Reminder packaging for improving adherence to self-administered long-term medications

Medication Self-Management for Home Care Users Receiving Multidose Drug Dispensing: Qualitative Interview Study

Background

Multidose drug dispensing (MDD) is an adherence aid where medicines are machine-dispensed in disposable unit bags, usually for a 14-day period. MDD replaces manually filled dosettes in many home care services in Norway. While evidence suggests that MDD can improve medication adherence and reduce errors, there are few studies on how patients manage MDD at home and how this affects their daily routines.

Objective

The aim of the study is to identify factors influencing medication self-management behavior among MDD users living at home and explore how MDD affects medication self-management.

Methods

We conducted semistructured interviews with 19 MDD users in Oslo between August 2019 and February 2020. The interviews were held at the participants' homes, and the interview transcripts were analyzed thematically.

Results

All participants in the study received some form of assistance with medication management from home care services. This assistance ranged from MDD delivery every other week to actual assistance with medication administration multiple times daily. However, regardless of the level of assistance received, participants primarily managed their MDD medications themselves. Daily medication routines and knowledge about medicines varied among the participants, with some taking an active role in their medication management, while others relied on others to take responsibility. The degree of involvement seemed determined by motivation rather than capability.

Conclusions

MDD can support medication self-management, but its effectiveness varies among patients. The level of medication management by MDD users is not solely determined by their actual capabilities. Factors such as interest in self-care and independence, available support, information, and cognitive capacity all play a role in determining the degree of autonomy.

Effect of electronic adherence monitoring on adherence and outcomes in chronic conditions: A systematic review and meta-analysis

INTRODUCTION

Electronic adherence monitoring (EAM) is increasingly used to improve adherence. However, there is limited evidence on the effect of EAM in across chronic conditions and on patient acceptability. We aimed to assess the effect of EAM on adherence and clinical outcomes, across all ages and all chronic conditions, and examine acceptability in this systematic review and meta-analysis.

METHODS

A systematic search of Ovid MEDLINE, EMBASE, Social Work Abstracts, PsycINFO, International Pharmaceutical Abstracts and CINAHL databases was performed from database inception to December 31, 2020. Randomised controlled trials (RCTs) that evaluated the effect of EAM on medication adherence as part of an adherence intervention in chronic conditions were included. Study characteristics, differences in adherence and clinical outcomes between intervention and control were extracted from each study. Estimates were pooled using random-effects meta-analysis, and presented as mean differences, standardised mean differences (SMD) or risk ratios depending on the data. Differences by study-level characteristics were estimated using subgroup meta-analysis to identify intervention characteristics associated with improved adherence. Effects on adherence and clinical outcomes which could not be meta-analysed, and patient acceptability, were synthesised narratively. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline was followed, and Risk of bias (RoB) assessed using the Cochrane Collaboration's RoB tool for RCTs. The review is registered with PROSPERO CRD42017084231.

FINDINGS

Our search identified 365 studies, of which 47 studies involving 6194 patients were included. Data from 27 studies (n = 2584) were extracted for the adherence outcome. The intervention group (n = 1267) had significantly better adherence compared to control (n = 1317), (SMD = 0.93, CI:0.69 to 1.17, p<0.0001) with high heterogeneity across studies (I2 = 86%). There was a significant difference in effect according to intervention complexity (p = 0.01); EAM only improved adherence when used with a reminder and/or health provider support. Clinical outcomes were measured in 38/47 (81%) of studies; of these data from 14 studies were included in a meta-analysis of clinical outcomes for HIV, hypertension and asthma. In total, 13/47 (28%) studies assessed acceptability; patient perceptions were mixed.

INTERPRETATION

Patients receiving an EAM intervention had significantly better adherence than those who did not, but improved adherence did not consistently translate into clinical benefits. Acceptability data were mixed. Further research measuring effects on clinical outcomes and patient acceptability are needed.

[Atrial fibrillation and cognitive impairment: features of the relationship, developmental and prevention mechanisms]

The article discusses the development of cognitive deficit in patients with atrial fibrillation (AF) and provides data on mechanisms of the development of cognitive disorders in AF. Under discussion are a possibility of reducing the risk of cognitive disorders with the anticoagulant therapy for prevention of stroke in AF and different properties of different anticoagulants, which may be important for patients. Thus, patients with cognitive disorders are more prone to missing the dose, which may entail serious, possibly fatal consequences. Therefore, the convenience of dosing may be essential. The drug rivaroxaban that has once-a-day dosing schedule and a calendar package, may help the patient better adhere to the doctor's recommendations. Therefore, rivaroxaban may help improving the compliance, which is the major condition for comprehensive, necessary protection of an elderly patient with AF, including the protection, with high safety, from stroke, from the risk of coronary complications, and from the impairment of kidney function.

A Smartphone App to Improve Oral Anticoagulation Adherence in Patients With Atrial Fibrillation: Prospective Observational Study

BACKGROUND

Poor adherence to oral anticoagulation in elderly patients with atrial fibrillation (AF) has been shown to negatively impact health care costs, morbidity, and mortality. Although various methods such as automated reminders, counseling, telephone support, and patient education have been effective in improving medication adherence, the burden on health care providers has been considerable. Recently, an attempt has been made to improve medication adherence without burdening health care providers by using smartphone apps; however, the use of the app for elderly patients with AF is still limited.

OBJECTIVE

The purpose of this study was to determine whether the newly developed smartphone app for patients with AF (the Smart AF), which integrates education, automatic reminder, and patient engagement strategies with a simple user interface, can improve medication adherence in elderly patients with AF.

METHODS

Patient enrollment was carried out by obtaining informed consent from patients with AF attending Kyoto Prefectural University of Medicine hospital between May 2019 and September 2020. Follow-up was planned at 1, 3, and 6 months after enrollment, and questionnaire reminders were automatically sent to patient apps at designated follow-up time points. A questionnaire-based survey of medication adherence was performed electronically using the self-reported 8-item Morisky Medication Adherence Scale (MMAS-8) as the survey tool.

RESULTS

A total of 136 patients with AF were enrolled in this study. During the follow-up period, 112 (82%) patients underwent follow-up at 1 month, 107 (79%) at 3 months, and 96 (71%) at 6 months. The mean age of the enrolled patients was 64.3 years (SD 9.6), and male participants accounted for 79.4% (108/136) of the study population. The mean CHADS2 (congestive heart failure, hypertension, age, diabetes, previous stroke, or transient ischemic attack) score was 1.2, with hypertension being the most common comorbidity. At the time of enrollment, 126 (93%) and 10 (7%) patients were taking direct oral anticoagulants and warfarin, respectively. For medication adherence as measured according to the MMAS-8, MMAS scores at 1 month, 3 months, and 6 months were significantly improved compared with baseline MMAS scores (all P values less than .01). The overall improvement in medication adherence achieved by the 6-month intervention was as follows: 77.8% (14/18) of the patients in the high adherence group (score=8) at baseline remained in the same state, 45.3% (24/53) of the patients in the medium adherence group (score=6 to <8) at baseline moved to the high adherence group, and 72% (18/25) of the patients in the low adherence group (score <6) moved to either the medium or high adherence group.

CONCLUSIONS

The Smart AF app improved medication adherence among elderly patients with AF. In the realm of medication management, an approach using a mobile health technology that emphasizes education, automatic reminder, and patient engagement may be helpful.

Barriers and Solutions to Improve Therapeutic Adherence from the Perspective of Primary Care and Hospital-Based Physicians

PURPOSE

To identify the barriers affecting treatment adherence in patients with chronic disease and to determine solutions through the physician's opinion of primary care and hospital settings.

METHODS

An observational study using the nominal group technique was performed to reach a consensus from experts. A structured face-to-face group discussion was carried out with physicians with more than 10 years of experience in the subject of treatment adherence/compliance in either the primary care setting or the hospital setting. The experts individually rated a list of questions using the Likert scale and prioritized the top 10 questions to identify barriers and seek solutions afterward. The top 10 questions that obtained the maximum score for both groups of experts were prioritized. During the final discussion group, participating experts analyzed the prioritized items and debated on each problem to reach consensual solutions for improvement.

RESULTS

A total of 17 professionals experts participated in the study, nine of them were from a primary care setting. In the expert group from the primary care setting, the proposed solution for the barrier identified as the highest priority was to simplify treatments, measure adherence and review medication. In the expert group from the hospital setting, the proposed solution for the barrier identified as the highest priority was training on motivational clinical interviews for healthcare workers undergraduate and postgraduate education. Finally, the expert participants proposed implementing an improvement plan with eight key ideas.

CONCLUSION

A consensual improvement plan to facilitate the control of therapeutic adherence in patients with chronic disease was developed, taking into account expert physicians' opinions from primary care and hospital settings about barriers and solutions to address therapeutic adherence in patients with chronic disease.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Patient Perspectives on Performance of a Smartphone App for Atrial FibrillationSelf-Management

INTRODUCTION

AF self-care requires patients to perform daily self-monitoring for symptoms, practice decision making to address symptom changes, and adhere to prescribed medication, diet, physical activity, and follow-up care. Technology can facilitate these critical self-care behaviors and ultimately improve patient outcomes. We assessed atrial fibrillation (AF) patients' experiences with a smartphone application (app) for AF self-management.

METHODS

A focus group with 9 AF patients and app users was conducted and analyzed using qualitative research methods. The focus group was recorded, transcribed, and coded using a priori and inductive coding strategies. Participant responses for each code were synthesized to identify primary themes.

RESULTS

We identified four superordinate themes from patients' experiences: (1) disconnect between tool and its intended use; (2) app as acknowledged tool for adherence; (3) knowledge as empowerment; (3) motives: self-interest vs supporting research. Results from this qualitative study underscore the need to clarify the app's intended use and to better accommodate patients with different AF experiences. The disconnect between a tool and its intended use can generate frustration for users.

DISCUSSION

The study reinforces that participants not only see how the app is a tool for adherence; they also see knowledge they gain via the app as empowering, suggesting a correlation between app use and self-efficacy.

Perceptions of community pharmacists to implementing technologies in the workplace: an exploratory study

Background The proliferation of different technologies in pharmacies has begun to change the role and work of pharmacists; however, while workplace integration of technologies has been shown to be beneficial, there are still barriers to their implementation. Few studies have investigated pharmacists' perceptions of these technologies. Objective To investigate the views of community pharmacists on the implementation of technologies in pharmacy practice. Setting Community pharmacies in Auckland, New Zealand. Methods Semi-structured interviews were conducted June-September 2018 with a convenience sample of 20 pharmacists. Interviews explored current medication management and technologies used to support this service, experiences with technologies, confidence in learning new technologies, and whether the introduction of technologies could solve any needs in pharmacy practice. Data were analysed using inductive thematic analysis. Main outcome measure Community pharmacists views on pharmacy technologies. Results Four key themes were identified: attitudes to existing medication management technologies, adapting to new technologies, acceptance of technology, and barriers to implementing technology in pharmacies. Pharmacists were accepting of technology to help with medication management and allowing them to provide more patient-centered care. Most pharmacists expressed confidence in using new technologies and viewed technology as a tool to address current limitations in their practice. Barriers to technology were cost, consequences of medication error, fear that technology may replace people, and an over-reliance on technology. Conclusion Community pharmacists made use of several types of technologies to promote medication management, including robotics. While mostly accepting of new technologies to streamline tasks and reduce error, pharmacists highlighted the importance of addressing barriers to technology implementation prior to workplace implementation.

Refining Boolean queries to identify relevant studies for systematic review updates

OBJECTIVE

Systematic reviews are important in health care but are expensive to produce and maintain. The authors explore the use of automated transformations of Boolean queries to improve the identification of relevant studies for updates to systematic reviews.

MATERIALS AND METHODS

A set of query transformations, including operator substitution, query expansion, and query reduction, were used to iteratively modify the Boolean query used for the original systematic review. The most effective transformation at each stage is identified using information about the studies included and excluded from the original review. A dataset consisting of 22 systematic reviews was used for evaluation. Updated queries were evaluated using the included and excluded studies from the updated version of the review. Recall and precision were used as evaluation measures.

RESULTS

The updated queries were more effective than the ones used for the original review, in terms of both precision and recall. The overall number of documents retrieved was reduced by more than half, while the number of relevant documents found increased by 10.3%.

CONCLUSIONS

Identification of relevant studies for updates to systematic reviews can be carried out more effectively by using information about the included and excluded studies from the original review to produce improved Boolean queries. These updated queries reduce the overall number of documents retrieved while also increasing the number of relevant documents identified, thereby representing a considerable reduction in effort required by systematic reviewers.

A systematic overview of systematic reviews evaluating medication adherence interventions

PURPOSE

To systematically summarize evidence from multiple systematic reviews (SRs) examining interventions addressing medication nonadherence and to discern differences in effectiveness by intervention, patient, and study characteristics.

SUMMARY

MEDLINE, the Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effects were searched for papers published from January 2004 to February 2017. English-language SRs examining benefits of medication adherence interventions were eligible. Inclusion was limited to adult patients prescribed medication for 1 of the following disease conditions: diabetes and prediabetes, heart conditions, hypertension and prehypertension, stroke, and cognitive impairment. Non-disease-specific SRs that considered medication adherence interventions for older adults, adults with chronic illness, and adults with known medication adherence problems were also included. Two researchers independently screened titles, abstracts, and full-text articles. They then extracted key variables from eligible SRs, reconciling discrepancies via discussion. A MeaSurement Tool to Assess systematic Reviews (AMSTAR) was used to assess SRs; those with scores below 8 were excluded. Conclusions regarding intervention effectiveness were extracted. Grades of Recommendation, Assessment, Development and Evaluation (GRADE) methodology was applied to assess evidence quality.

RESULTS

Of 390 SRs, 25 met the inclusion criteria and assessed adherence as a primary outcome. Intervention types most consistently found to be effective were dose simplification, patient education, electronic reminders to patients, and reduced patient cost sharing or incentives. Of 50 conclusions drawn by the SRs, the underlying evidence was low or very low quality for 45 SRs.

CONCLUSION

Despite an abundance of primary studies and despite only examining high-quality SRs, the vast majority of primary studies supporting SR authors' conclusions were of low or very low quality. Nonetheless, health system leaders seeking to improve medication adherence should prioritize interventions that have been studied and found to be effective at improving patient adherence, including dose simplification, education, reminders, and financial incentives.

Interventions for improving medication-taking ability and adherence in older adults prescribed multiple medications

BACKGROUND

Older people taking multiple medications represent a large and growing proportion of the population. Managing multiple medications can be challenging, and this is especially the case for older people, who have higher rates of comorbidity and physical and cognitive impairment than younger adults. Good medication-taking ability and medication adherence are necessary to ensure safe and effective use of medications.

OBJECTIVES

To evaluate the effectiveness of interventions designed to improve medication-taking ability and/or medication adherence in older community-dwelling adults prescribed multiple long-term medications.

SEARCH METHODS

We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, CINAHL Plus, and International Pharmaceutical Abstracts from inception until June 2019. We also searched grey literature, online trial registries, and reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs. Eligible studies tested interventions aimed at improving medication-taking ability and/or medication adherence among people aged ≥ 65 years (or of mean/median age > 65 years), living in the community or being discharged from hospital back into the community, and taking four or more regular prescription medications (or with group mean/median of more than four medications). Interventions targeting carers of older people who met these criteria were also included.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed abstracts and full texts of eligible studies, extracted data, and assessed risk of bias of included studies. We conducted meta-analyses when possible and used a random-effects model to yield summary estimates of effect, risk ratios (RRs) for dichotomous outcomes, and mean differences (MDs) or standardised mean differences (SMDs) for continuous outcomes, along with 95% confidence intervals (CIs). Narrative synthesis was performed when meta-analysis was not possible. We assessed overall certainty of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Primary outcomes were medication-taking ability and medication adherence. Secondary outcomes included health-related quality of life (HRQoL), emergency department (ED)/hospital admissions, and mortality.

MAIN RESULTS

We identified 50 studies (14,269 participants) comprising 40 RCTs, six cluster-RCTs, and four quasi-RCTs. All included studies evaluated interventions versus usual care; six studies also reported a comparison between two interventions as part of a three-arm RCT design. Interventions were grouped on the basis of their educational and/or behavioural components: 14 involved educational components only, 7 used behavioural strategies only, and 29 provided mixed educational and behavioural interventions. Overall, our confidence in results regarding the effectiveness of interventions was low to very low due to a high degree of heterogeneity of included studies and high or unclear risk of bias across multiple domains in most studies. Five studies evaluated interventions for improving medication-taking ability, and 48 evaluated interventions for improving medication adherence (three studies evaluated both outcomes). No studies involved educational or behavioural interventions alone for improving medication-taking ability. Low-quality evidence from five studies, each using a different measure of medication-taking ability, meant that we were unable to determine the effects of mixed interventions on medication-taking ability. Low-quality evidence suggests that behavioural only interventions (RR 1.22, 95% CI 1.07 to 1.38; 4 studies) and mixed interventions (RR 1.22, 95% CI 1.08 to 1.37; 12 studies) may increase the proportions of people who are adherent compared with usual care. We could not include in the meta-analysis results from two studies involving mixed interventions: one had a positive effect on adherence, and the other had little or no effect. Very low-quality evidence means that we are uncertain of the effects of educational only interventions (5 studies) on the proportions of people who are adherent. Low-quality evidence suggests that educational only interventions (SMD 0.16, 95% CI -0.12 to 0.43; 5 studies) and mixed interventions (SMD 0.47, 95% CI -0.08 to 1.02; 7 studies) may have little or no impact on medication adherence assessed through continuous measures of adherence. We excluded 10 studies (4 educational only and 6 mixed interventions) from the meta-analysis including four studies with unclear or no available results. Very low-quality evidence means that we are uncertain of the effects of behavioural only interventions (3 studies) on medication adherence when assessed through continuous outcomes. Low-quality evidence suggests that mixed interventions may reduce the number of ED/hospital admissions (RR 0.67, 95% CI 0.50 to 0.90; 11 studies) compared with usual care, although results from six further studies that we were unable to include in meta-analyses indicate that the intervention may have a smaller, or even no, effect on these outcomes. Similarly, low-quality evidence suggests that mixed interventions may lead to little or no change in HRQoL (7 studies), and very low-quality evidence means that we are uncertain of the effects on mortality (RR 0.93, 95% CI 0.67 to 1.30; 7 studies). Moderate-quality evidence shows that educational interventions alone probably have little or no effect on HRQoL (6 studies) or on ED/hospital admissions (4 studies) when compared with usual care. Very low-quality evidence means that we are uncertain of the effects of behavioural interventions on HRQoL (1 study) or on ED/hospital admissions (2 studies). We identified no studies evaluating effects of educational or behavioural interventions alone on mortality. Six studies reported a comparison between two interventions; however due to the limited number of studies assessing the same types of interventions and comparisons, we are unable to draw firm conclusions for any outcomes.

AUTHORS' CONCLUSIONS

Behavioural only or mixed educational and behavioural interventions may improve the proportion of people who satisfactorily adhere to their prescribed medications, but we are uncertain of the effects of educational only interventions. No type of intervention was found to improve adherence when it was measured as a continuous variable, with educational only and mixed interventions having little or no impact and evidence of insufficient quality to determine the effects of behavioural only interventions. We were unable to determine the impact of interventions on medication-taking ability. The quality of evidence for these findings is low due to heterogeneity and methodological limitations of studies included in the review. Further well-designed RCTs are needed to investigate the effects of interventions for improving medication-taking ability and medication adherence in older adults prescribed multiple medications.

Vitamin C supplementation reduces the odds of developing a common cold in Republic of Korea Army recruits: randomised controlled trial

INTRODUCTION

The Republic of Korea (ROK) military has a high incidence of respiratory diseases at training centres. Vitamin C has been reported to reduce the incidence of colds. For the purpose of preventing soldiers' respiratory diseases, this study aimed to investigate whether vitamin C intake can prevent common colds in the ROK Army soldiers.

METHODS

This was a randomised, placebo-controlled, and double-blind trial of soldiers who enlisted in the Korea Army Training Centre for 30 days from 12 February to 13 March 2018. The study participants were divided into groups (vitamin C vs placebo). The military medical records were searched to determine whether the participants had a common cold. Multiple logistic regression analysis was performed to identify the association between vitamin C intake and diagnosis of common colds. In addition, subgroup analysis on the relationship between vitamin C intake and common cold according to smoking status, training camp and physical rank was conducted.

RESULTS

A total of 1444 participants were included in our study. Of these participants, 695 received vitamin C (6000 mg/day, vitamin C group), while 749 participants received placebo (0 mg/day, placebo group). The vitamin C group had a 0.80-fold lower risk of getting a common cold than did the placebo group. Subgroup analyses showed that this effect was stronger among subjects in camp A, among never smokers and among those in physical rank 3.

CONCLUSION

Vitamin C intake provides evidence to suggest that reducing the common colds in Korean Army soldiers. Our results may serve as a basis for introducing military healthcare policies that can provide vitamin C supplementation for military personnel in basic military training.

Effect of multidose drug dispensing on the time in therapeutic range in patients using vitamin-K antagonists: A randomized controlled trial

BACKGROUND

A high number of vitamin K antagonist (VKA) users have a low proportion of time in therapeutic range (TTR) resulting in a high number of bleeding and thromboembolism events.

OBJECTIVE

Can the quality of anticoagulation be improved by dispensing VKAs via multidose drug dispensing (MDD).

METHOD

A randomized controlled trial in the Netherlands. Patients who used VKAs, ≥65 years of age with a TTR <65% were eligible for inclusion. All oral drugs were dispensed via MDD. In MDD systems, all oral chronic medication intended for one dosing moment is packed in plastic disposable pouches. Controls received VKAs by manual dispensing. The difference in TTR between the 6 months after- and 6 months before the index date. A mixed-effects model with the intervention, TTR before the index date, MDD system at baseline as covariates, and pharmacy as random effect. A per-protocol analysis was performed with all patients who completed the study as intended.

RESULTS

One hundred and seventy-nine patients were included. Mean age was 80.0 (SD 6.9) years. Mean TTR during the study was 79.2 ± 18.0% in the intervention group and 72.5 ± 20.1% in the control group. The intervention resulted in a 5.6% (95% CI: 0.1-11.1) increase in TTR compared to the control group. Per-protocol analysis resulted in an 8.3% (95% CI: 0.99-15.61) increase in TTR compared to the control group. No differences in reduction were observed between the intervention and control group.

CONCLUSION

The quality of anticoagulation can be improved with the use of MDD systems.

Does Antiretroviral Therapy Packaging Matter? Perceptions and Preferences of Antiretroviral Therapy Packaging for People Living with HIV in Northern Tanzania

INTRODUCTION

Despite improvements in treatment (eg, reduction in pill intake), antiretroviral therapy (ART) is dispensed in socially inefficient and uneconomical packaging. To make pills less conspicuous and decrease the risk of being stigmatized, people living with HIV (PLWH) often engage in self-repackaging - the practice of transferring ART from original packaging to alternative containers. This behavior has been associated with ART nonadherence and failure to achieve viral load suppression. While much of the literature on ART packaging has centered around medication adherence, patients stated preferences for ART packaging and packaging attributes that influence the observed ART nonadherence are understudied.

METHODS

We conducted a qualitative study to elucidate perceptions of ART packaging among PLWH at two large referral hospitals in Northern Tanzania. Interviews were conducted until thematic saturation was reached. Interviews were audio-recorded, transcribed and coded.

RESULTS

Of the 16 participants whose data were used in the final analysis, a majority were between 36 and 55 years of age (Mean 45.5 years SD: 11.1), had primary-level education (n=11, 68.8%), were self-employed (n=9, 56.3%), reported that they had self-repacked ART (n=14, 88%), and were taking ART for more than 6 years (n=11, 68.8%). Participants identified three attributes of ART packaging that increased anticipated HIV stigma and prompted self-repackaging, including visual identification, bulkiness, and the rattling noise produced by ART pill bottles.

CONCLUSION

Given the drastic reduction in the number of pills required for HIV treatment, there is an opportunity to not only assess the cost-effectiveness of innovative ART packaging but also evaluate the acceptability of such packaging among PLWH in order to address stigma and improve ART adherence.

Anticoagulant Therapy as a Tool for the Prevention of Cognitive Impairment Associated with Atrial Fibrillation

Atrial fibrillation (AF) is one of the most common cardiac arrhythmias in clinical practice and important additional risk factor for the development of cognitive impairment (CI) and dementia as it has been shown in recent studies. According to the Diagnostic and statistical manual of mental disorders latest revision CI refers to a decrease of one or more higher cortical functions that provide the processes of perception, storage, transformation and transmission of information compared to the premorbid level. The main hypothesis that explains the relationship between AF and dementia is the assumption that in the presence of this arrhythmia a brain substance is damaged due to microembolism and cerebral microbleeding. The high clinical significance of AF as well as CI served as a background for the development by European experts several consensus documents concerning the problem of the relationships between these conditions. In addition, they emphasize the role of anticoagulant therapy as a preventing tool for the development of stroke, which can be a factor in the CI progression in patients with AF, with particular priority to direct oral anticoagulants (DOACs). In randomized clinical trials, meta-analyses and systematic reviews have been shown that the use of DOACs, as compared to vitamin K antagonists, is a more rational strategy for preventing stroke associated with AF. Among the DOAC class, rivaroxaban is worth noticing as a drug that has a favorable efficacy profile for primary and secondary stroke prevention. Rivaroxaban distinguishing characteristics are a once daily administration as well as a calendar package which is practically important for patients with CI.

[Cognitive Dysfunction at the Background of Atrial Fibrillation: Clinical-Pathological Aspects, Diagnostics and Prevention, Issues of the Use of the Application of Anticoagulant Therapy]

Atrial fibrillation (AF) and cognitive dysfunction - common states with similar risk factors. Recently significant scientific epidemiological data has been received in favor of independence of effect of AF on possibility of development of cognitive dysfunction. In this review we present problems of prevalence, pathogenesis, and diagnostics of various variants of cognitive disorders at the background of AF, as well as methods of their prevention and tactics of anticoagulant therapy in the presence of cognitive disturbances.

Effect of dose administration aids on adherence to self-administered medications: a systematic review protocol

INTRODUCTION

Forgetting to take a medication is the most common reason for non-adherence to self-administered medication. Dose administration aids (DAAs) are a simple and common solution to improve unintentional non-adherence for oral tablets. DAAs can be in the form of compartmentalised pill boxes, automated medication dispensing devices, blister packs and sachets packets. This protocol aims to outline the methods that will be used in a systematic review of the current literature to assess the impact of DAAs on adherence to medications and health outcomes.

METHODS AND ANALYSIS

Randomised controlled trials will be identified through electronic searches in databases including EMBASE, MEDLINE, CINAHL and the Cochrane Library, from the beginning of each database until January 2020. Two reviewers will independently screen studies and extract data using the standardised forms. Data extracted will include general study information, characteristics of the study, participant characteristics, intervention characteristics and outcomes. Primary outcome is to assess the effects of DAAs on medication adherence. Secondary outcome is to evaluate the changes in health outcomes. The risk of bias will be ascertained by two reviewers in parallel using The Cochrane Risk of Bias Tool. A meta-analysis will be performed if data are homogenous.

ETHICS AND DISSEMINATION

Ethics approval will not be required for this study. The results of the review described within this protocol will be disseminated through publication in a peer-reviewed journal and relevant conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42018096087.

Protocol for a randomised controlled trial to evaluate the effectiveness of improving tuberculosis patients' treatment adherence via electronic monitors and an app versus usual care in Tibet

BACKGROUND

Treatment non-adherence is a serious challenge to effective tuberculosis (TB) control in Tibet. In this study we will pilot and evaluate the effectiveness of using new electronic monitors (e-monitors) and a smartphone app to improve treatment adherence among new pulmonary TB patients in Tibet.

METHODS

We will use a multicentre, parallel-group, individually randomised controlled, superiority trial with blinded outcome evaluation and unblinded treatment. We will randomise new pulmonary TB outpatients (aged ≥ 15 years old and free from communication impairment) from Shigatse, Tibet to either the intervention or control arm in a 1:1 ratio at the time of their diagnosis. All patients will be treated according to the World Health Organisation standard 6-month TB treatment regimen and the China National TB programme guidelines. Intervention arm patients will be given their medication via e-monitors that have automatic voice reminders, and record medication adherence data and share it with health staff via Cloud connection. Intervention patients will also be encouraged to receive smartphone-based video-observed treatment if their adherence is problematic. Control arm patients will receive their medication in e-monitors that will collect medication adherence history, but will have their reminder function deactivated and are not linked to the app. The primary outcome is the rate of poor adherence, measured monthly during treatment as a binary indicator where poor adherence means missing ≥ 20% of doses in a month. We will conduct a qualitative process evaluation to explore operational questions regarding acceptability, cultural appropriateness and burden of technology use, as well as a cost-effectiveness analysis and an analysis of the long-term effects of the intervention on TB control.

DISCUSSION

Our study is one of the first trials to evaluate the use of e-monitors and smartphone apps for customised treatment support in low- and middle-income countries (LMICs). All intervention activities are designed to be embedded into routine TB care with strong local ownership. Through the trial we intend to understand the feasibility of our intervention, its effectiveness, its cost-effectiveness and its long-term impacts to inform future scale-up in remote areas of China and other LMICs.

TRIAL REGISTRATION

Current Controlled Trials, ID: ISRCTN52132803 . Registered on 9 November 2018.

Older adults' strategies to prevent episodic medication non-adherence: results from a qualitative study

Purpose The purpose of the study was to explore methods and routines used by older adults to remember to take medications.

METHODS

The study was conducted using face-to-face interviews with a convenient sample of older people, who take at least one medication for the treatment of a chronic condition. Interviews were recorded and transcribed verbatim. Thematic analysis was used to analyse the collected data.

RESULTS

Participants (10 men and 28 women, mean age: 79.5) described the methods that aid them in remembering to take their medications. The study identified three content categories: incorporation of medication habits into daily schedule and routine, use of medication aids; and assistance and support from family.

CONCLUSION

Older people have less difficulty taking their medication regularly if it becomes another habit as part of a daily routine. Health-care professionals should promote various methods to support medication management.

Effectiveness of low-cost reminder package combined with case-based health education to improve hypertensive patients' medication adherence: a clustered randomized controlled trial

PURPOSE

Medication adherence (MA) is a key factor for hypertensive patients' blood pressure control and forgetfulness is one of the main reasons that cause medication non-adherence. If effective, low-cost reminder package (LCRP) has great potentials for large-scale promotion. Therefore, this study aims to evaluate the effectiveness of combining LCRP and health education to improve MA among hypertensive patients.

PATIENTS AND METHODS

A clustered randomized controlled trial was performed in Beijing. A total of 518 hypertensive patients recruited from 8 community health care centers were randomized to receive LCRP combined with case-based health education or usual care. Randomization was performed at community level. Multilevel modeling was used to evaluate the study effect.

RESULTS

MA scores did not differ significantly at baseline between the intervention group and the control group. The results of multilevel modeling indicated that MA scores increased more in the intervention group, and the intervention effect on MA was 0.287 (95% CI: [0.103, 0.471], P=0.002). Patients' systolic blood pressure (SBP) and diastolic blood pressure (DBP) were not improved (SBP: difference=0.536, 95% CI [-3.207, 4.278]; DBP: difference=-0.927, 95% CI [-3.283, 1.428]).

CONCLUSION

LCRP combined with case-based health education could significantly improve hypertensive patients' MA.

Are multidose drug dispensing systems initiated for the appropriate patients?

PURPOSE

It is unknown if multidose drug dispensing (MDD) systems are initiated for the appropriate patients. Therefore, the objective of this study was to compare the medication management problems of patients who were about to start with a MDD system (MDD patients) and patients who continued manually dispensed medication (non-MDD users) in order to identify if the appropriate patients receive a MDD system.

METHODS

Patient interviews (semi-structured) were conducted by 44 community pharmacists at the patient's home. Patients over 65 years of age, home dwelling and using at least five chronic drugs, were eligible for the study. An assessment tool was developed including 22 potential medication management problems, covering four domains: functional (7), organizational (7), medication adherence (6), and medication knowledge (2). Median scores were calculated with the interquartile range. Additionally, cognitive function was assessed with the Mini-Cog and frailty using the Groningen Frailty Indicator.

RESULTS

One hundred eighty-eight MDD users and 230 non-MDD users were interviewed. MDD users were older, more often female, and using more drugs. Forty-two percent of the MDD users were possibly cognitively impaired and 63% were assessed as frail compared to 20 and 27% respectively of the non-MDD users. MDD users had more potential organizational problems (3 vs. 1; p < 0.01), functional problems (2 vs. 1; p < 0.01), medication adherence problems (1 vs. 0; p < 0.01), and medication knowledge problems (1 vs. 0; p < 0.01) compared to non-MDD users. Seventy percent of the MDD users scored six or more potential medication management problems while this was 22% among non-MDD users.

CONCLUSIONS

The majority of MDD systems were initiated for patients who experienced multiple potential medication management problems suggesting a decreased medication management capacity.

Quality Measurement and Improvement Study of Surgical Coronary Revascularization: Medication Adherence (MISSION-2)

Background

Secondary preventive therapies play a key role in the prevention of adverse outcomes after coronary artery bypass grafting (CABG). However, medication adherence after CABG is often poor, and conventional interventions for improving adherence have limited success. With increasing penetration of smartphones, health-related smartphone applications might provide an opportunity to improve adherence. Carefully designed trials are needed to provide reliable evidence for the use of these applications in patients after CABG.

Methods

The Measurement and Improvement Studies of Surgical Coronary Revascularization: Medication Adherence (MISSION-2) study is a multicenter randomized controlled trial, aiming to randomize 1000 CABG patients to the intervention or control groups in a 1:1 ratio. We developed the multifaceted, patient-centered, smartphone-based Heart Health Application to encourage medication adherence in the intervention group through a health self-management program initiated during hospital admission for CABG. The application integrated daily scheduled reminders to take the discharge medications, cardiac educational materials, a dynamic dashboard to review cardiovascular risk factors and secondary prevention targets, and weekly questionnaires with interactive feedback. The primary outcome was secondary preventive medication adherence measured by the Chinese version of the 8-item Morisky Medication Adherence Scale at 6 months after randomization. Secondary outcomes included all-cause death, cardiovascular rehospitalization, and a composite of death, myocardial infarction, stroke, and repeat revascularization.

Discussion

Findings will not only provide evidence regarding the feasibility and effectiveness of the described intervention for improving adherence to CABG secondary preventive therapies but also explore a model for outpatient health self-management that could be translated to various chronic diseases and widely disseminated across resource-limited settings.

Trial Registration

https://clinicaltrials.gov (NCT02432469).

A systematic review on reminder systems in physical therapy

Background

The main goal of physical therapy is to help the patient gain a better health status. Several studies have investigated the use of reminders to prevent such failures on the patients' side. This article presents a systematic review of the literature concerning reminders in physical therapy.

Methods

Databases were searched until May 2017 and literatures were found from April 1992 until 2017. The literature recruitment strategy was based on applying several keywords and Medical Subject Heading (MeSH) combination running against title and abstract, including concepts such as reminder, physical therapy. The finally selected articles were categorized through reminder aspects such as how, who feedback. Data were extracted according to PRISMA guidelines.

Results

In 47% of studies, the reminder was sent to the patients, 29% to the physical therapists and 12% to the caretaker team. In 24% of the studies, paper-based letters were main medium for reminders while the rest were various types of media like emails and SMS mobile text messages. 35% of the articles showed positive effects of the reminders.

Conclusions

Many reminder methods consisted of SMS, phone calls, letters, emails and notices on the wall were used in physical therapy. Reminders may be used to improve patients' adherence to exercise programs.

The experiences and beliefs of older people in Scottish very sheltered housing about using multi-compartment compliance aids

Background Multi-compartment compliance aids (MCAs) are promoted as a potential solution to medicines non-adherence despite the absence of high quality evidence of effectiveness of MCA use impacting medicines adherence or any clinical outcomes. Furthermore, there is a lack of qualitative research which focuses on the perspectives of older people receiving MCAs. Objectives To describe experiences and beliefs surrounding very sheltered housing (VSH) residents’ use of MCAs with emphasis on issues of personalisation, reablement, shared decision-making, independence and support. Setting VSH in north east Scotland. Methods Qualitative, face-to-face interviews with 20 residents (≥ 65 years, using MCA > 6 months) in three VSH complexes. Interviews focused on: when and why the MCA was first introduced; who was involved in making that decision; how the MCA was used; perceptions of benefit; and any difficulties encountered. Interviews were audiorecorded, transcribed and analysed using a framework approach. Main outcome measure Experiences and beliefs surrounding use of MCAs. Results Nine themes were identified: shared decision-making; independence; knowledge and awareness of why MCA had been commenced; support in medicines taking; knowledge and awareness of medicines; competent and capable to manage medicines; social aspects of carers supporting MCA use; benefits of MCAs; and drawbacks. Conclusion Experiences and beliefs are diverse and highly individual, with themes identified aligning to key strategies and policies of the Scottish Government, and other developed countries around the world, specifically personalisation shared decision making, independence, reablement and support.

Implementation strategies for health systems in low-income countries: an overview of systematic reviews

BACKGROUND

A key function of health systems is implementing interventions to improve health, but coverage of essential health interventions remains low in low-income countries. Implementing interventions can be challenging, particularly if it entails complex changes in clinical routines; in collaborative patterns among different healthcare providers and disciplines; in the behaviour of providers, patients or other stakeholders; or in the organisation of care. Decision-makers may use a range of strategies to implement health interventions, and these choices should be based on evidence of the strategies' effectiveness.

OBJECTIVES

To provide an overview of the available evidence from up-to-date systematic reviews about the effects of implementation strategies for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on alternative implementation strategies and informing refinements of the framework for implementation strategies presented in the overview.

METHODS

We searched Health Systems Evidence in November 2010 and PDQ-Evidence up to December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of implementation strategies on professional practice and patient outcomes and that were published after April 2005. We excluded reviews with limitations important enough to compromise the reliability of the review findings. Two overview authors independently screened reviews, extracted data and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence) and assessments of the relevance of findings to low-income countries.

MAIN RESULTS

We identified 7272 systematic reviews and included 39 of them in this overview. An additional four reviews provided supplementary information. Of the 39 reviews, 32 had only minor limitations and 7 had important methodological limitations. Most studies in the reviews were from high-income countries. There were no studies from low-income countries in eight reviews.Implementation strategies addressed in the reviews were grouped into four categories - strategies targeting:1. healthcare organisations (e.g. strategies to change organisational culture; 1 review);2. healthcare workers by type of intervention (e.g. printed educational materials; 14 reviews);3. healthcare workers to address a specific problem (e.g. unnecessary antibiotic prescription; 9 reviews);4. healthcare recipients (e.g. medication adherence; 15 reviews).Overall, we found the following interventions to have desirable effects on at least one outcome with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects.1.Strategies targeted at healthcare workers: educational meetings, nutrition training of health workers, educational outreach, practice facilitation, local opinion leaders, audit and feedback, and tailored interventions.2.Strategies targeted at healthcare workers for specific types of problems: training healthcare workers to be more patient-centred in clinical consultations, use of birth kits, strategies such as clinician education and patient education to reduce antibiotic prescribing in ambulatory care settings, and in-service neonatal emergency care training.3. Strategies targeted at healthcare recipients: mass media interventions to increase uptake of HIV testing; intensive self-management and adherence, intensive disease management programmes to improve health literacy; behavioural interventions and mobile phone text messages for adherence to antiretroviral therapy; a one time incentive to start or continue tuberculosis prophylaxis; default reminders for patients being treated for active tuberculosis; use of sectioned polythene bags for adherence to malaria medication; community-based health education, and reminders and recall strategies to increase vaccination uptake; interventions to increase uptake of cervical screening (invitations, education, counselling, access to health promotion nurse and intensive recruitment); health insurance information and application support.

AUTHORS' CONCLUSIONS

Reliable systematic reviews have evaluated a wide range of strategies for implementing evidence-based interventions in low-income countries. Most of the available evidence is focused on strategies targeted at healthcare workers and healthcare recipients and relates to process-based outcomes. Evidence of the effects of strategies targeting healthcare organisations is scarce.

The Health Buddies App as a Novel Tool to Improve Adherence and Knowledge in Atrial Fibrillation Patients: A Pilot Study

BACKGROUND

Atrial fibrillation (AF) constitutes an important risk for stroke, especially in an ageing population. A new app (Health Buddies) was developed as a tool to improve adherence to non-vitamin K antagonist oral anticoagulants (NOACs) in an elderly AF population by providing a virtual contract with their grandchildren, spelling out daily challenges for both.

OBJECTIVE

The aim of this pilot study was to assess the feasibility and usability of the Health Buddies app in AF patients.

METHODS

Two workshops were conducted to steer app development and to test a first prototype. The feasibility of the finalized app was investigated by assessing the number of eligible AF patients (based on current prescription of NOACs, the presence of grandchildren between 5 and 15 years old, availability of a mobile phone, computer, or tablet), and the proportion of those who were willing to participate. Participants had to use the app for 3 months. The motivation of the patients to use the app was assessed based on the number of logins to the app. Their perception of its usefulness was examined by specific questionnaires. Additionally, the effects on knowledge level about AF and its treatment, and adherence to NOAC intake were investigated.

RESULTS

Out of 830 screened AF patients, 410 were taking NOACs and 114 were eligible for inclusion. However, only 3.7% (15/410) of the total NOAC population or 13.2% of the eligible patients (15/114) were willing to participate. The main reasons for not participating were no interest to participate in general or in the concept in particular (29/99, 29%), not feeling comfortable using technology (22/99, 22%), no interest by the grandchildren or their parents (20/99, 20%), or too busy a lifestyle (12/99, 12%). App use significantly decreased towards the end of the study period in both patients (P=.009) and grandchildren (P<.001). NOAC adherence showed a taking adherence and regimen adherence of 88.6% (SD 15.4) and 81.8% (SD 18.7), respectively. Knowledge level increased from 64.6% (SD 14.7) to 70.4% (SD 10.4) after 3 months (P=.09). The app scored positively on clarity, novelty, stimulation, and attractiveness as measured with the user experience questionnaire. Patients evaluated the educational aspect of this app as a capital gain.

CONCLUSIONS

Only a small proportion of the current AF population seems eligible for the innovative Health Buddies app in its current form. Although the app was positively rated by its users, a large subset of patients was not willing to participate in this study or to use the app. Efforts have to be made to expand the target group in the future.

Barriers and facilitators to adherence to secondary stroke prevention medications after stroke: analysis of survivors and caregivers views from an online stroke forum

OBJECTIVE

To identify barriers and facilitators of medication adherence in patients with stroke along with their caregivers.

DESIGN

Qualitative thematic analysis of posts about secondary prevention medications, informed by Perceptions and Practicalities Approach.

SETTING

Posts written by the UK stroke survivors and their family members taking part in the online forum of the Stroke Association, between 2004 and 2011.

PARTICIPANTS

84 participants: 49 stroke survivors, 33 caregivers, 2 not stated, identified using the keywords 'taking medication', 'pills', 'size', 'side-effects', 'routine', 'blister' as well as secondary prevention medication terms.

RESULTS

Perceptions reducing the motivation to adhere included dealing with medication side effects, questioning doctors' prescribing practices and negative publicity about medications, especially in regard to statins. Caregivers faced difficulties with ensuring medications were taken while respecting the patient's decisions not to take tablets. They struggled in their role as advocates of patient's needs with healthcare professionals. Not experiencing side effects, attributing importance to medications, positive personal experiences of taking tablets and obtaining modification of treatment to manage side effects were facilitators of adherence. Key practical barriers included difficulties with swallowing tablets, dealing with the burden of treatment and drug cost. Using medication storage devices, following routines and getting help with medications from caregivers were important facilitators of adherence.

CONCLUSIONS

An online stroke forum is a novel and valuable resource to investigate use of secondary prevention medications. Analysis of this forum highlighted significant barriers and facilitators of medication adherence faced by stroke survivors and their caregivers. Addressing perceptual and practical barriers highlighted here can inform the development of future interventions aimed at improving adherence to secondary prevention medication after stroke.

Effect of Reminder Devices on Medication Adherence: The REMIND Randomized Clinical Trial

IMPORTANCE

Forgetfulness is a major contributor to nonadherence to chronic disease medications and could be addressed with medication reminder devices.

OBJECTIVE

To compare the effect of 3 low-cost reminder devices on medication adherence.

DESIGN, SETTING, AND PARTICIPANTS

This 4-arm, block-randomized clinical trial involved 53 480 enrollees of CVS Caremark, a pharmacy benefit manager, across the United States. Eligible participants were aged 18 to 64 years and taking 1 to 3 oral medications for long-term use. Participants had to be suboptimally adherent to all of their prescribed therapies (with a medication possession ratio of 30% to 80%) in the 12 months before randomization. Participants were stratified on the basis of the medications they were using at randomization: medications for cardiovascular or other nondepression chronic conditions (the chronic disease stratum) and antidepressants (the antidepressant stratum). In each stratum, randomization occurred within blocks defined by whether all of the patient's targeted medications were dosed once daily. Patients were randomized to receive in the mail a pill bottle strip with toggles, digital timer cap, or standard pillbox. The control group received neither notification nor a device. Data were collected from February 12, 2013, through March 21, 2015, and data analyses were on the intention-to-treat population.

MAIN OUTCOMES AND MEASURES

The primary outcome was optimal adherence (medication possession ratio ≥80%) to all eligible medications among patients in the chronic disease stratum during 12 months of follow-up, ascertained using pharmacy claims data. Secondary outcomes included optimal adherence to cardiovascular medications among patients in the chronic disease stratum as well as optimal adherence to antidepressants.

RESULTS

Of the 53 480 participants, mean (SD) age was 45 (12) years and 56% were female. In the primary analysis, 15.5% of patients in the chronic disease stratum assigned to the standard pillbox, 15.1% assigned to the digital timer cap, 16.3% assigned to the pill bottle strip with toggles, and 15.1% assigned to the control arm were optimally adherent to their prescribed treatments during follow-up. There was no statistically significant difference in the odds of optimal adherence between the control and any of the devices (standard pillbox: odds ratio [OR], 1.03 [95% CI, 0.95-1.13]; digital timer cap: OR, 1.00 [95% CI, 0.92-1.09]; and pill bottle strip with toggles: OR, 0.94 [95% CI, 0.85-1.04]). In direct comparisons, the odds of optimal adherence were higher with a standard pillbox than with the pill bottle strip (OR, 1.10 [95% CI, 1.00-1.21]). Secondary analyses yielded similar results.

CONCLUSIONS AND RELEVANCE

Low-cost reminder devices did not improve adherence among nonadherent patients who were taking up to 3 medications to treat common chronic conditions. The devices may have been more effective if coupled with interventions to ensure consistent use or if targeted to individuals with an even higher risk of nonadherence.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02015806.

Putting evidence into practice: evidence-based interventions for oral agents for cancer

BACKGROUND

The limited evidence available suggests that adherence to oral agents for cancer is a significant clinical problem and may have a substantial impact on treatment success or failure. Adherence is a difficult issue among patients who are very sick with a life-threatening disease who often must adhere to complex treatment protocols independently at home.

OBJECTIVES

This article aims to identify effective interventions for the promotion, treatment, and management of adherence to oral agents for cancer and to synthesize the literature for use in clinical practice.

METHODS

As part of the Oncology Nursing Society (ONS) Putting Evidence Into Practice (PEP) initiative, a comprehensive examination of the current literature was conducted to identify effective interventions for patients prescribed oral agents for cancer. The ONS PEP weight-of-evidence classification schema levels of evidence were used to categorize interventions to assist nurses in identifying strategies that are effective at improving adherence.

FINDINGS

The majority of evidence found was conducted in conditions other than cancer; therefore, research is needed to identify whether these interventions are effective at promoting adherence in patients with cancer.

Developing and testing an electronic medication administration monitoring device for community dwelling seniors: a feasibility study

Background

Medication non-adherence, polypharmacy, and adverse drug events are major healthcare issues leading to significant morbidity, mortality, and healthcare expenditures. Currently, there are no methods to systematically track medication usage in community-dwelling seniors. The eDosette prototype was created to make medication use patterns visible via the Internet. This study aims to demonstrate feasibility, usability, and acceptability of the eDosette in community-dwelling seniors in primary care.

Methods

A 2-week feasibility study involving a convenience sample of 10 patients from an academic family medicine teaching unit in Hamilton, Ontario, Canada, was conducted over a 6-month period between April and October 2015. The eDosette transmitted hourly electronic data via the Internet on each participant’s pattern of medication use; this data was converted into an individualized medication administration record (MAR). Based on the MARs from the 10 participants, the frequency of missed medication doses, the time of dose administration, and each participant’s adherence rate for their prescribed medications could be determined. A medication adherence survey and a patient usability and acceptability survey were administered to all the participants of the study.

Results

The eDosette was able to record a participant’s medication use and transmit this data electronically via the Internet with sufficient quality to create participant-specific MARs. A total of 418 doses were captured by the eDosette throughout the study; only 5% (n = 22 doses) were missing information or had poor image quality. Analysis of the MARs revealed that 19% (n = 79 doses) were taken outside a 2-h window of the average dose administration time, and two doses were completely missed by all participants during this feasibility study. Participant feedback found the eDosette easy and acceptable to use. Participant feedback also identified hardware and software issues that require attention prior to a larger study.

Conclusions

The eDosette is a feasible and novel technology that can be successfully installed into the homes of community-dwelling seniors to help in monitoring actual medication use patterns. This study provided details for further device development and evidence to support the need for a larger pilot study on the eDosette’s impact on medication adherence.

Beliefs regarding medication and side effects influence treatment adherence in adolescents with attention deficit hyperactivity disorder

Adherence to attention deficit hyperactivity disorder (ADHD) treatment is important because, when untreated, it may have serious consequences with lifelong effects. In the case of adolescents on long-term medicine prescription, more knowledge is needed regarding adherence and factors influencing adherence, which was the purpose of this study. Adolescents (n = 101) on ADHD medication ≥6 months were administrated questionnaires at a monitoring appointment: Medication Adherence Report Scale (MARS), beliefs about medicines (BMQ) and the Brief Illness Perception Questionnaire (B-IPQ). Adherence was high, the mean value was 88% of the maximum MARS score, and correlated positively with the "BMQ-necessity-concerns differential" but negatively with "BMQ-concerns" and "BMQ-side effects". Adolescents with more belief in the necessity of the medication, less concerns and less experience of side effects tended to be more adherent to medication prescription ("intentional non-adherence"), while "unintentional non-adherence" (forgetfulness) was associated with how much they perceived that their ADHD affected their lives. In a multiple regression model, the variance of MARS total (R ² = 0.21) and "intentional non-adherence" (R ² = 0.24) was explained by the "BMQ-necessity-concern differential" and "BMQ-experienced side effects". The variance of "unintentional non-adherence" (R ² = 0.12) was explained by the "BMQ-necessity-concern differential" and "B-IPQ-consequences of ADHD". In conclusion, adolescents on long-term medication reported good adherence, mainly influenced by more beliefs in the necessity versus concerns of the medications, less experienced side effects and more perceived consequences of ADHD. BMQ could be useful to identify risks of low adherence, which should be counteracted by partially gender-specific interventions.

Post-discharge evaluation of medication adherence and knowledge of hypertension among hypertensive stroke patients in northwestern China

OBJECTIVES

The aims of this study were to assess the knowledge of hypertension (HTN) and investigate risk factors associated with medication adherence among hypertensive stroke patients after discharge in northwestern China.

PATIENTS AND METHODS

A cross-sectional study involving 440 Chinese hypertensive stroke patients was conducted in a tertiary hospital in Xi'an, China. Data were collected by telephone interviews and patients' medical records.

RESULTS

It was found that 35.23% of patients were compliant with their antihypertensive drug treatments, and 42.95%, 52.27% and 4.77% of patients had poor, moderate and adequate knowledge of HTN, respectively. Gender, blood pressure (BP) categories, BP monitoring and HTN knowledge were independently associated with antihypertensive medication adherence.

CONCLUSION

The medication adherence among hypertensive stroke patients in northwestern China was poor. Knowledge of HTN was suboptimal. More attention and effective strategies should be designed to the factors affecting medication adherence. As knowledge positively affects medication adherence, clinical pharmacists should play an important role in patients' medication education.

Multicompartment compliance aids in the community: the prevalence of potentially inappropriate medications

AIMS

To assess the prevalence of potentially inappropriate medications (PIMs) use in a population of community-based multicompartment compliance aid (MCA) users in north-east Scotland.

METHODS

Data for MCAs dispensed by 48 of the 50 community pharmacies in Aberdeen City between 1^st June to 31^st October 2014, together with concurrently prescribed medications, patient demographics and Carstairs index of social deprivation were recorded. Drug-specific quality indicators for PIMs from the Swedish National Board of Health and Welfare were applied and bivariate logistic regression analysis used to assess for associations with demographic variables.

RESULTS

The median age was 82 years (range 12-105 years, 59% female). A total of 1977 PIMs were identified affecting 57.8% of patients. A quarter of patients were prescribed ≥10 medications and 43% had a prescription containing at least one clinically significant drug-drug interaction (DDI). Ten drug groups accounted for 76% of all DDIs. A significant increase in the risk for at least one PIM was associated with female sex (for all indicators of PIM use), age <80 years (three or more psychotropic medicines [OR 5.88, 2.96-11.70, P < 0.001]) and lower socioeconomic status (prescription of ≥10 medications [OR: 1.43, 95% CI: 1.16-1.78], prescription of a long-acting benzodiazepine [OR: 1.84, CI: 1.14-2.98]).

CONCLUSIONS

MCA use is associated with a significant incidence of PIMs particularly affecting those younger than 80 years and those living in deprived areas. Our findings indicate the need for a more aggressive multidisciplinary approach to the review of the medications prescribed to MCA users.

Interventions to improve adherence to lipid-lowering medication

BACKGROUND

Lipid-lowering drugs are widely underused, despite strong evidence indicating they improve cardiovascular end points. Poor patient adherence to a medication regimen can affect the success of lipid-lowering treatment.

OBJECTIVES

To assess the effects of interventions aimed at improving adherence to lipid-lowering drugs, focusing on measures of adherence and clinical outcomes.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO and CINAHL up to 3 February 2016, and clinical trials registers (ANZCTR and ClinicalTrials.gov) up to 27 July 2016. We applied no language restrictions.

SELECTION CRITERIA

We evaluated randomised controlled trials of adherence-enhancing interventions for lipid-lowering medication in adults in an ambulatory setting with a variety of measurable outcomes, such as adherence to treatment and changes to serum lipid levels. Two teams of review authors independently selected the studies.

DATA COLLECTION AND ANALYSIS

Three review authors extracted and assessed data, following criteria outlined by the Cochrane Handbook for Systematic Reviews of Interventions. We assessed the quality of the evidence using GRADEPro.

MAIN RESULTS

For this updated review, we added 24 new studies meeting the eligibility criteria to the 11 studies from prior updates. We have therefore included 35 studies, randomising 925,171 participants. Seven studies including 11,204 individuals compared adherence rates of those in an intensification of a patient care intervention (e.g. electronic reminders, pharmacist-led interventions, healthcare professional education of patients) versus usual care over the short term (six months or less), and were pooled in a meta-analysis. Participants in the intervention group had better adherence than those receiving usual care (odds ratio (OR) 1.93, 95% confidence interval (CI) 1.29 to 2.88; 7 studies; 11,204 participants; moderate-quality evidence). A separate analysis also showed improvements in long-term adherence rates (more than six months) using intensification of care (OR 2.87, 95% CI 1.91 to 4.29; 3 studies; 663 participants; high-quality evidence). Analyses of the effect on total cholesterol and LDL-cholesterol levels also showed a positive effect of intensified interventions over both short- and long-term follow-up. Over the short term, total cholesterol decreased by a mean of 17.15 mg/dL (95% CI 1.17 to 33.14; 4 studies; 430 participants; low-quality evidence) and LDL-cholesterol decreased by a mean of 19.51 mg/dL (95% CI 8.51 to 30.51; 3 studies; 333 participants; moderate-quality evidence). Over the long term (more than six months) total cholesterol decreased by a mean of 17.57 mg/dL (95% CI 14.95 to 20.19; 2 studies; 127 participants; high-quality evidence). Included studies did not report usable data for health outcome indications, adverse effects or costs/resource use, so we could not pool these outcomes. We assessed each included study for bias using methods described in the Cochrane Handbook for Systematic Reviews of Interventions. In general, the risk of bias assessment revealed a low risk of selection bias, attrition bias, and reporting bias. There was unclear risk of bias relating to blinding for most studies.

AUTHORS' CONCLUSIONS

The evidence in our review demonstrates that intensification of patient care interventions improves short- and long-term medication adherence, as well as total cholesterol and LDL-cholesterol levels. Healthcare systems which can implement team-based intensification of patient care interventions may be successful in improving patient adherence rates to lipid-lowering medicines.

Views of patients and professionals about electronic multicompartment medication devices: a qualitative study

OBJECTIVES

To explore the perceived acceptability, advantages and disadvantages of electronic multicompartment medication devices.

DESIGN

Qualitative study using 8 focus groups and 10 individual semistructured interviews. Recordings were transcribed and analysed thematically. Strategies were employed to ensure the findings were credible and trustworthy.

PARTICIPANTS AND SETTING

Community pharmacists (n=11), general practitioners (n=9), community nurses (n=12) and social care managers (n=8) were recruited from the National Health Service (NHS) and local authority services. Patients (n=15) who were current conventional or electronic multicompartment medication device users or had medication adherence problems were recruited from community pharmacies. 3 informal carers participated.

RESULTS

Electronic multicompartment medication devices which prompt the patient to take medication may be beneficial for selected individuals, particularly those with cognitive impairment, but who are not seriously impaired, provided they have a good level of dexterity. They may also assist individuals where it is important that medication is taken at fixed time intervals. These are likely to be people who are being supported to live alone. No single device suited everybody; smaller/lighter devices were preferred but their usefulness was limited by the small number/size of storage compartments. Removing medications was often challenging. Transportability was an important factor for patients and carers. A carer's alert if medication is not taken was problematic with multiple barriers to implementation and no consensus as to who should receive the alert. There was a lack of enthusiasm among professionals, particularly among pharmacists, due to concerns about responsibility and funding for devices as well as ensuring devices met regulatory standards for storage and labelling.

CONCLUSIONS

This study provides indicators of which patients might benefit from an electronic multicompartment medication device as well as the kinds of features to consider when matching a patient with a device. It also highlights other considerations for successful implementation including issues of responsibility, regulation and funding.

Systematic review of the health and societal effects of medication organisation devices

BACKGROUND

Suboptimal medication adherence is a significant threat to public health and resources. Devices that organise weekly doses by time and day are commonly used to reduce unintentional non-adherence. However, there is limited evidence to support their use. This systematic review was conducted to evaluate current evidence for their efficacy, safety and costs.

METHODS

A pre-defined search of electronic databases from inception to January 2013 augmented with hand-searching was conducted. No limits were placed on publication date. Studies that compared organisation devices used by patients administering their own medication with standard medication packaging regardless of study design were eligible for inclusion. Studies that solely explored dispensing aspects of organisation devices were included whether or not they compared this to standard care. Screening of articles for inclusion and data extraction were completed independently by two reviewers with disagreements resolved by discussion. Outcomes were categorised into impact on health, medication adherence, healthcare utilisation, dispensing errors, supply procedures and costs. Risk of bias was also assessed.

RESULTS

Seventeen studies met the inclusion criteria. Health outcomes were investigated in seven studies of which three reported a positive effect associated with organisation devices. Medication adherence was reported in eight studies of which three reported a positive effect. Three studies reported health care utilisation data but overall results are inconclusive. No optimal dispensing or supply procedures were identified. Economic assessment of the impact of organisation devices is lacking. All studies were subject to a high risk of bias.

CONCLUSIONS

Evidence regarding the effects of medication organisation devices was limited, and the available evidence was susceptible to a high risk of bias. Organisation devices may help unintentional medication non-adherence and could improve health outcomes. There is a strong need for more studies that explore the impact of such devices on patients, and an equally pressing need for studies that explore the impacts on healthcare services.

TRIAL REGISTRATION

This systematic review is registered with PROSPERO (Registration number CRD42011001718 ).

The feasibility of determining the effectiveness and cost-effectiveness of medication organisation devices compared with usual care for older people in a community setting: systematic review, stakeholder focus groups and feasibility randomised controlled trial

BACKGROUND

Medication organisation devices (MODs) provide compartments for a patient's medication to be organised into the days of the week and the recommended times the medication should be taken.

AIM

To define the optimal trial design for testing the clinical effectiveness and cost-effectiveness of MODs.

DESIGN

The feasibility study comprised a systematic review and focus groups to inform a randomised controlled trial (RCT) design. The resulting features were tested on a small scale, using a 2 × 2 factorial design to compare MODs with usual packaging and to compare weekly with monthly supply. The study design was then evaluated.

SETTING

Potential participants were identified by medical practices.

PARTICIPANTS

Aged over 75 years, prescribed at least three solid oral dosage form medications, unintentionally non-adherent and self-medicating. Participants were excluded if deemed by their health-care team to be unsuitable.

INTERVENTIONS

One of three MODs widely used in routine clinical practice supplied either weekly or monthly.

OBJECTIVES

To identify the most effective method of participant recruitment, to estimate the prevalence of intentional and unintentional non-adherence in an older population, to provide a point estimate of the effect size of MODs relative to usual care and to determine the feasibility and acceptability of trial participation.

METHODS

The systematic review included MOD studies of any design reporting medication adherence, health and social outcomes, resource utilisation or dispensing or administration errors. Focus groups with patients, carers and health-care professionals supplemented the systematic review to inform the RCT design. The resulting design was implemented and then evaluated through questionnaires and group discussions with participants and health-care professionals involved in trial delivery.

RESULTS

Studies on MODs are largely of poor quality. The relationship between adherence and health outcomes is unclear. Of the limited studies reporting health outcomes, some reported a positive relationship while some reported increased hospitalisations associated with MODs. The pre-trial focus groups endorsed the planned study design, but suggested a minimum recruitment age of 50-60 years. A total of 35.4% of patients completing the baseline questionnaire were excluded because they already used a MOD. Active recruitment yielded a higher consent rate, but passive recruitment was more cost-effective. The prevalence of intentional non-adherence was 24.7% [n = 71, 95% confidence interval (CI) 19.7% to 29.6%] of participants. Of the remaining 76 participants, 46.1% (95% CI 34.8% to 57.3%) were unintentionally non-adherent. There was no indication of a difference in adherence between the study arms. Participants reported a high level of satisfaction with the design. Five adverse/serious adverse events were identified in the MOD study arms and none was identified in the control arms. There was no discernible difference in health economic outcomes between the four study arms; the mean intervention cost was £20 per month greater for MOD monthly relative to usual supply monthly.

CONCLUSIONS

MOD provision to unintentionally non-adherent older people may cause medication-related adverse events. The primary outcome for a definitive MOD trial should be health outcomes. Such a trial should recruit patients by postal invitation and recruit younger patients.

FUTURE WORK

A study examining the association between MOD initiation and adverse effects is necessary and a strategy to safely introduce MODs should be explored. A definitive study testing the clinical effectiveness and cost-effectiveness of MODs is also required.

STUDY REGISTRATION

Current Controlled Trials ISRCTN 30626972 and UKCRN 12739.

FUNDING

This project was funded by National Institute for Health Research (NIHR) Health Technology Assessment Programme and will be published in full in Health Technology Assessment; Vol. 20, No. 50. See the NIHR Journals Library website for further project information.

How effectively are your patients taking their medicines? A critical review of the Strathclyde Compliance Risk Assessment Tool in relation to the 'MMAS' and 'MARS'

RATIONALE, AIMS AND OBJECTIVES

A useful assessment tool that can support health care professionals in anticipating elderly patients' care needs regarding additional support in managing their own medicines is essential, but currently lacking. Thus, the aim of the study was to assess whether the 13-item Strathclyde Compliance Risk Assessment Tool (SCRAT) is an appropriate instrument for identifying community-dwelling elderly people who may be at risk of medication non-adherence.

METHOD

An 8-week survey was performed from October to November 2009. Patients were ≥65 years old, receiving ≥3 medications and were either using multi-compartment compliance aids or receiving social care support, or both. The data were collected in 45 face-to-face structured interviews using the 13-item SCRAT, 5-item Medication Adherence Rating Scale (MARS) and 8-item Modified Morisky Adherence Scale (MMAS) in sheltered housing complexes in Glasgow, Scotland. Interviews were analysed quantitatively using SPSS version 21 software.

RESULTS

The SCRAT instrument showed substantial inter-rater reliability (Cohen's kappa of 0.730 for the 13-item scale). There was a significant strong negative correlation between the 13-item SCRAT total risk score and 8-item MMAS (r = -0.654; P = 0.0036), and the 13-item SCRAT total risk score and 5-item MARS (r = -0.481; P = 0.0084). The SCRAT instrument showed satisfactory internal consistency (Cronbach's alpha of 0.853 for the 13-item scale). The area under the receiver operator characteristic curve (AUC ± standard error; 95% confidence interval) showed that the SCRAT had good discriminatory capacity and was able to distinguish between adherent and non-adherent participants on the MARS (0.729 ± 0.17; 0.39, 1.00). The best cut-off (sensitivity, specificity) was <3 (75%, 45%). In the sub-analyses, there was a significant difference in total risk score (3 vs. 2, P = 0.011) between users and non-users of multi-compartment compliance aids.

CONCLUSION

The study shows that the 13-item SCRAT has the potential to be used in identifying elderly participants who may have problems managing their own medicines and it may help to determine the level and type of assistance that patients require to manage their medicines.

Meta-analyses of Theory Use in Medication Adherence Intervention Research

OBJECTIVE

This systematic review applied meta-analytic procedures to integrate primary research that examined theory- or model-linked medication adherence interventions.

METHODS

Extensive literature searching strategies were used to locate trials testing interventions with medication adherence behavior outcomes measured by electronic event monitoring, pharmacy refills, pill counts, and self-reports. Random-effects model analysis was used to calculate standardized mean difference effect sizes for medication adherence outcomes.

RESULTS

Codable data were extracted from 146 comparisons with 19,348 participants. The most common theories and models were social cognitive theory and motivational interviewing. The overall weighted effect size for all interventions comparing treatment and control participants was 0.294. The effect size for interventions based on single-theories was 0.323 and for multiple-theory interventions was 0.214. Effect sizes for individual theories and models ranged from 0.041 to 0.447. The largest effect sizes were for interventions based on the health belief model (0.477) and adult learning theory (0.443). The smallest effect sizes were for interventions based on PRECEDE (0.041) and self-regulation (0.118).

CONCLUSION

These findings suggest that theory- and model-linked interventions have a significant but modest effect on medication adherence outcomes.

Medication adherence interventions that target subjects with adherence problems: Systematic review and meta-analysis

BACKGROUND

Inadequate medication adherence is a pervasive, under-recognized cause of poor health outcomes. Many intervention trials designed to improve medication adherence have targeted adults with adherence problems. No previous reviews have synthesized the effectiveness of medication adherence interventions focused on subjects with medication adherence difficulties.

OBJECTIVE

This systematic review and meta-analysis synthesized findings from medication adherence intervention studies conducted among adults with medication adherence difficulties.

METHODS

Primary research studies were eligible for inclusion if they tested an intervention designed to increase medication adherence among adults with documented adherence difficulties and reported medication adherence behavior outcomes. Comprehensive search strategies of 13 computerized databases, author and ancestry searches, and hand searches of 57 journals were used to locate eligible primary research. Participant demographics, intervention characteristics, and methodological features were reliably coded from reports along with medication adherence outcomes. Effect sizes for outcomes were calculated as standardized mean differences, and random effects models were used to estimate overall mean effects. Exploratory dichotomous and continuous variable moderator analyses were employed to examine potential associations between medication adherence effect size and sample, intervention, and methodological characteristics.

RESULTS

Data were extracted from 53 reports of studies involving 8243 individual primary study participants. The overall standardized mean difference effect size for treatment vs. control subjects was 0.301. For treatment pre- vs. post-intervention comparisons, the overall effect size was 0.533. Significantly larger effect sizes were associated with interventions incorporating prompts to take medications than interventions lacking medication prompts (0.497 vs. 0.234). Larger effect sizes were also found for interventions that linked medication taking with existing habits compared to interventions that did not (0.574 vs. 0.222). Effect sizes were largest among studies that measured adherence by pill counts or electronic event monitoring systems. Analysis of study design features identified several potential risks of bias. Statistically significant publication bias was detected, but adherence effect sizes were not significantly associated with other risks of bias.

CONCLUSIONS

These findings document that interventions targeting individuals with medication adherence problems can have modest but significant effects on medication-taking behavior. The findings support the use of behavioral strategies such as prompts and linking medications to habits to increase medication adherence in adults with adherence challenges. Face-to-face interventions appear to be critical for patients who have experienced past problems with medication adherence.

Patient views on an electronic dispensing device for prepackaged polypharmacy: a qualitative assessment in an ambulatory setting

OBJECTIVE

To collect opinions on medication management aids (MMAs) in general and on an electronic MMA (e-MMA) dispensing prepackaged polypharmacy in sealed pouches.

STUDY SETTING

The setting involved community-dwelling older adults in Basel, Switzerland, in 2013.

STUDY DESIGN

The study involved 1) a 14-day trial with the e-MMA and 2) a focus group to identify general attributes of MMAs, their applicability to the e-MMA, and possible target groups for the e-MMA.

DATA COLLECTION METHODS

Six participants using long-term polypharmacy and willing to try new technologies completed the 14-day trial and participated in the focus group. Inductive content analysis was performed to extract data.

PRINCIPAL FINDINGS

Participants rated ten of 17 general attributes as clearly applicable to the e-MMA and five as unsuitable. Attributes pertained to three interrelating themes: product design, patient support, and living conditions. Envisaged target groups were patients with time-sensitive medication regimens, patients with dementia, the visually impaired, and several patients living together to prevent accidental intake of the wrong medication.

CONCLUSION

The evaluated e-MMA for prepackaged polypharmacy met the majority of the requirements set for an MMA. Patients' living conditions, such as mobility, remain the key determinants for acceptance of an e-MMA.

Process evaluation of the impact and acceptability of a polypill for prevention of cardiovascular disease

IMPORTANCE

The Use of a Multidrug Pill In Reducing cardiovascular Events (UMPIRE) trial has shown improved adherence with the use of a polypill strategy when compared with usual medications for cardiovascular disease (CVD) prevention. To advance from efficacy to impact, we need a better understanding of why and how such a strategy might be deployed in complex health systems.

OBJECTIVE

To understand, from the perspective of UMPIRE trial participants and professionals, how and why a polypill strategy improves adherence compared with usual care, why improvement is greater in some subgroups, and to explore the acceptability of a polypill strategy among trial participants and healthcare professionals.

DESIGN, SETTING AND PARTICIPANTS

A preplanned process evaluation, based on qualitative interviews, was conducted with a subsample of 102 trial participants and 41 healthcare professionals at the end of the UMPIRE trial in India and Europe.

RESULTS

Most patients contrasted the simplicity of the polypill with usual medications that they found complex and, for many in India, expensive. Patients with low baseline adherence struggled most with complex medication lists, and those without established disease described less motivation to adhere when compared with people who had already been diagnosed with CVD; people in the latter group had already undertaken self-directed measures to adhere to CVD preventive medicines prior to entering the trial. Taking medication was one of many adaptations described by patients; these included dietary changes, stopping smoking and maintaining exercise. Most patients liked the polypill strategy, although some participants and health professionals were concerned that it would provide less tailored therapy for individual needs.

CONCLUSIONS

Adherence to treatment lists with multiple medications is complex and influenced by several factors. Simplifying medication by using a once-daily polypill is one approach to CVD prevention that may enhance adherence. Prescribers should also consider the wide variety of adjustments that individuals need to make to cope with daily medication.