Medication nonadherence: a diagnosable and treatable medical condition

Not obtaining a medication the first time it is prescribed: primary non-adherence to cardiovascular pharmacotherapy

Primary medication non-adherence describes the situation when a first prescription for a new medication is never filled. Primary non-adherence is an important, yet understudied aspect of reduced effectiveness of pharmacotherapy. This review summarizes the frequency, impact, reasons, predictors, and interventions regarding primary non-adherence to cardiovascular/cardiometabolic drugs. The current literature reveals a high prevalence of primary non-adherence. The individual risk of primary non-adherence is determined on multiple factors, e.g., primary non-adherence of lipid-lowering drugs is higher compared to antihypertensive medications. However, the overall rate of primary non-adherence is > 10%. Additionally, this review identifies specific areas for research to better understand why patients forgo evidence-based beneficial pharmacotherapy and to explore targeted interventions. At the same time, measures to reduce primary non-adherence-once proven to be effective-may represent an important new opportunity to reduce cardiovascular diseases.

Investigating medication adherence among Taiwanese patient with hypertension, hyperlipidemia, and diabetes: A pilot study using the Chinese version of a Two-Part Medication Nonadherence Scale and the NHI MediCloud system

BACKGROUND

This pilot study aimed to investigate medication nonadherence among Taiwanese patients with diabetes, hypertension, and hyperlipidemia using the Chinese version of the Two-Part Medication Nonadherence Scale (C-TPMNS) and the National Health Insurance (NHI) Medicloud system. The study revealed insights into the factors contributing to nonadherence and the implications for improving patient adherence to medications for chronic conditions. However, the small sample size limits the generalizability of the findings. Additionally, the study identified the need for further research with larger and more diverse samples to validate the preliminary findings.

METHODS

The study conducted surveys individuals in central Taiwan who received three-high medications and those who returned expired medications from chain pharmacies. A structured questionnaire including the C-TPMNS was administered, and additional data on medical history and HbA1c, LDL, and blood pressure levels were collected from the NHI Medicloud system. Data analysis was performed using multiple ordered logistic regression and Wald test methods. Setting interpretation cutoff point to determine medication nonadherence.

RESULTS

The study found that 25.8% of participants were non-adherent to prescribed medications. Non-adherent individuals had significantly higher systolic blood pressure (SBP ≥ 140 mmHg) than adherent participants. Non-adherence was also associated with factors such as lower education, single status, living alone, abnormal glucose postprandial concentration, and triglyceride levels. The C-TPMNS demonstrated good reliability (Cronbach's alpha = 0.816) and validity (area under the ROC curve = 0.72).

CONCLUSION

The study highlighted the complexity of medication nonadherence with diverse determinants and emphasized the importance of tailored interventions. The findings underscored the need for region-specific research to comprehensively address medication nonadherence, especially focusing on adherence to medications for hypertension, hyperlipidemia, and diabetes. The study also identified the need for larger, more diverse studies to validate and expand upon the initial findings and emphasized the importance of pharmacist interventions and patient empowerment in managing chronic conditions and improving overall health outcomes.

Factors Influencing Therapeutic Non-Adherence Behavior Among Patients with Type 2 Diabetes in Two Public Hospitals in the Gambia: A Cross-Sectional Study

Background

Type 2 Diabetes Mellitus (DM) is a significant public health problem in The Gambia. While therapeutic non-adherence is widely recognized as a common and costly problem, very little is known about therapeutic adherence behavior among patients with diabetes in The Gambia.

Purpose

The objective of this study was to determine the prevalence and factors that influence diabetic therapeutic non-adherence behavior among patients with type 2 diabetes in The Gambia.

Methods

A cross-sectional study design was used, and participants were recruited from Edward Francis Small Teaching Hospital (EFSTH) and Kanifing General Hospital (KGH). The sample size of 145 patients with type 2 diabetes was included and data was collected using a structured questionnaire. Adherence to anti-diabetic medications was measured using the Morisky Medications Adherence Scale (MMAS-8). Logistic regression was used to determine the factors associated with diabetic therapeutic non-adherence.

Results

The prevalence of non-adherence to anti-diabetic treatment was 27.6%. Perceived barrier (forgetfulness, long-term medication use, and medication side effects) to diabetic treatment (OR = 0.265, 95% CI: 0.113-0.621, p = 0.041) was statistically significantly associated with non-adherence to anti-diabetic treatment. However, the frequency of doctor's visits (OR = 0.310, 95% CI: 0.046-2.111) was not significantly associated with non-adherence to anti-diabetic treatment.

Conclusion

The rate of non-adherence to antidiabetic treatment in this study was high. Perceived barriers to antidiabetic treatment such as forgetfulness, long-term medication use, and medication side effects influenced therapeutic non-adherence to antidiabetic treatment. While interventions should focus on how to eliminate these barriers, health education on diabetic self-care may help reinforce the importance of medication adherence to prevent complications.

A multimodal aftercare intervention improves the outcome after kidney transplantation - results of the KTx360° aftercare program using claims data

Background

The after-care treatment project KTx360° aimed to reduce graft failure and mortality after kidney transplantation (KTx).

Methods

The study was conducted in the study centers Hannover, Erlangen and Hannoversch Muenden from May 2017 to October 2020 under the trial registration ISRCTN29416382. The program provided a multimodal aftercare program including specialized case management, telemedicine support, psychological and exercise assessments, and interventions. For the analysis of graft failure, which was defined as death, re-transplantation or start of long-term dialysis, we used longitudinal claims data from participating statutory health insurances (SHI) which enabled us to compare participants with controls. To balance covariate distributions between these nonrandomized groups we used propensity score methodology, in particular the inverse probability of treatment weighting (IPTW) approach.

Findings

In total, 930 adult participants were recruited at three different transplant centres in Germany, of whom 320 were incident (enrolled within the first year after KTx) and 610 prevalent (enrolled >1 year after KTx) patients. Due to differences in the availability of the claims data, the claims data of 411 participants and 418 controls could be used for the analyses. In the prevalent group we detected a significantly lower risk for graft failure in the study participants compared to the matched controls (HR = 0.13, 95% CI = 0.04-0.39, p = 0.005, n = 389 observations), whereas this difference could not be detected in the incident group (HR = 0.92, 95% CI = 0.54-1.56, p = 0.837, n = 440 observations).

Interpretation

Our findings suggest that a multimodal and multidisciplinary aftercare intervention can significantly improve outcome after KTx, specifically in patients later after KTx. For evaluation of effects on these outcome parameters in patients enrolled within the first year after transplantation longer observation times are necessary.

Funding

The study was funded by the Global Innovation fund of the Joint Federal Committee of the Federal Republic of Germany, grant number 01NVF16009.

Validating methods used to identify non-adherence adverse drug events in Canadian administrative health data

AIMS

Medication non-adherence is a type of adverse drug event that can lead to untreated and exacerbated chronic illness, and that drives healthcare utilization. Research using medication claims data has attempted to identify instances of medication non-adherence using the proportion of days covered or by examining gaps between medication refills. We sought to validate these measures compared to a gold standard diagnosis of non-adherence made in hospital.

METHODS

This was a retrospective analysis of adverse drug events diagnosed during three prospective cohorts in British Columbia between 2008 and 2015 (n = 976). We linked prospectively identified adverse drug events to medication claims data to examine the sensitivity and specificity of typical non-adherence measures.

RESULTS

The sensitivity of the non-adherence measures ranged from 22.4% to 37.5%, with a proportion of days covered threshold of 95% performing the best; the non-persistence measures had sensitivities ranging from 10.4% to 58.3%. While a 7-day gap was most sensitive, it classified 61.2% of the sample as non-adherent, whereas only 19.6% were diagnosed as such in hospital.

CONCLUSIONS

The methods used to identify non-adherence in administrative databases are not accurate when compared to a gold standard diagnosis by healthcare providers. Research that has relied on administrative data to identify non-adherent patients both underestimates the magnitude of the problem and may label patients as non-adherent who were in fact adherent.

Pathways to Poor Adherence to Antiretroviral Therapy Among People Living with HIV: The Role of Food Insecurity and Alcohol Misuse

Daily adherence to antiretroviral therapy (ART) increases the length and quality of life of people living with HIV (PLHIV). We explored whether socioeconomic status directly impacts ART adherence and whether part of the effect is mediated by pathways through alcohol misuse or food insecurity. A cross-sectional study was conducted in Rio de Janeiro/Brazil (November/2019 to March/2020) with PLHIV aged ≥ 18 years. Validated instruments were used to measure alcohol use, food insecurity, and ART adherence. Using structural equation modeling we assessed the direct and indirect effects of variables on ART adherence. Participants reported significant challenges: hunger: 12%, alcohol use: 64%, and missing ART doses: 24%. Results showed that lower socioeconomic status increased poor adherence and that this effect was mediated through higher food insecurity. Alcohol misuse also increased poor adherence through a strong direct effect. Providing socio-economic support coupled with interventions to mitigate alcohol's harmful impact can aid HIV care.

Remote intensive management to improve antiplatelet adherence in acute myocardial infarction: a secondary analysis of the randomized controlled IMMACULATE trial

This study aim to investigate if remote intensive coaching for the first 6 months post-AMI will improve adherence to the twice-a-day antiplatelet medication, ticagrelor. Between July 8, 2015, to March 29, 2019, AMI patients were randomly assigned to remote intensive management (RIM) or standard care (SC). RIM participants underwent 6 months of weekly then two-weekly consultations to review medication side effects and medication adherence coaching by a centralized nurse practitioner team, whereas SC participants received usual cardiologist face-to-face consultations. Adherence to ticagrelor were determined using pill counting and serial platelet reactivity measurements for 12 months. A total of 149 (49.5%) of participants were randomized to RIM and 152 (50.5%) to SC. Adherence to ticagrelor was similar between RIM and SC group at 1 month (94.4 ± 0.7% vs. 93.6±14.7%, p = 0.537), 6 months (91.0±14.6% vs. 90.6±14.8%, p = 0.832) and 12 months (87.4±17.0% vs. 89.8±12.5%, p = 0.688). There was also no significant difference in platelet reactivity between the RIM and SC groups at 1 month (251AU*min [212-328] vs. 267AU*min [208-351], p = 0.399), 6 months (239AU*min [165-308] vs. 235AU*min [171-346], p = 0.610) and 12 months (249AU*min [177-432] vs. 259AU*min [182-360], p = 0.678). Sensitivity analysis did not demonstrate any association of ticagrelor adherence with bleeding events and major adverse cardiovascular events. RIM, comprising 6 months of intensive coaching by nurse practitioners, did not improve adherence to the twice-a-day medication ticagrelor compared with SC among patients with AMI. A gradual decline in ticagrelor adherence over 12 months was observed despite 6 months of intensive coaching.

Influence of Participant Perceptions of Adherence-Related Interactions with Study/Study Team on Drug Levels: HPTN069 Analysis of Self-Reported Adherence Experiences While on Study

Adherence to HIV pre-exposure prophylaxis (PrEP) study drug is critical for safety, tolerability, and efficacy trials, and may be affected by how adherence is communicated by the study staff to trial participants. Increasingly, clinical trials investigating PrEP are creating and implementing 'participant-centered' approaches that discuss potential non-adherence neutrally (without negative judgement) and support efforts to adhere versus insisting on perfect adherence. In the HPTN069/ACTG A5305 study, we evaluated participant experiences of potentially negative adherence-related interactions with study teams using ten items to characterize the frequency of such experiences. We related these individual items and a combined set of seven negative experience items (total negative experience score) to drug concentrations (detectable or consistent with daily-dosing). The exploratory analyses used logistic regression for each experience item on the full sample and disaggregated by sex. Several experiences were related to drug detection and to daily-dosing, although more so for participants identifying as men than women. Total negative experience scores associated with not having detection drug concentrations for the full sample, and remained significant even when controlling for sex, age, and race. Daily dosing was associated with total negative experience score for men in the sample. Additional investigations into adherence-related interactions with study teams that are most problematic or helpful in general and uniquely for men and women are warranted.

Effect on medication adherence of applying a specialty pharmacy care model to nonspecialty medications: A quasi-experimental cohort study

PURPOSE

Medication nonadherence is a multifactorial healthcare problem that contributes to increased healthcare costs and morbidity. To improve medication adherence, specialty pharmacies offer services not typically provided by retail pharmacies such as benefits investigation, financial assistance, medication synchronization, and proactive refill reminders. This study assessed the impact of the specialty pharmacy care model on medication adherence for patients on nonspecialty medications.

METHODS

This study was a quasi-experimental cohort comparison of patients who were transferred from a health-system retail pharmacy to a health-system specialty pharmacy between April 1, 2020, and June 30, 2021. The primary endpoint in this study was the difference in mean medication adherence proportion of days covered (PDC) between the post-transfer and pretransfer periods. Secondary outcomes included the proportion of patients with PDC of greater than 80%, medication adherence by drug group, shipment volumes, number of medications per shipment, and the mean copay per medication.

RESULTS

In this study of 163 patients, use of a specialty pharmacy care model led to a significant increase of 7.0% in mean PDC, a significant increase in the percentage of patients with PDC of greater than 80%, a significant decrease in the number of shipments per 30 days per patient, a significant increase in the number of medications included per shipment, and a significant reduction in the mean copay per medication.

CONCLUSION

The findings in this study suggest that the application of the specialty pharmacy care model to nonspecialty pharmacy patients may improve medication adherence, decrease the number of shipments per patient sent from the pharmacy, and reduce patient copays.

SMS text intervention for uncontrolled hypertension among hypertensive homeless adults in shelter clinics of New York City: protocol for a pragmatic randomised trial study

INTRODUCTION

Uncontrolled hypertension (HTN) is prevalent in persons experiencing homelessness (PEH) and contributes to significant suffering and financial cost. Mobile health approaches such as short messaging service (SMS) texting have led to better control of HTN in the general population. Despite the high utilisation of mobile phones by PEH, SMS texting to support HTN control has not been evaluated among this population. We hypothesise that an SMS testing programme will enhance health communication, information management, outreach and care coordination, and provide behavioural support to address some barriers to HTN management in PEH.

METHODS AND ANALYSIS

This study will use a mixed-methods study design to address two objectives: First, it will evaluate, in a randomised controlled trial, the efficacy of a 6-month SMS texting strategy vs an attention control on blood pressure reduction and adherence to medications and clinical appointments in 120 adults PEH with uncontrolled HTN. Outcomes will be measured at 0, 2, 4 and 6 months. Second, it will assess patients' and providers' acceptability and experience of SMS texting using semistructured interviews with PEH (n=30) and providers (n=10). The study will be conducted in shelter clinics in New York City in collaboration with community organisations. The primary statistical analysis will be on an intention-to-treat basis. The trial results will be reported as comparative summary statistics (difference in response rate or means) with 95% CIs and in accordance with the Consolidated Standards of Reporting Trials (CONSORT). Interviews will be transcribed, coded and analysed using an inductive grounded theory analysis.

ETHICS AND DISSEMINATION

This study has been approved by the Institutional Review Board (IRB) at George Washington University. Written consent will be obtained from participants. The findings will be disseminated in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05187013.

Effect and usability of mobile health applications for medication adherence in patients with heart failure: A systematic review

BACKGROUND

This review aimed to evaluate the effect of mobile health applications (apps) use on medication adherence in heart failure (HF) patients, and to verify their quality of use.

METHODS

We searched MEDLINE, Embase, Web of Science, Scopus, CINAHL, LILACS, Cochrane, Clinical Trial Registries, Google Scholar, ProQuest, Open Access Theses and dissertations (OATD), Annual Symposium Proceedings of the American Medical Informatics Association (AMIA).

RESULTS

Of the 836 records identified, eight studies (five randomized clinical trials (RCTs) and three observational studies) were included, totaling 484 participants, with a mean age ranging from 51.1 to 72 years and 65% were male. The apps improved medication adherence when compared with their comparators in only two RCTs (n = 111, Cohen d = 3.23, 95% confidence interval (CI) 2.66; 3.80 and n = 80, d = 1.20, 95% CI 0.71; 1.66), and two observational studies, one of them with large effect size (n = 142, Cohen d = 1.51, 95% CI 1.12; 1.90). Apps proved to be more effective interventions than their comparators allowed continuous monitoring of patients. All included studies used self-report measures to assess medication adherence behaviors and their results should be interpreted with caution, as such tools may cause social desirability bias or recall bias.

CONCLUSION

The included studies indicate a possible outcome in favor of the use of apps to improve medication adherence in HF patients, but with very low quality level of evidence. Further studies are needed to investigate the effects of the use of apps, optimal frequency and duration of its use in HF patients.

A Systematic Review of the Hill-Bone Compliance to Blood Pressure Therapy Scale

Background

Poor medication adherence hampers hypertension control and increases the risk of adverse health outcomes. Medication adherence can be measured with direct and indirect methods. The Hill-Bone Compliance to High Blood Pressure Therapy (HBCHBPT) Scale, one of the most popular adherence measures, indirectly assesses adherence to hypertension therapy in three behavioral domains: appointment keeping, diet and medication adherence.

Aim

To synthesize evidence on the use of the HBCHBPT Scale, including psychometric properties, utility in diverse patient populations, and directions for future clinical use and research.

Methods

We searched electronic databases, specifically CINAHL, PubMed, PsychInfo, Embase, and Web of Science. We included original studies that used the HBCHBPT Scale or its subscales to measure a health outcome, or methodological studies involving translations and validations of the scale. We extracted and synthesized data following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines.

Results

Fifty studies were included in this review, 44 on hypertension, two on diabetes, and others on other chronic conditions. The scale was successfully translated into numerous languages and used in descriptive and intervention studies. The scale demonstrated sound psychometric properties (Cronbach's α coefficient 0.75) and sensitivity to capture intervention effects when used to evaluate the effectiveness of high blood pressure adherence interventions. The medication-taking subscale of HBCHBPT performs best and is widely used in diverse contexts to assess medication adherence for chronic conditions.

Conclusion

The HBCHBPT Scale has high versatility globally and has been used in various settings by various healthcare worker cadres and researchers. The scale has several strengths, including high adherence phenotyping capabilities, contributing to the paradigm shift toward personalized health care.

Exploring Patient Beliefs and Medication Adherence in the Mediterranean Context: A Cross-Sectional Study in Patients with Cardiovascular Diseases and Cardiometabolic Disorders in Greece-The IACT-Study

BACKGROUND

Evidence has shown that poor adherence to vascular medications contributes to a considerable proportion of all cardiovascular disease (CVD) events and mortality. The aim of the present work was to examine patients' beliefs/views that affect their level of adherence to the assigned medical treatment in the context of a multi-center study in Greece.

METHODS

Between July 2022 and April 2023, 1988 patients (1180 females) with established cardiovascular disease or relevant cardiometabolic disorders were chosen from seven medical centers in Greece. The 4-item Morisky Medication Adherence Questionnaire gauged medication adherence and investigated patients' beliefs/views regarding treatment.

RESULTS

Among participants, 51.2% showed perfect medication adherence, contrasting with 48.8% displaying poor adherence. Patients with negative medication beliefs were around three times more likely to be non-adherent (OR = 2.73; 95% CI = 2.28-3.28). Non-adherers held concerns about drug efficacy (OR = 2.34; 95% CI = 1.10-4.97) and favored alternative therapies (OR = 2.25; 95% CI = 1.75-2.91).

CONCLUSION

The findings highlight the significance of addressing patient beliefs/views to improve medication adherence. The distinct Mediterranean context, influenced by cultural, socioeconomic, and clinical factors, emphasizes the need for tailored interventions. This underscores the call for contextually sensitive strategies to boost medication adherence and improve health outcomes in this unique region.

Randomized prospective trial to detect and distinguish between medication nonadherence, drug-drug interactions, and disease progression in chronic cardiometabolic disease

BACKGROUND

Disentangling nonadherence (NA), drug-drug interactions (DDIs), and disease progression from each other is an important clinical challenge for providers caring for patients with cardiometabolic diseases. NAs and DDIs are both ubiquitous and often overlooked. We studied a novel chronic disease management (CDM) test to detect medication adherence and the presence and severity of DDIs.

MATERIALS AND METHODS

We conducted a prospective, randomized controlled trial of 236 primary care physicians using computer-based, simulated patients, measuring clinical care with and without access to the CDM test. The primary outcomes were whether use of the CDM test increased the accuracy of diagnoses and ordering better treatments and how effective the intervention materials were in getting participants to order the CDM test.

RESULTS

Physicians given the CDM test results showed a + 13.2% improvement in their diagnosis and treatment quality-of-care scores (p < 0.001) in the NA patient cases and a + 13.6% improvement in the DDI cases (p < 0.001). The difference-in-difference calculations between the intervention and control groups were + 10.4% for NA and + 10.8% for DDI (p < 0.01 for both). After controlling for physician and practice co-factors, intervention, compared to control, was 50.4x more likely to recognize medication NA and 3.3x more likely to correctly treat it. Intervention was 26.9x more likely to identify the DDI and 15.7x more likely to stop/switch the interacting medication compared to control. We found no significant improvements for the disease progression patient cases.

CONCLUSION

Distinguishing between nonadherence, drug-drug interactions, and disease progression is greatly improved using a reliable test, like the CDM test; improved diagnostic accuracy and treatment has the potential to improve patient quality of life, medication safety, clinical outcomes, and efficiency of health delivery.

TRIAL REGISTRATION

clinicaltrials.gov (NCT05192590).

Patients' and GPs' duties and responsibilities in long-term care after myocardial infarction: a qualitative study of patients' perspectives

BACKGROUND

Cardiovascular disease is one of the main causes of death in Europe and around the world. Effective and individualized long-term treatment of patients with chronic diseases such as cardiovascular disease and myocardial infarction reduces mortality and the risk of recurrence and prevents secondary disease. However, there is little data on patients' views.

OBJECTIVE

To examine patients' perspectives on long-term care after myocardial infarction.

METHODS

A qualitative interview study with patients after myocardial infarction in Berlin and Brandenburg, Germany. Fifteen episodic interviews were conducted, transcribed, coded, and analyzed using framework analysis.

RESULTS

Participants consistently emphasized major functions fulfilled by general practitioners: monitoring, advice, diagnosis, referral, coordination. Furthermore, other functions such as empathy and feeling emotionally valued. Major patient roles emerged such as information sharing, lifestyle change, and coping. Responsibility toward doctors was expressed in terms of active participation in describing their symptoms, following the doctor's directions, and sharing in decision-making. Self-responsibility in participants showed 2 contrasting approaches. On the one hand, a passive attitude (acceptance, helplessness), and on the other, active resistance and taking action.

CONCLUSION

The study underlines the importance of communication and awareness of the patient's perspective. General practitioners must address patients' aims and fears, encourage their initiative, and focus on empathy and education.

A Case of Cutaneous Vasculitis in the Setting of Systemic Lupus Erythematosus and Cocaine Use

Cocaine, one of most prevalent illicit substances in the United States, affects a multitude of organ systems and precedes numerous negative health outcomes. Many of the consequences of cocaine are linked to induction of vasoconstriction. For this reason, cocaine users are placed at considerable risk of ischemic stroke, myocardial infarction, and cardiac arrhythmias. Furthermore, a prominent contaminant, levamisole, has been widely implicated in predisposing individuals to developing or exacerbating cutaneous vasculitides. This report details a 31-year-old woman with acute, localized necrotic skin lesions after cocaine use. Her clinical picture was complicated by a 17-year history of systemic lupus erythematosus (SLE) and Raynaud's phenomenon. This case examines the challenge of forming a differential diagnosis, initiating an appropriate workup, and interpreting serologic-based and immunologic-based studies to differentiate between SLE and drug-based etiologies of skin necrosis. Finally, we discuss appropriate treatment plans to mitigate symptoms and reduce future instances of drug-induced vasculitis.

Association between medication adherence and health-related quality of life of patients with diabetes

PURPOSE

The purpose was to evaluate the association between medication adherence and health-related quality of life (HRQoL) of patients with diabetes.

METHODS

In this cross-sectional study, a total of 518 patients were recruited from the outpatient departments of different general public and private hospitals in Greece during the COVID-19 pandemic using a consecutive sampling method. HRQoL was assessed with the EQ-5D-5L instrument and medication adherence with the corresponding subscale of the Adherence Starts with Knowledge 20 questionnaire. The relationship between HRQoL and adherence was explored by employing Spearman's correlations and multiple binary logistic and linear stepwise regressions using robust standard errors.

RESULTS

A total of 15.1 and 1.9% of the patients reported that they had taken a medicine either more or less often than prescribed in the last month and week, respectively. Statistically significant but modest correlations of medication non-adherence with the EQ-5D index (rho =  - 0.223), EQ-VAS (rho =  - 0.230), and all the HRQoL domains (rho ranging from 0.211, for pain/discomfort, to 0.136, for mobility issues) were found. These significant associations persisted even after controlling for several other known potential factors of HRQoL in the multivariable analyses, except for the mobility and anxiety/depression dimensions.

CONCLUSION

Medication non-adherence appears to be independently associated with lower HRQoL and health levels in patients with diabetes. It is crucial to plan interventions to enhance medication adherence not only to obtain greater value from the available resources, but also to improve HRQoL of patients with diabetes.

Optimal medical therapy with or without surgical revascularization and long-term outcomes in ischemic cardiomyopathy

OBJECTIVES

Optimal medical therapy in patients with heart failure and coronary artery disease is associated with improved outcomes. However, whether this association is influenced by the performance of coronary artery bypass grafting is less well established. Thus, the aim of this study was to determine the possible relationship between coronary artery bypass grafting and optimal medical therapy and its effect on the outcomes of patients with ischemic cardiomyopathy.

METHODS

The Surgical Treatment for Ischemic Heart Failure trial randomized 1212 patients with coronary artery disease and left ventricular ejection fraction 35% or less to coronary artery bypass grafting with medical therapy or medical therapy alone with a median follow-up over 9.8 years. For the purpose of this study, optimal medical therapy was collected at baseline and 4 months, and defined as the combination of 4 drugs: angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, beta-blocker, statin, and 1 antiplatelet drug.

RESULTS

At baseline and 4 months, 58.7% and 73.3% of patients were receiving optimal medical therapy, respectively. These patients had no differences in important parameters such as left ventricular ejection fraction and left ventricular volumes. In a multivariable Cox model, optimal medical therapy at baseline was associated with a lower all-cause mortality (hazard ratio, 0.78; 95% confidence interval, 0.66-0.91; P = .001). When landmarked at 4 months, optimal medical therapy was also associated with a lower all-cause mortality (hazard ratio, 0.82; 95% confidence interval, 0.62-0.99; P = .04). There was no interaction between the benefit of optimal medical therapy and treatment allocation.

CONCLUSIONS

Optimal medical therapy was associated with improved long-term survival and lower cardiovascular mortality in patients with ischemic cardiomyopathy and should be strongly recommended.

Translation and validation of the Arabic version of the Morisky, Green and Levine (MGL) adherence scale

The Morisky Green Levine (MGL) adherence scale is a 4-item tool used for the detection of medication nonadherence among patients with chronic health conditions. Despite being widely used in Arabic-speaking research contexts, it has never been validated in Arabic language. The aim of this study was to translate and validate the MGL tool into Arabic. A standard forward-backward process was used to translate the questionnaire. Cronbach’s alpha coefficient was measured to assess internal consistency of the scale. The test-retest reliability measured the consistency of participants’ responses over time. Construct validity was evaluated by Explanatory factor analysis (EFA); Kaiser-Meyer-Olkin value and Bartlett’s test of sphericity were determined. Convergent validity was assessed using a preexisting medications Arabic Adherence Assessment Tool (AAAT). The model fit was evaluated using confirmatory factor analysis (CFA). Associations between the MGL scale scores and the patient demographic/clinical characteristics were tested by linear regressions. A total of 201 participants were included into the study. The MGL scale categorization revealed that 20.9%, 59.2% and 19.9% of the participants had high, moderate and low levels of adherence respectively. Adequate internal consistency (alpha = 0.593) was observed. A significant strong ICC and Pearson’s correlations were generated between responses at time 1 and time 2. EFA results elucidated the suitability of the data for factor analysis. Pearson’s coefficient (r) revealed a significant strong correlation between MGL scale and AAAT. CFA results confirmed a good fit for the suggested model. Linear regression revealed higher number of medications, more frequent outpatient clinic visits and not experiencing medication adverse effect factors significantly associated with better adherence. The Arabic version of MLG scale is a reliable valid tool to assess adherence among Arabic-speaking communities. Implementing interventions targeting patients not compliant to regular clinic visits and those at higher risk of experiencing medication side effects can greatly enhance medication adherence.

A bitter pill to swallow? Impact of affective temperaments on treatment adherence: a systematic review and meta-analysis

BACKGROUND

Predominant affective temperament may affect adherence to prescribed pharmacotherapeutic interventions, warranting systematic review and meta-analysis.

METHODS

The Scopus, Web of Science, PubMed, and OVID MedLine databases were inquired since inception up to 31st of March 2022 for records of any study design documenting quantitative evidence about affective temperaments as measured by the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego (TEMPS-A) questionnaire and treatment adherence measured by the means of major rating scales on the matter. People with low vs. high levels of treatment adherence, matched for otherwise clinically relevant variables, were deemed as cases and controls, respectively, using standardized mean differences (SMDs) in pertinent scores under random-effects meta-analysis.

RESULTS

Nine studies encompassing 1138 subjects pointed towards significantly higher cyclothymic (SMD = -0.872; CI: [-1.51 to -0.24]; p = 0.007), irritable (SMD = -0.773; CI: [-1.17 to -0.37]; p < 0.001) and depressive (SMD = -0.758; CI: [-1.38 to -0.14]; p = 0.017) TEMPS-A scores both for psychiatric and nonpsychiatric samples with poorer adherence.

LIMITATIONS

Intrinsic limitations of the present report include the heterogeneity of the operational definitions documented across different primary studies, which nonetheless reported on the sole medication-treatment adherence, thus limiting the generalizability of the present findings based on a handful of comparisons.

CONCLUSIONS

Though further primary studies need to systematically account for different clinical and psychosocial moderators across different clinical populations and operational definitions, cyclothymic, depressive, and irritable temperament scores may nonetheless predict treatment adherence and, thus, overall treatment outcomes.

Clinical Variation in the Treatment Practices for Medication Nonadherence, Drug-Drug Interactions, and Recognition of Disease Progression in Patients with Chronic Cardiometabolic Diseases: A Cross-Sectional Patient Simulation Study among Primary Care Physicians

Background

Medication nonadherence in patients with chronic diseases is common, costly, and often underdiagnosed. In the United States, approximately 40-50% of patients with cardiometabolic conditions are not adherent to long-term medications. Drug-drug interactions (DDI) are also underrecognized and may lead to medication nonadherence in this patient population. Treatment complexity associated with cardiometabolic conditions contributes to increased risk for adverse drug events and DDIs.

Methods

We recruited a nationally representative sample of 246 board-certified family and internal medicine physicians to evaluate how they assessed, identified, and treated medication nonadherence, DDIs, and worsening disease. Participating physicians were asked to care for three online simulated patients, each with at least one chronic cardiometabolic disease, including atrial fibrillation, heart failure, diabetes mellitus, or hypertension, and who were taking prescription medications for their disease. Physicians' scores were based on evidence-based care recommendation criteria, including overall care quality and treatment for medication nonadherence and DDIs.

Results

Overall, quality-of-care scores across all cases ranged from 13% to 87% with an average of 50.8% ± 12.1%. The average overall diagnostic plus treatment score was 21.9% ± 13.6%. Participants identified nonadherence in just 3.6% of cases, DDIs in 8.9% of cases, and disease progression in 30.3% of cases.

Conclusions

Based on these study results, primary care physicians were unable to adequately diagnose and treat patients with chronic cardiometabolic diseases who either suffered from medication nonadherence, DDIs, or progression of the disease. Improved standardization and technique in identifying these diagnoses is needed in primary care. Trial Registration. This trial is registered with clinicaltrials.gov, NCT05192590.

Probabilistic Prediction of Nonadherence to Psychiatric Disorder Medication from Mental Health Forum Data: Developing and Validating Bayesian Machine Learning Classifiers

Background

Medication nonadherence represents a major burden on national health systems. According to the World Health Organization, increasing medication adherence may have a greater impact on public health than any improvement in specific medical treatments. More research is needed to better predict populations at risk of medication nonadherence.

Objective

To develop clinically informative, easy-to-interpret machine learning classifiers to predict people with psychiatric disorders at risk of medication nonadherence based on the syntactic and structural features of written posts on health forums.

Methods

All data were collected from posts between 2016 and 2021 on mental health forum, administered by Together 4 Change, a long-running not-for-profit organisation based in Oxford, UK. The original social media data were annotated using the Tool for the Automatic Analysis of Syntactic Sophistication and Complexity (TAASSC) system. Through applying multiple feature optimisation techniques, we developed a best-performing model using relevance vector machine (RVM) for the probabilistic prediction of medication nonadherence among online mental health forum discussants.

Results

The best-performing RVM model reached a mean AUC of 0.762, accuracy of 0.763, sensitivity of 0.779, and specificity of 0.742 on the testing dataset. It outperformed competing classifiers with more complex feature sets with statistically significant improvement in sensitivity and specificity, after adjusting the alpha levels with Benjamini-Hochberg correction procedure. Discussion. We used the forest plot of multiple logistic regression to explore the association between written post features in the best-performing RVM model and the binary outcome of medication adherence among online post contributors with psychiatric disorders. We found that increased quantities of 3 syntactic complexity features were negatively associated with psychiatric medication adherence: "dobj_stdev" (standard deviation of dependents per direct object of nonpronouns) (OR, 1.486, 95% CI, 1.202-1.838, P < 0.001), "cl_av_deps" (dependents per clause) (OR, 1.597, 95% CI, 1.202-2.122, P, 0.001), and "VP_T" (verb phrases per T-unit) (OR, 2.23, 95% CI, 1.211-4.104, P, 0.010). Finally, we illustrated the clinical use of the classifier with Bayes' monograph which gives the posterior odds and their 95% CI of positive (nonadherence) versus negative (adherence) cases as predicted by the best-performing classifier. The odds ratio of the posterior probability of positive cases was 3.9, which means that around 10 in every 13 psychiatric patients with a positive result as predicted by our model were following their medication regime. The odds ratio of the posterior probability of true negative cases was 0.4, meaning that around 10 in every 14 psychiatric patients with a negative test result after screening by our classifier were not adhering to their medications.

Conclusion

Psychiatric medication nonadherence is a large and increasing burden on national health systems. Using Bayesian machine learning techniques and publicly accessible online health forum data, our study illustrates the viability of developing cost-effective, informative decision aids to support the monitoring and prediction of patients at risk of medication nonadherence.

Getting to the Root of Things: The Role of Epistemic Motivation and Construal Levels in Strategic Problem Formulation

When formulating strategic problems, managers and executives routinely overlook relevant causes. This oversight, in turn, compromises the effectiveness of solutions and strategies. To illuminate the factors determining the success of problem formulation, we develop a model of the individual-level drivers of problem formulation comprehensiveness—the number of nonredundant and relevant causes to a problem that individuals identify. Specifically, we theorize that epistemic motivation—the desire to learn and hold well-informed views of the world—is an important driver of comprehensiveness. Furthermore, we suggest that high construal levels—an abstract thinking style—enhance the benefits of epistemic motivation because they direct individual information processing away from the symptoms of a problem toward its underlying causes. We test this interaction model in two experimental studies involving Chinese top executives and university students in the United States. The results of our two studies are consistent with our theoretical model. High construal levels strengthen the effect of epistemic motivation, resulting in greater comprehensiveness of problem formulation. We discuss the implications of our work for theory and practice.

Behavioral Nudges as Patient Decision Support for Medication Adherence: The ENCOURAGE Randomized Controlled Trial

BACKGROUND

Medication adherence is generally low and challenging to address because patient actions control healthcare delivery outside of medical environments. Behavioral nudging changes clinician behavior, but nudging patient decision-making requires further testing. This trial evaluated whether behavioral nudges can increase statin adherence, measured as the proportion of days covered (PDC).

METHODS

In a 12-month parallel-group, unblinded, randomized controlled trial, adult patients in Intermountain Healthcare cardiology clinics were enrolled. Inclusion required an indication for statins and membership in SelectHealth insurance. Subjects were randomized 1:1 to control or nudges. Nudge content, timing, frequency, and delivery route were personalized by CareCentra using machine learning of subject motivations and abilities from psychographic assessment, demographics, social determinants, and the Intermountain Mortality Risk Score. PDC calculation used SelectHealth claims data.

RESULTS

Among 182 subjects, age averaged 63.2±8.5 years, 25.8% were female, baseline LDL-C was 82.5±32.7 mg/dL, and 93.4% had coronary disease. Characteristics were balanced between nudge (n = 89) and control arms (n = 93). The statin PDC was greater at 12 months in the nudge group (PDC: 0.742±0.318) compared to controls (PDC: 0.639±0.358, P = 0.042). Adherent subjects (PDC ≥80%) were more concentrated in the nudge group (66.3% vs controls: 50.5%, P = 0.036) while a composite of death, myocardial infarction, stroke, and revascularization was non-significant (nudges: 6.7% vs control: 10.8%, P = 0.44).

CONCLUSIONS

Persuasive behavioral nudges driven by artificial intelligence resulted in a clinically important increase in statin adherence in general cardiology patients. This precision patient decision support utilized computerized nudge design and delivery with minimal on-going human input.

The Transition to Noncommunicable Disease: How to Reduce Its Unsustainable Global Burden by Increasing Cognitive Access to Health Self-Management

The global epidemic of noncommunicable diseases (NCDs), such as cardiovascular disease and diabetes, is creating unsustainable burdens on health systems worldwide. NCDs are treatable but not curable. They are less amenable to top-down prevention and control than are the infectious diseases now in retreat. NCDs are mostly preventable, but only individuals themselves have the power to prevent and manage the diseases to which the enticements of modernity and rising prosperity have made them so susceptible (e.g., tobacco, fat-salt-carbohydrate laden food products). Rates of nonadherence to healthcare regimens for controlling NCDs are high, despite the predictable long-term ravages of not self-managing an NCD effectively. I use international data on adult functional literacy to show why the cognitive demands of today's NCD self-management (NCD-SM) regimens invite nonadherence, especially among individuals of below-average or declining cognitive capacity. I then describe ways to improve the cognitive accessibility of NCD-SM regimens, where required, so that more patients are better able and motivated to self-manage and less likely to err in life-threatening ways. For the healthcare professions, I list tools they can develop and deploy to increase patients' cognitive access to NCD-SM. Epidemiologists could identify more WHO "best buy" interventions to slow or reverse the world's "slow-motion disaster" of NCDs were they to add two neglected variables when modeling the rising burdens of disease. The neglected two are both cognitive: the distribution of cognitive capacity levels of people in a population and the cognitive complexity of their health environments.

The Attitude towards Polypills Questionnaire (APPQ): a phase I-III development and validation study in patients with cerebrovascular disease

BACKGROUND AND PURPOSE

The polypill approach has been proposed to reduce patients' pill burden, increase medication adherence and lower stroke incidence. However, little is known about patients' attitudes towards polypills for cerebrovascular medication.

METHODS

Based on the European Organization for Research and Treatment of Cancer Quality of Life Group questionnaire development guidelines, a questionnaire to measure patients' attitudes towards polypills for the secondary prevention of stroke (phase I-III) was developed. In phase I, issues were generated via literature review and interviews with patients and healthcare professionals. The issues were operationalized into items in phase II. In phase III the questionnaire was validated in a large single-centre sample, and test-retest and internal validity were evaluated.

RESULTS

In phase I, 34 relevant issues were identified through literature search and interviews. Pre-testing the questionnaire indicated high applicability and comprehensibility. The final Attitudes towards Polypills Questionnaire was tested in N = 260 patients and showed a two-factor structure. The factors were labelled 'concerns' and 'benefits'. The scales showed acceptable and good internal validity (concerns, Cronbach's α = 0.85; benefits, α = 0.93), but the scales' test-retest validity was ambiguous. On a 0 to 3 rating scale, concerns were rated lower than benefits (mean 1.07, SD 0.69 vs. mean 1.87, SD 0.89).

CONCLUSIONS

The Attitudes towards Polypills Questionnaire showed high comprehensibility and content validity to assess German language patients' attitudes towards a polypill medication. Our data and questionnaire may aid the implementation of polypill treatments in clinical practice and can be used in the design of future clinical trials on polypill therapy. Further validation of the questionnaire is advised.

Active neural networks to detect mentions of changes to medication treatment in social media

Objective

We address a first step toward using social media data to supplement current efforts in monitoring population-level medication nonadherence: detecting changes to medication treatment. Medication treatment changes, like changes to dosage or to frequency of intake, that are not overseen by physicians are, by that, nonadherence to medication. Despite the consequences, including worsening health conditions or death, 50% of patients are estimated to not take medications as indicated. Current methods to identify nonadherence have major limitations. Direct observation may be intrusive or expensive, and indirect observation through patient surveys relies heavily on patients’ memory and candor. Using social media data in these studies may address these limitations.

Methods

We annotated 9830 tweets mentioning medications and trained a convolutional neural network (CNN) to find mentions of medication treatment changes, regardless of whether the change was recommended by a physician. We used active and transfer learning from 12 972 reviews we annotated from WebMD to address the class imbalance of our Twitter corpus. To validate our CNN and explore future directions, we annotated 1956 positive tweets as to whether they reflect nonadherence and categorized the reasons given.

Results

Our CNN achieved 0.50 F₁-score on this new corpus. The manual analysis of positive tweets revealed that nonadherence is evident in a subset with 9 categories of reasons for nonadherence.

Conclusion

We showed that social media users publicly discuss medication treatment changes and may explain their reasons including when it constitutes nonadherence. This approach may be useful to supplement current efforts in adherence monitoring.

Validation of an Arabic Version of the Adherence to Refills and Medications Scale (ARMS)

BACKGROUND

Medication non-adherence is a complex multifactorial phenomenon impacting patients with various health conditions worldwide. Therefore, its detection can improve patient outcomes and minimize the risk of adverse consequences. Even though multiple self-reported medication adherence assessment scales are available, very few of them exist in Arabic language. Therefore, the aim of this study was to validate a newly translated Arabic version of the Adherence to Refills and Medications Scale (ARMS) among patients with chronic health conditions.

METHODS

This is a single-center cross-sectional study that was conducted between October 10th 2018 and March 23rd 2021. ARMS was first translated to Arabic using the forward-backward translation method. The translated scale was then piloted among 21 patients with chronic health conditions (e.g., diabetes, hypertension, etc.…) to examine its reliability and comprehensibility using the test-retest method. Thereafter, the Arabic-translated ARMS was self-administered to adult patients aged ≥18 years with chronic health conditions visiting the primary care clinics of a university-affiliated tertiary care hospital in Riyadh, Saudi Arabia. Construct validity was examined using factor analysis with varimax rotation.

RESULTS

Of the 264 patients who were invited to participate, 202 (76.5%) consented and completed the questionnaire. Most of the participants were males (69.9%), married (75.2%), having a college degree or higher (50.9%), retired or unemployed (65.2%), aged ≥ 50 years (65.2%), and are diabetic (95.9%). The 12-item Arabic-translated ARMS mean score was 17.93 ± 4.90, and the scale yielded good internal consistency (Cronbach's alpha = 0.802) and test-retest reliability (Intraclass correlation coefficient = 0.97). Two factors were extracted explaining 100% of the of the total variance (factor 1 = 52.94% and factor 2 = 47.06%).

CONCLUSIONS

The 12-item Arabic version of ARMS demonstrated good validity and reliability. Therefore, it should help in the detection of medication non-adherence among Arabic-speaking patient population and minimize the risk of adverse consequences.

Appointment Length with Patients in Medical Consultations in Bangladesh: A Hospital-Based Cross-Sectional Study

In medical consultations, the length of the visit has a significant impact on the quality of care. It is significantly associated with a better quality of treatment and better health outcomes. In this study, we analyzed doctors’ consultation length with patients and associated factors in Bangladesh. A cross-sectional survey was conducted among the patients (N = 763) who visited the doctors in six district/upazila (sub-district) hospitals in the Chittagong Hill Tracts (CHT) area. Linear regression analyses were performed to identify the determining factors associated with the length of doctors’ appointments with patients. Data were analyzed using IBM SPSS version 24.0. Among the patients, 319 (41.8%) were female and 688 (90.2%) lived in rural/suburban areas. This study revealed that the average length of medical consultations was 9.10 min. Additionally, our findings illustrated that doctors’ patient-centered communication behavior (β = 0.23, p < 0.001) appeared to be the strongest predictor of longer visit length. It was also found that patients’ higher education level (β = 0.10, p = 0.006), having adequate knowledge about the health problem (β = 0.13, p < 0.001), follow-up visits (β = 0.13, p < 0.001), and the presence of female doctors (β = 0.19, p < 0.001) were significantly associated with longer interview times between doctors and patients in primary care settings. Given that doctors’ patient-centered communication behavior appears to play the most important role, this study suggests that practicing professionalism in medical consultations, developing effective communication skills and increasing awareness of sociodemographic discrepancies are important to ensure longer appointment lengths and better health outcomes of patients, regardless their sociodemographic and socioeconomic status.

Adherence and persistence analysis in patients treated with double antiplatelet therapy (DAPT) at two years in real life

INTRODUCTION

Double antiplatelet therapy (DAPT) is indicated for the treatment of coronary artery diseases (CAD). The optimal duration of therapy with DAPT continues to be a subject of debate in the scientific community. To improve adherence to DAPT, the FDC (fixed dose combination) of Acetylsalicylic acid (ASA) and clopidogrel was developed into a single pill instead of two separate pills thus facilitating the dosage and administration of the therapy and increasing compliance. The aim of this study was to assess adherence and persistence over a period of two years in patients treated with DAPT composed of: ASA/clopidogrel, ASA/prasugrel, ASA/ticagrelor and FDC with ASA and clopidogrel in real life and to assess whether the use of ASA and clopidogrel FDC is associated with improved adherence.

MATERIALS AND METHODS

In the following retrospective pharmacological-observational non-interventional study, all patients treated with DAPT in the Hospital of Pescara from January 2010 to October 2019 were considered. Persistence to treatment is defined as the duration of time from initiation to discontinuation of treatment. Adherence was calculated as the ratio between Received Daily Dose (RDD) and Prescribed Daily Dose (PDD).

RESULTS

277 patients treated with ASA/clopidogrel, 77 patients treated with ASA/prasugrel, 57 patients treated with ASA/ticagrelor and 108 patients treated with FDC of ASA/clopidogrel were analysed. Persistence curves at two years showed a statistically significant difference (p < 0.001). Adherence to therapy was optimal with an absolute value at two years of 0.96. Adherence was better in patients treated with ASA/prasugrel with a value of 0.98 and with 97 % of patients with an adherence value greater than or equal to 0.8, while, it was worse in patients treated with FDC ASA/clopidogrel with an absolute value of 0.94 and with 88 % of patients with an optimal adherence value. No statistically significant difference was found between the ASA/clopidogrel FDC in comparison to each component taken as a separate pill (p = 0.0752).

CONCLUSION

DAPT along with ASA/clopidogrel showed a statistically significant better persistence than ASA/ticagrelor and ASA/prasugrel. Whereas, to our knowledge and as per the current literature no statistically significant differences were found, in terms of adherence in real life, between the use of ASA/Clopidogrel FDC and the use of two different pills.

Remote digital monitoring of medication intake: methodological, medical, ethical and legal reflections

In 2017, regulatory approval was given in the US for a 'digital pill', a pill for which actual ingestion could be remotely monitored. The pill, Abilify Mycite is marketed by Otsuka but the monitoring system derives from Proteus Digital Health. In this paper, we focus on this digital pill and another equivalent system from AiCure which relies on facial recognition. Both systems not only remind the patient to take a pill but also verify the actual intake. In this process, patient-related data beyond the fact that the pill has been taken are also collected and sent to a remote computer system of the system-providing company and possibly to third parties.Although marketed as 'innovative', the introduction of such systems raises questions as to the limitation of patient autonomy, secondary uses of patient data, impact on the physician's liability, and artificial inflation of drug prices. Whereas incorrect medication taking can be problematic, it can be questioned whether remote intake-monitoring systems are, from an ethical, legal and social perspective, the ideal way to address this. In this paper, we will reflect on this question from the position of the different potential stakeholders involved.

Capillary Microfluidics for Monitoring Medication Adherence

Medication adherence is a medical and societal issue worldwide, with approximately half of patients failing to adhere to prescribed treatments. The goal of this Minireview is to examine how recent work on microfluidics for point-of-care diagnostics may be used to enhance adherence to medication. It specifically focuses on capillary microfluidics since these devices are self-powered, easy to use, and well established for diagnostics and drug monitoring. Considering that an improvement in medication adherence can have a much larger effect than the development of new medical treatments, it is long overdue for the research communities working in chemistry, biology, pharmacology, and material sciences to consider developing technologies to enhance medication adherence. For these reasons, this Minireview is not meant to be exhaustive but rather to provide a quick starting point for researchers interested in joining this complex but intriguing and exciting field of research.

Directly Measured Adherence to Treatment in Chronic Heart Failure: LEVEL-CHF Registry

BACKGROUND

Currently, most available data on the medication adherence of patients with chronic heart failure are based on indirect methods. We examined the level of adherence to medical therapy using a direct method - serum drug level testing.

METHODS

We carried out a prospective single-centre registry of patients with chronic heart failure (LEVEL-CHF registry), in whom we analysed serum levels of the medications prescribed for the treatment of heart failure: angiotensin converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers and mineralocorticoid receptor antagonists. We labelled a patient as non-adherent if at least one serum level of a prescribed drug was unmeasurable (below the detection limit). Patients with all tested drugs identifiable in serum were labelled as adherent. We enrolled 274 patients (208 men and 66 women) mean age 62 years.

RESULTS

82.5% of patients were adherent and 17.5% non-adherent to prescribed medications. 3.6% were completely non-adherent without any detectable drugs in serum. Patients aged <60 years were more likely to be non-adherent than older patients (OR 2.15). No other clinical or laboratory parameters predicted non-adherence.

CONCLUSIONS

A significant proportion of outpatients with chronic heart failure were non-adherent to treatment when assessed by a direct method of serum drug level testing. Non-adherence was more likely in younger patients.

Overview of Self-Management Skills and Associated Assessment Tools for Children with Inflammatory Bowel Disease

Self-management is a multi-modal approach for managing chronic conditions that encompasses a number of different elements; knowledge, adherence, self-regulation, communication, and cognitive factors. Self-management has been shown to be beneficial for adults with inflammatory bowel disease (IBD), and for children with IBD it may help them learn to take control of their complex treatment regimens and lead to positive disease outcomes. The development of self-management skills for children with IBD is vital in order to maximize their potential for health autonomy, but it is still an emergent field in this population. This review provides an over-arching view of the self-management elements specific to children with IBD, and highlights outcome measures that may be used to assess skills within each field as well as the efficacy of targeted interventions.

Disparity in physician-patient communication by ethnicity: evidence from Bangladesh

Background

Physician-patient communication behavior (PPCB) is the primary process by which medical decision-making occurs and health outcome depends. Physician-patient communication differences may partly from the ethnic disparities. To examine this problem, this study aims to explore whether physician-patient communication differs by ethnicity during primary care medical consultations.

Methods

The study was conducted among the Bengali and ethnic minority patients (N = 850) who visited a physician for medical consultations. Data were collected using a structured post-consultation questionnaire. T-test was conducted to compare the communication between the Bengali and ethnic minority patients. Multiple linear regression analyses were performed to identify the factors associated with favorable communication behavior from the physicians.

Results

Bengali patients received more supportive communication behaviors from the Bengali doctors than that of ethnic minority patients including physicians’ cheerful greetings, encouraging patients to express health problems and asking questions, listening carefully, responding to questions and concerns, explaining to patients about medical examination procedures, medication, probable side effects, discussing treatment options, involved the patients in decisions, and spending adequate time. Results of linear regression showed that respondents’ level of education, internet use, knowledge about the health issue, having a pre-organized plan about the content of medical consultation, information seeking about the health problem, visiting female doctors, and a quiet ambience of the doctor’s room are significantly associated with a better PPCB score for the Bengali patients. In contrast, age, being the resident of an urban area, perception of affecting a minor health problem, having a pre-organized plan about the content of medical consultation, patients’ involvement in physicians’ decision-making about the treatment, and talking time resulted in better physician-patient communication for the ethnic minority patients.

Conclusion

This study suggests that reducing disparity in the socio-economic status of the ethnic minority groups through development programs and educating healthcare providers on how to use patient-centered communication skills to engage with their patients is one solution to improve equity in the delivery of healthcare and ensure than patients are receiving high-quality treatment, no matter their race or ethnicity.

Effect of patients beliefs about medications on adherence to drugs in diabetic patients attending family medicine outpatient clinic in Ismailia, Egypt

Background

Adherence affected by many factors in the patient or in the treatment. One of these factors is beliefs about medicine, which is modifiable. This study aimed to assess the effect of beliefs about medicines on adherence to medications in diabetic patients.

Methods

It is a cross-sectional descriptive-analytic study, conducted between March 2019 and June 2019, in Family medicine outpatient clinic, Suez Canal University, Egypt. A consecutive sample of diabetic patients presented to the clinic in the period of study was included until fulfilling sample size (82 patients). They filled validated questionnaires of the Morisky Medication Adherence Scale, Beliefs about Medicine, and socio-demographic characteristics.

Results

About half of the patients were non-adherent (54.9%). The necessity beliefs mean was 18.6, while the median was 20, concerns beliefs mean was 14.2, while the median was 14, overuse beliefs mean was 12.2, while the median was 13, finally mean and median of harm score was 11.0. There was a statistically significant relationship between age, education, concern, and harm score with adherence (p = 0.04, 0.02, < 0.001, and 0.03). Age was a positive predictor of adherence; and concern beliefs score was a negative predictor of adherence.

Conclusions

Physicians should inquire about their patient medication beliefs and its effect on patient adherence to discover and solve concerns of diabetic patients to improve non-adherence.

A systematic review of the cost-effectiveness of medicationadherence-enhancing intervention for asthma

Objective: This systematic review aimed to evaluate the cost-effectiveness of medication adherence-improving interventions in patients with asthma.Data source: Search engines including PubMed, Scopus and EBSCOhost were used to locate relevant studies from the inception of the databases to 19 October 2018. Drummond's checklist was used to appraise the quality of the economic evaluation.Study selection: Economic studies evaluating the cost-effectiveness of medication adherence enhancing interventions for asthmatic patients were selected. Relevant information including study characteristics, quality assessment, health outcomes and costs of intervention were narratively summarized. The primary outcome of interest was cost-effectiveness (CE) values and the secondary outcomes were costs, medication adherence and clinical consequences.Results: Twenty studies including 11 randomized controlled trials, 6 comparative studies and 3 modeled studies using Markov models were included in the review. Among these, 15 studies evaluated an educational intervention with 13 showing cost-effectiveness in improving health outcomes. The CE of an internet-based intervention showed similar results between groups, while 3 studies of simplified drug regimens and adding a technology-based training program achieved the desirable cost-effectiveness outcome.Conclusion: Overall, our results would support that all of the identified medication adherence-enhancing interventions were cost-effective considering the increased adherence rate, improved clinical effectiveness and the reduced costs of asthma care. However, it was not possible to identify the most cost-effective intervention. More economic studies with sound methodological conduct will be needed to provide stronger evidence in deciding the best approach to improve medication adherence.

Patient preferences for medication adherence financial incentive structures: A discrete choice experiment

BACKGROUND

Medication adherence for chronic conditions continues to be a challenge for patients. Patient incentives for medication adherence may help. Financial incentives delivered at the point of care may act as cues for medication-taking behavior.

OBJECTIVES

The purpose of this study was to investigate patient preferences for specific structures of financial medication adherence incentives that could feasibly be delivered at the point of care.

METHODS

A discrete choice experiment (DCE) was performed using a national online survey. Study participants were adults who self-reported taking at least one prescription medication for one or more chronic conditions. Following an orthogonal design generated in SAS, the DCE included 32 paired-choice tasks. Data were analyzed using mixed logit models and stratified on participants' income level.

RESULTS

In the full cohort (n = 933), form of financial reward (such as gift-card or cash) was 1.02 times as important to participants as the probability of incentive receipt, 1.58 times as important as monetary value, and 1.93 times as important as timing of receipt. Participants were willing to give up $31.04 of an incentive's monetary value (95% CI = $27.11-$34.98) to receive the incentive 5 months sooner (1-month vs. 6-month time-lag); $60.79 (95% CI = $53.19-$68.39) for probability of receipt to increase from a 1 out of 100 chance to a 1 out of 20 chance; and $10.52 (95% CI = $6.46-$14.58) to receive an incentive in the form of a Visa® gift-card instead of grocery store voucher. These patterns of trade-offs between attributes were generally consistent among participants with lower and higher income.

CONCLUSIONS

Regardless of socioeconomic status, patient preferences for financial medication adherence incentives delivered at the point of care may be most heavily influenced by incentive form and probability of receipt. This has implications for designing medication adherence programs in terms of incentive sustainability, patient engagement, plan star ratings, and patient outcomes.

The Impact of Treatment Adherence on Quality of Life Among Type 2 Diabetes Mellitus Patients - Findings from a Cross-Sectional Study

AIM

The current study was conducted to assess the factors contributing to treatment adherence and its impact on the quality of life (QoL) in type 2 diabetes mellitus (T2DM) patients.

METHODS

A cross-sectional study was conducted between January 2020 to March 2020 among T2DM patients. The data was collected from T2DM out-patient clinics. The participants were recruited by using a simple random sampling method. To assess the association of demographics with the level of adherence, binary logistics regression analysis was applied. Moreover, the Mann-Whitney U-test was used to evaluate the impact of adherence on QoL.

RESULTS

A total of 384 patients participated in this study. Amongst them, 60.2% were male and 39.8% were female. Low adherence was seen in illiterate patients and patients older than 40 years. The results showed that good QoL in T2DM patients was significantly associated with treatment adherence (p= 0.004).

CONCLUSION

The finding of the current study showed that the non-adherence prevailed in illiterate strata of the study population and the medication adherence significantly affects the QoL in T2DM patients. These findings suggest that health regulatory agencies should focus on implementing disease-education interventions for improving the adherence to medications in patients with long-term conditions.

Medication Adherence and Its Association With Quality of Life Among Hypertensive Patients Attending Primary Health Care Centers in Saudi Arabia

Background Chronic diseases require long-term medication and adherence to medication is important for the control of disease as well as prevention of complications. Non-compliance may lead to worsening of the disease, which may affect patients' quality of life. This study aimed to assess the level of medication adherence and its association with quality of life (QOL) among hypertensive patients in Buraidah, Saudi Arabia. Methods A cross-sectional study was carried out in which 299 hypertensive patients were recruited from the randomly selected primary health care centers. Medication adherence was assessed by Hill-Bone Medication Adherence Scale, and quality of life was assessed by the World Health Organization's Quality of Life (WHOQOL)-BREF. Multivariate linear regression was used to assess the association of medication adherence with quality of life. Data was analyzed using SPSS version 21.0 (IBM Inc., Armonk, USA). Results The prevalence of poor adherence was found to be 38.8%. We did not find a significant association of medication adherence with any of the four (physical, psychological, social relationship, and environmental) domains of WHOQOL-BREF. However, poor medication adherence was associated with poor perceived overall QOL adjusted β=-0.012 (95% confidence interval [CI]: -0.021 to -0.002; p=0.018) and health adjusted β=-0.013 (95% CI: -0.025 to -0.002; p<0.018). Conclusion We found a high prevalence of non-adherence among hypertensive patients. This calls for developing interventions to improve compliance with medications to prevent complications of hypertension. Our study could not find a significant association of medication adherence with any of the domains of QOL, while poor adherence was associated with lower overall perceived QOL and health. Nonetheless, worsening of disease due to non-adherence may affect the QOL of patients. We recommend large scale prospective studies to explore the relationship between medication adherence and QOL.

A weighting method for simultaneous adjustment for confounding and joint exposure-outcome misclassifications

Joint misclassification of exposure and outcome variables can lead to considerable bias in epidemiological studies of causal exposure-outcome effects. In this paper, we present a new maximum likelihood based estimator for marginal causal effects that simultaneously adjusts for confounding and several forms of joint misclassification of the exposure and outcome variables. The proposed method relies on validation data for the construction of weights that account for both sources of bias. The weighting estimator, which is an extension of the outcome misclassification weighting estimator proposed by Gravel and Platt (Weighted estimation for confounded binary outcomes subject to misclassification. Stat Med 2018; 37: 425–436), is applied to reinfarction data. Simulation studies were carried out to study its finite sample properties and compare it with methods that do not account for confounding or misclassification. The new estimator showed favourable large sample properties in the simulations. Further research is needed to study the sensitivity of the proposed method and that of alternatives to violations of their assumptions. The implementation of the estimator is facilitated by a new R function (ipwm) in an existing R package (mecor).

Designing an Intervention to Improve Management of High-Risk Lupus Patients Through Care Coordination

Health care disparities are a major cause for large discrepancies in health outcomes between different populations with systemic lupus erythematosus in the United States.A team-based model that incorporates a care coordination strategy in the management of high-risk lupus patients can provide an effective method to overcome the obstacles posed by health care disparities.Access, behavioral modification, community outreach programs, depression, and education are key aspects that need to be addressed when designing interventions to improve the quality of care for high-risk lupus patients.

Factors Influencing Medication Non-Adherence among Chinese Older Adults with Diabetes Mellitus

Objectives: This study aimed to examine the prevalence of medication non-adherence among older adults with diabetes mellitus (DM) in Shandong province, China and to identify its influencing factors. Methods: A sample of 1002 older adults aged 60 or above with DM was analyzed. Medication adherence was measured using the Morisky–Green–Levine (MGL) Medication Adherence Scale. Descriptive statistical analysis, chi-square test, univariate and multivariate logistic regression analyses were employed. Results: The prevalence of self-reported medication non-adherence among older adults with DM was 19.9%. Female respondents (adjusted odds ratio (AOR) = 1.56, 95% CI: 1.09–2.24) and respondents who perceived medication adherence to be unimportant (AOR = 1.69, 95% CI: 1.05–2.74) were more likely to experience medication non-adherence. Respondents with 5 years of disease duration or longer were less likely (AOR = 0.63, 95% CI: 0.46–0.87) to experience medication non-adherence. Conclusions: This study showed that about one out of five older adults with DM in Shandong province, China, experienced medication non-adherence, and that gender, disease duration and perceived importance of medication adherence were associated with medication non-adherence in this population group. Provision of counseling and health education programs could be the future priority to raise patients’ awareness of the importance of medication adherence and improve patients’ self-management of DM.

A pilot study assessing the impact of a polypharmacy mock medication simulation on student adherence and empathy

INTRODUCTION

With non-adherence rates rising among patients, educational activities to prepare future practitioners to be more empathetic and have a more personal understanding of patients' complex medication regimens need to be developed and assessed. The objective of this study was to assess student adherence as well as change in empathy after students immerse themselves in a polypharmacy mock medication simulation.

METHODS

First professional year pharmacy (P1) students were recruited to participate in a pilot polypharmacy simulation consisting of eight prescriptions taken for seven days. Baseline characteristics and empathy (Kiersma-Chen Empathy Scale [KCES]) were assessed in pre-surveys, and student medication adherence, empathy (KCES), and insight into activity were assessed in post-surveys.

RESULTS

There was not a statistically significant change in the total mean empathy score between pre- and post-KCES (83 vs. 82, p = 1.0). One KCES question, "I will not allow myself to be influenced by someone's feeling when determining the best treatment," produced a significant change in mean score (4.77 vs. 4.10, p = 0.02). The average percentage of late and missed doses as self-reported by students, was 5.63% and 5.04%, respectively. Two themes emerged regarding student perception of the experience: improved patient counseling regarding adherence and improved empathy and patient perspective on medication regimen complexity.

CONCLUSIONS

Despite a lack of significant change in KCES after participating in the mock medication regimen, qualitative analysis revealed students believed the experience improved their patient counseling skills regarding adherence and further developed their empathy and patient perspective regarding medication regimen complexity.

Rethinking decision-making in the context of preventive medication: How taking statins becomes "the right thing to do"

To understand decision-making in the context of longterm preventive medication, we explore the way "deciding" articulates with household medication practices and other everyday routines. Taking statins as a case study, we use qualitative data from interviews with 34 participants in the UK who had all been offered statins; 19 were currently taking them. Although all participants reference similar information about statins, the way they assemble and use their knowledge varies: there is a marked asymmetry between participants taking statins and those not taking them. Deliberation is a prominent feature of accounts of deciding not to take statins, but seldom visible within accounts of those taking them. Statin-takers emphasise that they have "no choice" about taking them, while non-takers stress the need to "think about it"; statin-takers' accounts prioritise biomedical tests over experiential knowledge, whereas non-takers sometimes prioritise experiential knowledge. All participants reference similar theoretical and experiential knowledge about side-effects, but whereas non-takers often use this knowledge to explain their decision to decline statins, those taking statins downplay both their own experiences and the likelihood that these are due to statins. To account for these asymmetries, we propose a model of decision-making in which deciding upon a course of action entails constructing a narrative presentation of medication use that frames it as "the right thing to do". This model helps us examine the two-way interactions between decision-making and the material practices through which regular medication gets taken, interactions often elided from accounts both of decision-making and of medication practice. In the context of longterm medication, the boundaries between "deciding" and "doing" are blurred; decision-making is situated within a web of collaborative, discursively-informed practices.

Prescribing for moderate or severe unipolar depression in patients under the long-term care of UK adult mental health services

BACKGROUND

A quality improvement programme addressing prescribing practice for depression was initiated by the Prescribing Observatory for Mental Health.

METHODS

A baseline clinical audit against evidence-based practice standards was conducted in UK adult mental health services.

RESULTS

A total of 55 mental health services submitted data for 2082 patients, under the care of a community psychiatric team (CMHT) for at least a year, with a diagnosis of moderate or severe unipolar depression, 54% of whom had a comorbid psychiatric diagnosis. Selective serotonin reuptake inhibitors were prescribed for 35% of the patients, other newer generation antidepressants for 60%, tricyclic antidepressants for 6% and monoamine oxidase inhibitors for <1%. The most commonly prescribed individual antidepressants were mirtazapine (33%, usually in combination with another antidepressant), venlafaxine (25%) and sertraline (21%). Patients with severe depression were more likely (p < 0.001) to be co-prescribed an antipsychotic medication, lithium, or to have received electroconvulsive therapy. There was a documented clinical review in the last year in 85%, with a symptom rating scale used in 11%. A documented comprehensive treatment history was accessible for 50% of those prescribed antidepressant medication.

CONCLUSION

Patients with moderate or severe depression remaining under the care of a CMHT for longer than a year are clinically complex. The failure to achieve a level of wellness allowing discharge from mental health services may be partly related to the finding that not all patients had the benefit of a systematic approach to clinical assessment and sequential testing of available evidence-based pharmacological interventions.

Development and Validation of eRADAR: A Tool Using EHR Data to Detect Unrecognized Dementia

OBJECTIVES

Early recognition of dementia would allow patients and their families to receive care earlier in the disease process, potentially improving care management and patient outcomes, yet nearly half of patients with dementia are undiagnosed. Our aim was to develop and validate an electronic health record (EHR)-based tool to help detect patients with unrecognized dementia (EHR Risk of Alzheimer's and Dementia Assessment Rule [eRADAR]).

DESIGN

Retrospective cohort study.

SETTING

Kaiser Permanente Washington (KPWA), an integrated healthcare delivery system.

PARTICIPANTS

A total of 16 665 visits among 4330 participants in the Adult Changes in Thought (ACT) study, who undergo a comprehensive process to detect and diagnose dementia every 2 years and have linked KPWA EHR data, divided into development (70%) and validation (30%) samples.

MEASUREMENTS

EHR predictors included demographics, medical diagnoses, vital signs, healthcare utilization, and medications within the previous 2 years. Unrecognized dementia was defined as detection in ACT before documentation in the KPWA EHR (ie, lack of dementia or memory loss diagnosis codes or dementia medication fills).

RESULTS

Overall, 1015 ACT visits resulted in a diagnosis of incident dementia, of which 498 (49%) were unrecognized in the KPWA EHR. The final 31-predictor model included markers of dementia-related symptoms (eg, psychosis diagnoses, antidepressant fills), healthcare utilization pattern (eg, emergency department visits), and dementia risk factors (eg, cerebrovascular disease, diabetes). Discrimination was good in the development (C statistic = .78; 95% confidence interval [CI] = .76-.81) and validation (C statistic = .81; 95% CI = .78-.84) samples, and calibration was good based on plots of predicted vs observed risk. If patients with scores in the top 5% were flagged for additional evaluation, we estimate that 1 in 6 would have dementia.

CONCLUSION

The eRADAR tool uses existing EHR data to detect patients with good accuracy who may have unrecognized dementia. J Am Geriatr Soc 68:103-111, 2019.

Multicap to improve adherence after acute coronary syndromes: results of a randomized controlled clinical trial

BACKGROUND

Adherence to treatment after a myocardial infarction (MI) is poor, even in the early postinfarction period. Combining evidence-based drugs into a multicap could improve adherence in this population. No previous randomized trial assessing fixed-dose combination therapy has included patients early after a MI. We aimed to assess if a multicap containing four secondary prevention drugs increases adherence to treatment at 6 months after MI hospitalization. The study was designed as a randomized, parallel, open-label, controlled trial.

METHODS

Patients were randomized within 7 days of a MI to either multicap or control group. The multicap group received a capsule containing aspirin, atenolol, ramipril, and simvastatin. The control group received each drug in separate pills. The primary outcome was adherence at 6 months. We also measured blood pressure, heart rate, serum cholesterol levels, C-reactive protein, and platelet aggregation.

RESULTS

The study was stopped prematurely when 100 patients were included for futility. At 6 months, 92 (95.8%) patients were adherent to medical treatment: 98.0% in the multicap group and 93.5% in the control group [relative risk (RR) 1.05; 95% confidence interval (CI) 0.96-1.14; p = 0.347]. There were no differences between groups in systolic blood pressure (p = 0.662), diastolic blood pressure (p = 0.784), heart rate (p = 0.533), total cholesterol (p = 0.760), LDL-c (p = 0.979), C-reactive protein (p = 0.399), or in the proportion of patients with adequate platelet aggregation inhibition (p = 0.600).

CONCLUSIONS

The study did not find any improvement in the adherence at 6 months after a MI with a multicap-based strategy (Multicap for Increase Adherence After Acute Myocardial Infarction; [ ClinicalTrials.gov identifier: NCT02271178]).