative data. Two blinded physicians will ascertain ADE status through a case review.

DISCUSSION

We expect the ISTOP-ADE intervention to be feasible and to improve the quality of patient care through improved medication adherence, reduced ADE duration and reduced number of ADEs resulting in an emergency department or inpatient encounter. This in turn could lower health-care utilization, saving costs and lowering the burden on emergency departments and family practices. The success of ISTOP-ADE would present opportunities to implement this intervention through health systems, health insurance agents and commercial pharmacies.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02059044. Date registered: 10 January 2014.

Unintentional prescription drug non-compliance for financial reasons in families with a child with a limiting health condition

Area probability sampling via U.S. postal addresses was used to select households from seven high poverty U.S. metropolitan areas. In person and telephone interviews with one adult household member were used to determine the odds of delaying or failing to fill a needed prescription for families with a child member with a limiting health condition. Logistic models indicate families with a child with a limiting health condition are 1.57 times more likely to delay or fail to fill a needed prescription, and families with more than one child with a limiting condition are 1.85 times more likely. Implications are set forth.

Impact of patient programs on adherence and persistence in inflammatory and immunologic diseases: a meta-analysis

OBJECTIVES

Patient adherence and persistence is important to improve outcomes in chronic conditions, including inflammatory and immunologic (I&I) diseases. Patient programs that aim at improving medication adherence or persistence play an essential role in optimizing care. This meta-analysis assessed the effectiveness of patient programs in the therapeutic area of I&I diseases.

METHODS

A global systematic literature review was conducted with inclusion criteria of: patient programs in I&I diseases; published in English language between January 2008 and September 2013; and reporting measures of adherence or persistence, including medication possession ratio >80% and persistence rate. A meta-analysis was performed using a random effects model. Subgroup analyses based on the type of program was performed whenever feasible.

RESULTS

Of 67 studies reviewed for eligibility, a total of 17 studies qualified for inclusion in the meta-analysis. Overall, patient programs increased adherence (odds ratio [OR]=2.48, 95% confidence interval [CI]=1.68-3.64, P<0.00001) as compared with standard of care. Combination patient programs that used both informational and behavioral strategies were superior in improving adherence (OR=3.68, 95% CI=2.20-6.16, P<0.00001) compared with programs that used only informational (OR=2.16, 95% CI=1.36-3.44, P=0.001) or only behavioral approaches (OR=1.85, 95% CI=1.00-3.45, P=0.05). Additionally, patients were more likely to be persistent (OR=2.26, 95% CI=1.16-4.39, P=0.02) in the intervention group as compared with the control group. Persistence (in days) was significantly (P=0.007) longer, by 42 additional days, in the intervention group than in the control group.

CONCLUSIONS

Patient programs can significantly improve adherence as well as persistence in the therapeutic area of I&I diseases. Programs employing a multimodal approach are more effective in improving adherence than programs with informational or behavioral strategies alone. This in turn may improve patient outcomes.