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Paskins Z, Babatunde O, Sturrock A, Toh LS, Horne R, Maidment I. Supporting patients to get the best from their osteoporosis treatment: a rapid realist review of what works, for whom, and in what circumstance. Osteoporos Int 2022; 33:2245-2257. [PMID: 35688897 PMCID: PMC9568441 DOI: 10.1007/s00198-022-06453-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 05/28/2022] [Indexed: 11/23/2022]
Abstract
Systematic reviews that examine effectiveness of interventions to improve medicines optimisation do not explain how or why they work. This realist review identified that interventions which effectively optimise medicines use in osteoporosis include opportunities to address patients' perceptions of illness and treatment and/or support primary care clinician decision making. INTRODUCTION In people with osteoporosis, adherence to medicines is poorer than other diseases and patients report follow-up is lacking, and multiple unmet information needs. We conducted a rapid realist review to understand what contextual conditions and mechanisms enable interventions to support osteoporosis medication optimisation. METHODS A primary search identified observational or interventional studies which aimed to improve medicines adherence or optimisation; a supplementary second search identified research of any design to gain additional insights on emerging findings. Extracted data was interrogated for patterns of context-mechanism-outcome configurations, further discussed in team meetings, informed by background literature and the Practicalities and Perception Approach as an underpinning conceptual framework. RESULTS We identified 5 contextual timepoints for the person with osteoporosis (identifying a problem; starting medicine; continuing medicine) and the practitioner and healthcare system (making a diagnosis and giving a treatment recommendation; reviewing medicine). Interventions which support patient-informed decision making appear to influence long-term commitment to treatment. Supporting patients' practical ability to adhere (e.g. by lowering treatment burden and issuing reminders) only appears to be helpful, when combined with other approaches to address patient beliefs and concerns. However, few studies explicitly addressed patients' perceptions of illness and treatment. Supporting primary care clinician decision making and integration of primary and secondary care services also appears to be important, in improving rates of treatment initiation and adherence. CONCLUSIONS We identified a need for further research to identify a sustainable, integrated, patient-centred, and cost- and clinically effective model of long-term care for people with osteoporosis.
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Affiliation(s)
- Z Paskins
- School of Medicine, Keele University, Keele, UK.
- Haywood Academic Rheumatology Centre, Stoke-on-Trent, Staffordshire, UK.
| | - O Babatunde
- School of Medicine, Keele University, Keele, UK
| | - A Sturrock
- Department of Nursing, Midwifery and Health, Northumbria University, Newcastle upon Tyne, UK
| | - L S Toh
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, UK
| | - R Horne
- Centre for Behavioural Medicine, UCL School of Pharmacy, University College London, London, UK
| | - I Maidment
- Clinical Pharmacy, Aston University, Birmingham, UK
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Chang CB, Yang RS, Chang LY, Peng JK, Tsai KS, Huang WJ, Yang TH, Chan DC. One-year outcomes of an osteoporosis liaison services program initiated within a healthcare system. Osteoporos Int 2021; 32:2163-2172. [PMID: 33954815 DOI: 10.1007/s00198-021-05859-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 01/21/2021] [Indexed: 11/30/2022]
Abstract
UNLABELLED Due to the huge gap in the care of patients with osteoporosis and fragility fractures, we aimed to explore the effectiveness of the osteoporosis liaison service (OLS) in osteoporosis care. We found that OLS can improve osteoporosis care, including increasing medication compliance, increasing calcium/vitamin D/protein intake, and reducing fall rate. INTRODUCTION A significant gap exists in the care of patients with osteoporosis and fragility fractures. This study aimed to evaluate 1-year outcomes of an osteoporosis liaison service (OLS) program that includes two independent components: medication management services (MMS) to improve medication adherence and fracture liaison services (FLS) for secondary prevention. METHODS Patients with new hip fracture or untreated vertebral fractures enrolled in the FLS program (n = 600), and those with osteoporosis medication management issues but not necessarily fragility fractures enrolled in the MMS program (n = 499) were included. To evaluate outcomes, care coordinators assessed baseline items adapted from the 13 Best Practices Framework (BPF) standards of the International Osteoporosis Foundation, with telephone follow-up every 4 months for 1 year. RESULTS Mean age of this cohort was 76.2 ± 10.3 years, 78.8% were female. After 1-year participation in the program, all patients had received bone mineral density tests, and medication adherence for the entire cohort at 12 months was 91.9 ± 19.6%, with significant improvement in fall rates (23.4% reduction), exercise rates (16.8% increase), calcium intake (26.5% increase), vitamin D intake (26.4% increase), and adequate protein intake (17.3% increase) (all p < 0.05). After 1-year OLS program, the overall rates of mortality, incident fracture, and falls were 6.6%, 4.0%, and 24.3%, respectively. CONCLUSIONS The OLS program is associated with improved osteoporosis care, including increased medication adherence, calcium/vitamin D and protein intake, and reduced fall rate.
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Affiliation(s)
- C-B Chang
- Department of Geriatrics and Gerontology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Medicine, Chu-Tung Branch, National Taiwan University Hospital, Zhudong Township, Hsinchu County, Taiwan
| | - R-S Yang
- Department of Orthopaedics, National Taiwan University Hospital, Taipei, Taiwan
| | - L-Y Chang
- Natioanl Taiwan University College of Medicine, Taipei, Taiwan
| | - J-K Peng
- Department of Family Medicine, Bei-Hu Branch, National Taiwan University Hospital, Taipei, Taiwan
| | - K-S Tsai
- Superintendent Office, Far Eastern Polyclinic of Far Eastern Medical Foundation, Taipei, Taiwan
| | - W-J Huang
- Department of Geriatrics and Gerontology, National Taiwan University Hospital, Taipei, Taiwan
| | - T-H Yang
- Department of Orthopaedics, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu City, Taiwan
| | - D-C Chan
- Department of Geriatrics and Gerontology, National Taiwan University Hospital, Taipei, Taiwan.
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
- Superintendent Office, Hsin-Chu Branch, National Taiwan University Hospital, No. 25, Ln442, Jingguo Rd., Hsinchu City, 30059, Taiwan.
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Loh P, Chua SS, Karuppannan M. The extent and barriers in providing pharmaceutical care services by community pharmacists in Malaysia: a cross-sectional study. BMC Health Serv Res 2021; 21:822. [PMID: 34399749 PMCID: PMC8365940 DOI: 10.1186/s12913-021-06820-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 07/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Since the introduction of pharmaceutical care concept by Hepler and Strand in 1990, community pharmacists worldwide have been realigning their roles from being product-focused to patient-orientated to improve patient's quality of life. The objectives of this study were to determine the type of services, with emphasis on the extent of pharmaceutical care services provided by community pharmacists and the barriers in providing such services in Malaysia. METHODS A cross-sectional observational study was conducted using an online questionnaire. Community pharmacists in Malaysia were invited to participate in the study via emails. The questionnaire was structured based on the Malaysian Community Pharmacy Benchmarking Guidelines, the five practice principles of pharmaceutical care by the American Pharmacists Association and other studies. The online questionnaire was opened for 6 months, from April to September 2018. A reminder to participate was sent via email to the community pharmacists every fortnight. RESULTS A total of 420 community pharmacists responded to the online questionnaire. Besides essential services such as treatment for minor illness, medicine dispensing and counselling, most of the respondents were providing health screening and monitoring (99.5%), selection and recommendation of health supplements (90.5%), patient medication review (68.8%), weight management (52.4%) and counselling on smoking cessation (51.0%). More than half (53.3%) of the respondents reported that they were providing pharmaceutical care services to patients with chronic diseases. Based on the practice principles of pharmaceutical care, the respondents were involved in patients' data collection (23.3%), medical information evaluation (18.6%), formulating a drug therapy plan (9.3%), implementing a drug therapy plan (4.5%), and monitoring and modifying the plan (18.3%). Lack of separation between prescribing and dispensing was perceived as the main barrier to the implementation of pharmaceutical care services by a majority of the respondents (84.0%). CONCLUSIONS The present study found that pharmaceutical care services provided by community pharmacists in Malaysia were inadequate compared to international practice principles. Areas that need improvement included collaboration with patients' other health care providers; more proactive management of patient's medicine regimen; having proper patient monitoring and follow-up mechanisms, and documentation.
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Affiliation(s)
- Pengyeow Loh
- School of Pharmacy, Faculty of Health & Medical Sciences, Taylor's University, Subang Jaya, Selangor, Malaysia.
| | - Siew Siang Chua
- School of Pharmacy, Faculty of Health & Medical Sciences, Taylor's University, Subang Jaya, Selangor, Malaysia
| | - Mahmathi Karuppannan
- Department of Pharmacy Practice, Faculty of Pharmacy, Universiti Teknologi MARA Cawangan Selangor, Puncak Alam Campus, Bandar Puncak Alam, Selangor, Malaysia
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Wilson N, Hurkmans E, Adams J, Bakkers M, Balážová P, Baxter M, Blavnsfeldt AB, Briot K, Chiari C, Cooper C, Dragoi R, Gäbler G, Lems W, Mosor E, Pais S, Simon C, Studenic P, Tilley S, de la Torre J, Stamm TA. Prevention and management of osteoporotic fractures by non-physician health professionals: a systematic literature review to inform EULAR points to consider. RMD Open 2021; 6:rmdopen-2019-001143. [PMID: 32144136 PMCID: PMC7059534 DOI: 10.1136/rmdopen-2019-001143] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 02/02/2020] [Accepted: 02/05/2020] [Indexed: 12/29/2022] Open
Abstract
Objective To perform a systematic literature review (SLR) about the effect of non-pharmacological interventions delivered by non-physician health professionals to prevent and manage osteoporotic fractures. Methods Eight clinical questions based on two criteria guided the SLR: (1) adults≥50 years at high risk of osteoporotic fracture and (2) interventions delivered by non-physician health professionals to prevent and manage osteoporotic fractures. Interventions focused on diagnostic procedures to identify risk of falling, therapeutic approaches and implementation strategies. Outcomes included fractures, falls, risk of falling and change in bone mineral density. Systematic reviews and randomised controlled trials were preferentially selected. Data were synthesised using a qualitative descriptive approach. Results Of 15 917 records, 43 articles were included. Studies were clinically and methodologically diverse. We identified sufficient evidence that structured exercise, incorporating progressive resistance training delivered to people who had undergone hip fracture surgery, and multicomponent exercise, delivered to people at risk of primary fracture, reduced risk of falling. The effectiveness of multidisciplinary fracture liaison services in reducing refracture rate was confirmed. There was insufficient evidence found to support the effectiveness of nutrients and falls prevention programmes in this patient population. Conclusion Despite study heterogeneity, our SLR showed beneficial effects of some interventions delivered by non-physician health professionals and the positive impact of multidisciplinary team working and patient educational approaches to prevent and manage osteoporotic fractures. These results informed a EULAR taskforce that developed points to consider for non-physician health professionals to prevent and manage osteoporotic fractures.
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Affiliation(s)
- Nicky Wilson
- School of Health Sciences, University of Southampton, Southampton, Hampshire, UK
| | - Emailie Hurkmans
- Department Social Affaire and Health, ECORYS Nederland BV, Rotterdam, Zuid-Holland, Netherlands
| | - Jo Adams
- School of Health Sciences, University of Southampton, Southampton, Hampshire, UK
| | - Margot Bakkers
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe, Zurich, Switzerland
| | - Petra Balážová
- EULAR Young PARE, Zurich, Switzerland.,Slovak League Against Rheumatism, Piestany, Slovakia
| | - Mark Baxter
- Medicine for Older People, University Hospital Southampton, Southampton, UK
| | | | - Karine Briot
- INSERM U1153, Paris Descartes University, Reference Center for Genetic Bone Diseases, Department of Rheumatology, Cochin Hospital, Paris, France
| | - Catharina Chiari
- Section for Outcomes Research, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Wien, Austria
| | - Cyrus Cooper
- School of Health Sciences, University of Southampton, Southampton, Hampshire, UK
| | - Razvan Dragoi
- Department of Balneology, Rehabilitation and Rheumatology, University of Medicine and Pharmacy Victor Babes Timisoara, Timisoara, Romania
| | - Gabriele Gäbler
- Section for Outcomes Research, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Wien, Austria
| | - Willem Lems
- Department of Rheumatology, VU University Medical Centre Amsterdam, Amsterdam, Noord-Holland, Netherlands
| | - Erika Mosor
- Section for Outcomes Research, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Sandra Pais
- School of Health (ESSUAlg), University of Algarve, Faro, Portugal
| | - Cornelia Simon
- Department of Balneology, Rehabilitation and Rheumatology, University of Medicine and Pharmacy Victor Babes Timisoara, Timisoara, Romania
| | - Paul Studenic
- Department of Internal Medicine 3, Division of Rheumatology, Medical University Vienna, Vienna, Austria
| | - Simon Tilley
- Trauma & Orthopaedics, University Hospital Southampton, Southampton, UK
| | - Jenny de la Torre
- Centre for Biomedical Research, Department of Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal
| | - Tanja A Stamm
- Section for Outcomes Research, Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
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Adams J, Wilson N, Hurkmans E, Bakkers M, Balážová P, Baxter M, Blavnsfeldt AB, Briot K, Chiari C, Cooper C, Dragoi RG, Gäbler G, Lems W, Mosor E, Pais S, Simon C, Studenic P, Tilley S, de la Torre-Aboki J, Stamm TA. 2019 EULAR points to consider for non-physician health professionals to prevent and manage fragility fractures in adults 50 years or older. Ann Rheum Dis 2021; 80:57-64. [PMID: 32332077 PMCID: PMC7788058 DOI: 10.1136/annrheumdis-2020-216931] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 03/31/2020] [Accepted: 04/02/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To establish European League Against Rheumatism (EULAR) points to consider for non-physician health professionals to prevent and manage fragility fractures in adults 50 years or older. METHODS Points to consider were developed in accordance with EULAR standard operating procedures for EULAR-endorsed recommendations, led by an international multidisciplinary task force, including patient research partners and different health professionals from 10 European countries. Level of evidence and strength of recommendation were determined for each point to consider, and the mean level of agreement among the task force members was calculated. RESULTS Two overarching principles and seven points to consider were formulated based on scientific evidence and the expert opinion of the task force. The two overarching principles focus on shared decisions between patients and non-physician health professionals and involvement of different non-physician health professionals in prevention and management of fragility fractures. Four points to consider relate to prevention: identification of patients at risk of fracture, fall risk evaluation, multicomponent interventions to prevent primary fracture and discouragement of smoking and overuse of alcohol. The remaining three focus on management of fragility fractures: exercise and nutritional interventions, the organisation and coordination of multidisciplinary services for post-fracture models of care and adherence to anti-osteoporosis medicines. The mean level of agreement among the task force for the overarching principles and the points to consider ranged between 8.4 and 9.6. CONCLUSION These first EULAR points to consider for non-physician health professionals to prevent and manage fragility fractures in adults 50 years or older serve to guide healthcare practice and education.
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Affiliation(s)
- Jo Adams
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Nicky Wilson
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Emalie Hurkmans
- Department Care I, Musculoskeletal System & Neurology, Dutch National Health Care Institute, Diemen, The Netherlands
| | - Margot Bakkers
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Petra Balážová
- EULAR Young PARE, Zurich, Switzerland
- Slovak League Against Rheumatism, Piestany, Slovakia
| | - Mark Baxter
- Medicine for Older People, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Karine Briot
- INSERM U1153, Paris Descartes University, Reference Center for Genetic Bone Diseases - Department of Rheumatology, Cochin Hospital, Paris, France
| | - Catharina Chiari
- Department of Orthopedics and Trauma-Surgery, Medical University of Vienna, Vienna, Austria
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Razvan Gabriel Dragoi
- Rehabilitation, Physical Medicine and Rheumatology, 'Victor Babes' University of Medicine and Pharmacy, Timisoara, Timisoara, Romania
| | - Gabriele Gäbler
- Section for Outcomes Research, Centre for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Willem Lems
- Department of Rheumatology, VU University Medical Centre Amsterdam, Amsterdam, Noord-Holland, The Netherlands
| | - Erika Mosor
- Section for Outcomes Research, Centre for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Sandra Pais
- Centre for Biomedical Research, Department of Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal
| | - Cornelia Simon
- Department of Balneology, Rehabilitation and Rheumatology, 'Victor Babes' University of Medicine and Pharmacy, Timisoara, Timisoara, Romania
| | - Paul Studenic
- Internal Medicine 3, Division of Rheumatology, Medical University Vienna, Vienna, Austria
| | - Simon Tilley
- Medicine for Older People, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Trauma & Orthopaedics, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Tanja A Stamm
- Section for Outcomes Research, Centre for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute Arthritis and Rehabilitation, Vienna, Austria
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Cornelissen D, de Kunder S, Si L, Reginster JY, Evers S, Boonen A, Hiligsmann M. Interventions to improve adherence to anti-osteoporosis medications: an updated systematic review. Osteoporos Int 2020; 31:1645-1669. [PMID: 32358684 PMCID: PMC7423788 DOI: 10.1007/s00198-020-05378-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 03/04/2020] [Indexed: 01/25/2023]
Abstract
An earlier systematic review on interventions to improve adherence and persistence was updated. Fifteen studies investigating the effectiveness of patient education, drug regimen, monitoring and supervision, and interdisciplinary collaboration as a single or multi-component intervention were appraised. Multicomponent interventions with active patient involvement were more effective. INTRODUCTION This study was conducted to update a systematic literature review on interventions to improve adherence to anti-osteoporosis medications. METHODS A systematic literature review was carried out in Medline (using PubMed), Embase (using Ovid), Cochrane Library, Current Controlled Trials, ClinicalTrials.gov , NHS Centre for Review and Dissemination, CINHAL, and PsycINFO to search for original studies that assessed interventions to improve adherence (comprising initiation, implementation, and discontinuation) and persistence to anti-osteoporosis medications among patients with osteoporosis, published between July 2012 and December 2018. Quality of included studies was assessed. RESULTS Of 585 studies initially identified, 15 studies fulfilled the inclusion criteria of which 12 were randomized controlled trials. Interventions were classified as (1) patient education (n = 9), (2) drug regimen (n = 3), (3) monitoring and supervision (n = 2), and (4) interdisciplinary collaboration (n = 1). In most subtypes of interventions, mixed results on adherence (and persistence) were found. Multicomponent interventions based on patient education and counseling were the most effective interventions when aiming to increase adherence and/or persistence to osteoporosis medications. CONCLUSION This updated review suggests that patient education, monitoring and supervision, change in drug regimen, and interdisciplinary collaboration have mixed results on medication adherence and persistence, with more positive effects for multicomponent interventions with active patient involvement. Compared with the previous review, a shift towards more patient involvement, counseling and shared decision-making, was seen, suggesting that individualized solutions, based on collaboration between the patient and the healthcare provider, are needed to improve adherence and persistence to osteoporosis medications.
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Affiliation(s)
- D Cornelissen
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, P.O. Box 616, Room 0.038, 6200, Maastricht, MD, Netherlands.
| | - S de Kunder
- Department of Primary and Community Care, Center for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Center, Nijmegen, Netherlands
| | - L Si
- The George Institute for Global Health, UNSW Sydney, Kensington, Australia
| | - J-Y Reginster
- WHO Collaborating Center for Public Health Aspects of Musculoskeletal Health and Ageing, Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
- Biomarkers of Chronic Diseases, Biochemistry Department, College of Science, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - S Evers
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, P.O. Box 616, Room 0.038, 6200, Maastricht, MD, Netherlands
- Centre for economic evaluation, Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, Netherlands
| | - A Boonen
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, P.O. Box 616, Room 0.038, 6200, Maastricht, MD, Netherlands
- Department of Internal Medicine, Rheumatology, Maastricht University Medical Centre and CAPHRI, Maastricht University, Maastricht, Netherlands
| | - M Hiligsmann
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, P.O. Box 616, Room 0.038, 6200, Maastricht, MD, Netherlands
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Hiligsmann M, Cornelissen D, Vrijens B, Abrahamsen B, Al-Daghri N, Biver E, Brandi ML, Bruyère O, Burlet N, Cooper C, Cortet B, Dennison E, Diez-Perez A, Gasparik A, Grosso A, Hadji P, Halbout P, Kanis JA, Kaufman JM, Laslop A, Maggi S, Rizzoli R, Thomas T, Tuzun S, Vlaskovska M, Reginster JY. Determinants, consequences and potential solutions to poor adherence to anti-osteoporosis treatment: results of an expert group meeting organized by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) and the International Osteoporosis Foundation (IOF). Osteoporos Int 2019; 30:2155-2165. [PMID: 31388696 PMCID: PMC6811382 DOI: 10.1007/s00198-019-05104-5] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 07/18/2019] [Indexed: 11/22/2022]
Abstract
UNLABELLED Many patients at increased risk of fractures do not take their medication appropriately, resulting in a substantial decrease in the benefits of drug therapy. Improving medication adherence is urgently needed but remains laborious, given the numerous and multidimensional reasons for non-adherence, suggesting the need for measurement-guided, multifactorial and individualized solutions. INTRODUCTION Poor adherence to medications is a major challenge in the treatment of osteoporosis. This paper aimed to provide an overview of the consequences, determinants and potential solutions to poor adherence and persistence to osteoporosis medication. METHODS A working group was organized by the European Society on Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal diseases (ESCEO) to review consequences, determinants and potential solutions to adherence and to make recommendations for practice and further research. A systematic literature review and a face-to-face experts meeting were undertaken. RESULTS Medication non-adherence is associated with increased risk of fractures, leading to a substantial decrease in the clinical and economic benefits of drug therapy. Reasons for non-adherence are numerous and multidimensional for each patient, depending on the interplay of multiple factors, suggesting the need for multifactorial and individualized solutions. Few interventions have been shown to improve adherence or persistence to osteoporosis treatment. Promising actions include patient education with counselling, adherence monitoring with feedback and dose simplification including flexible dosing regimen. Recommendations for practice and further research were also provided. To adequately manage adherence, it is important to (1) understand the problem (initiation, implementation and/or persistence), (2) to measure adherence and (3) to identify the reason of non-adherence and fix it. CONCLUSION These recommendations are intended for clinicians to manage adherence of their patients and to researchers and policy makers to design, facilitate and appropriately use adherence interventions.
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Affiliation(s)
- M Hiligsmann
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, the Netherlands.
| | - D Cornelissen
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, the Netherlands
| | - B Vrijens
- Research and Development, AARDEX Group and Department of Public Health, University of Liège, Liege, Belgium
| | - B Abrahamsen
- Open Patient Data Explorative Network, Institute of Clinical Resesarch, University of Southern Denmark, Odense, Denmark
- Department of Medicine, Holbæk Hospital, Holbæk, Denmark
- NDORMS, University of Oxford, Oxford, UK
| | - N Al-Daghri
- Chair for Biomarkers of Chronic Diseases, Biochemistry Department, College of Science, King Saud University, Riyadh, Saudi Arabia
| | - E Biver
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - M L Brandi
- FirmoLab, Fondazione FIRMO e Università di Firenze, Florence, Italy
| | - O Bruyère
- Division of Public Health, Epidemiology and Health Economics, Liège, Belgium and WHO Collaborating Centre for Public Health Aspects of Musculoskeletal Health and Aging, University of Liège, Liege, Belgium
| | - N Burlet
- Global Head of Patient Insights Innovation, Patient Solution Unit, Sanofi, Lyon, France
| | - C Cooper
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, UK
- NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, UK
| | - B Cortet
- Department of Rheumatology and EA 4490, University-Hospital of Lille, Lille, France
| | - E Dennison
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, UK
| | - A Diez-Perez
- Musculoskeletal Research Unit, IMIM-Parc Salut Mar, CIBERFES, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - A Gasparik
- Department of Public Health, University of Medicine, Pharmacy, Science and Technology of Targu Mures, Targu Mures, Romania
| | - A Grosso
- Patient partner, Geneva, Switzerland
| | - P Hadji
- Frankfurt Centre of Bone Health, Frankfurt, Germany & Philips-University of Marburg, Marburg, Germany
| | - P Halbout
- International Osteoporosis Foundation, Nyon, Switzerland
| | - J A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
- Mary McKillop Health Institute, Catholic University of Australia, Melbourne, Australia
| | - J M Kaufman
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
| | - A Laslop
- Scientific Office, Austrian Federal Office for Safety in Health Care, Vienna, Austria
| | - S Maggi
- CNR Aging Branch-NI, Padua, Italy
| | - R Rizzoli
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - T Thomas
- Department of Rheumatology, Hôpital Nord, CHU Saint-Etienne, Saint-Etienne and INSERM U1059, Université de Lyon-Université Jean Monnet, Saint-Etienne, France
| | - S Tuzun
- Department of Physical Medicine and Rehabilitation, Cerrahpaşa Medical Faculty, İstanbul University Cerrahpaşa, Istanbul, Turkey
| | - M Vlaskovska
- Medical Faculty, Department of Pharmacology, Medical University Sofia, Sofia, Bulgaria
| | - J Y Reginster
- Chair for Biomarkers of Chronic Diseases, Biochemistry Department, College of Science, King Saud University, Riyadh, Saudi Arabia
- Division of Public Health, Epidemiology and Health Economics, Liège, Belgium and WHO Collaborating Centre for Public Health Aspects of Musculoskeletal Health and Aging, University of Liège, Liege, Belgium
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Jaleel A, Saag KG, Danila MI. Improving drug adherence in osteoporosis: an update on more recent studies. Ther Adv Musculoskelet Dis 2018; 10:141-149. [PMID: 30023009 DOI: 10.1177/1759720x18785539] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 05/30/2018] [Indexed: 11/15/2022] Open
Abstract
Similar to other chronic diseases such as diabetes and hypertension, osteoporosis has struggled with suboptimal medication adherence, resulting in an increased risk of fractures and all-cause mortality. The goal of this narrative review was to summarize interventions to improve medication adherence in osteoporosis. Because past reviews of this topic covered published literature through 2013, we conducted our literature search to include the period between January 2012 and November 2017. We identified 10 studies evaluating healthcare system and patient interventions aimed at improving osteoporosis treatment adherence, including three fracture liaison service (FLS) programs, one pharmacist-delivered counseling program, and six patient-directed interventions consisting of three coaching or counseling programs and three interventions using reminder prompts. Four out of the six patient-directed interventions did not lead to significant improvements in outcomes, suggesting that patient-directed interventions may have limited success in this setting. The healthcare system interventions that evaluated FLS programs and pharmacist-directed tailored counseling were effective at improving medication adherence; however, the studies were not randomized, they were costly, resource intensive and effective in countries with more centralized healthcare, possibly limiting their generalizability. In conclusion, while healthcare system interventions such as FLS, and pharmacist-delivered counseling appeared to be successful in improving osteoporosis medication adherence in some settings, behavioral interventions including patient counseling and reminder prompts for medication utilization were not, perhaps due to patient perceptions regarding osteoporosis consequences and need for treatment. Thus, these patient attributes may define patients 'at high risk' for poor adherence and developing intervention approaches to enhance patient knowledge and understanding of osteoporosis and its consequences may improve the perception of the need for treatment, optimize osteoporosis care and thereby improve overall outcomes of patients with osteoporosis. We hope that the knowledge gained through our review will help inform the design of further programs aimed at optimizing osteoporosis care.
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Affiliation(s)
| | - Kenneth G Saag
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Maria I Danila
- University of Alabama at Birmingham, Faculty Office Tower, Room 838510 20th Street South, Birmingham, AL 35294-3408, USA
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Danila MI, Outman RC, Rahn EJ, Mudano AS, Redden DT, Li P, Allison JJ, Anderson FA, Wyman A, Greenspan SL, LaCroix AZ, Nieves JW, Silverman SL, Siris ES, Watts NB, Miller MJ, Curtis JR, Warriner AH, Wright NC, Saag KG. Evaluation of a Multimodal, Direct-to-Patient Educational Intervention Targeting Barriers to Osteoporosis Care: A Randomized Clinical Trial. J Bone Miner Res 2018; 33:763-772. [PMID: 29377378 PMCID: PMC6016546 DOI: 10.1002/jbmr.3395] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 12/14/2017] [Accepted: 01/10/2018] [Indexed: 11/06/2022]
Abstract
Osteoporosis treatment rates are declining, even among those with past fractures. Novel, low-cost approaches are needed to improve osteoporosis care. We conducted a parallel group, controlled, randomized clinical trial evaluating a behavioral intervention for improving osteoporosis medication use. A total of 2684 women with self-reported fracture history after age 45 years not using osteoporosis therapy from US Global Longitudinal Study of Osteoporosis in Women (GLOW) sites were randomized 1:1 to receive a multimodal, tailored, direct-to-patient, video intervention versus usual care. The primary study outcome was self-report of osteoporosis medication use at 6 months. Other outcomes included calcium and vitamin D supplementation, bone mineral density (BMD) testing, readiness for behavioral change, and barriers to treatment. In intent-to-treat analyses, there were no significant differences between groups (intervention versus control) in osteoporosis medication use (11.7% versus 11.4%, p = 0.8), calcium supplementation (31.8% versus 32.6%, p = 0.7), vitamin D intake (41.3% versus 41.9%, p = 0.8), or BMD testing (61.8% versus 57.1%, p = 0.2). In the intervention group, fewer women were in the precontemplative stage of behavior change, more women reported seeing their primary care provider, had concerns regarding osteonecrosis of the jaw, and difficulty in taking/remembering to take osteoporosis medications. We found differences in BMD testing among the subgroup of women with no prior osteoporosis treatment, those who provided contact information, and those with no past BMD testing. In per protocol analyses, women with appreciable exposure to the online intervention (n = 257) were more likely to start nonbisphosphonates (odds ratio [OR] = 2.70; 95% confidence interval [CI] 1.26-5.79) compared with the usual care group. Although our intervention did not increase the use of osteoporosis therapy at 6 months, it increased nonbisphosphonate medication use and BMD testing in select subgroups, shifted participants' readiness for behavior change, and altered perceptions of barriers to osteoporosis treatment. Achieving changes in osteoporosis care using patient activation approaches alone is challenging. © 2018 American Society for Bone and Mineral Research.
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Affiliation(s)
- Maria I Danila
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ryan C Outman
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Amy S Mudano
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - David T Redden
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Peng Li
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Fred A Anderson
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Allison Wyman
- University of Massachusetts Medical School, Worcester, MA, USA
| | | | - Andrea Z LaCroix
- Group Health Cooperative, Seattle, WA, USA.,University of California San Diego, La Jolla, CA, USA
| | | | | | - Ethel S Siris
- Columbia University Medical Center, New York, NY, USA
| | - Nelson B Watts
- Mercy Health Osteoporosis and Bone Health Services, Cincinnati, OH, USA
| | - Michael J Miller
- Department of Pharmaceutical Sciences, Irma Lerma Rangel College of Pharmacy, Texas A&M University, College Station, TX, USA
| | | | - Amy H Warriner
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Kenneth G Saag
- University of Alabama at Birmingham, Birmingham, AL, USA
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van den Berg P, van Haard PMM, van der Veer E, Geusens PP, van den Bergh JP, Schweitzer DH. A dedicated Fracture Liaison Service telephone program and use of bone turnover markers for evaluating 1-year persistence with oral bisphosphonates. Osteoporos Int 2018; 29:813-824. [PMID: 29260291 DOI: 10.1007/s00198-017-4340-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 12/04/2017] [Indexed: 12/20/2022]
Abstract
UNLABELLED Telephone call intervention did not improve alendronate persistence in Fracture Liaison Service (FLS) patients in this study. A bone turnover marker cut-off point for alendronate persistence is proposed for individual FLS patients. INTRODUCTION FLS aims to prevent subsequent fractures, which should include improving patients' persistence with prescribed oral bisphosphonates. We studied the influence of telephone calls and the predictive value of changes in bone turnover markers (BTMs) for evaluating persistence with alendronate. METHODS Postmenopausal women with a recent fracture and osteoporosis who started alendronate were randomized to receive three phone calls (PC) (after 1, 4, and 12 months) or no phone calls (no PC). s-CTX and P1NP were measured at baseline and after 3, 6, 9, and 12 months. As a reference group, 30 postmenopausal osteopenic patients with a recent fracture were analyzed as well. Persistence was assessed using the Dutch National Switch Point Pharmacies-GPs database and cross-referenced with PC, no PC, and BTM changes. Cut-off values of BTMs were calculated based on least significant change (LSC) and also on underrunning median values of the untreated osteopenic postmenopausal reference group with a recent fracture. RESULTS Out of 119 patients, 93 (78%) completed 12 months follow-up (45 PC and 48 no PC). Mean age was 69 years. Persistence was similar in PC and no PC participants. The cut-off value > 29% (< 415 ng/L) as LSC of s-CTX and > 36% (< 53.1 μg/L) as LSC of P1NP was determined optimally showing alendronate persistence after 1 year (being 93 and 88%, respectively). CONCLUSIONS In this context, telephone calls did not improve persistence. In around 90% of patients, 1-year alendronate persistence was confirmed by achieving LSC of s-CTX and of P1NP at 12 months.
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Affiliation(s)
- P van den Berg
- Department of Orthopedics and Surgery, Fracture Liaison Service, Reinier de Graaf Gasthuis, Delft, the Netherlands.
| | - P M M van Haard
- Department of Medical Laboratories, Association of Clinical Chemistry, Reinier the Graaf Gasthuis, Delft, the Netherlands
| | - E van der Veer
- Laboratory Medicine, University Medical Centre, Groningen, the Netherlands
| | - P P Geusens
- Department of Internal Medicine, Subdivision Rheumatology, Maastricht University Medical Center, Maastricht, the Netherlands
- Hasselt University, Hasselt, Belgium
| | - J P van den Bergh
- Department of Internal Medicine, Subdivision Rheumatology, Maastricht University Medical Center, Maastricht, the Netherlands
- Department of Internal Medicine, VieCuri Medical Centre Noord-Limburg, Maastricht University Medical Center, Maastricht, the Netherlands
| | - D H Schweitzer
- Department of Internal Medicine and Endocrinology, Reinier the Graaf Gasthuis, Delft, the Netherlands
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11
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Toh LS, Lai PSM, Othman S, Shah A, Dang CPL, Low BY, Wong KT, Anderson C. Exploring the current and future role of the pharmacists in osteoporosis screening and management in Malaysia. Int J Clin Pharm 2018; 40:450-457. [PMID: 29380234 DOI: 10.1007/s11096-018-0597-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 01/19/2018] [Indexed: 10/18/2022]
Abstract
Background Several studies have found that pharmacists can assist in screening and prevention of osteoporosis by referring patients for bone mineral density scans and counselling on lifestyle changes. In Malaysia, screening osteoporosis in all elderly women is not mandatory due to its cost. One approach to address this gap is to develop a pharmacist-led osteoporosis screening and prevention program. However, there is a paucity of data on the perspectives of Malaysian pharmacists in this area. Objective To explore the perspective of stakeholders (policy makers, doctors, pharmacists, nurses and patients) towards the role of pharmacists in osteoporosis screening and management. Setting A primary care clinic located within a teaching hospital in Kuala Lumpur, Malaysia. Method Patients (n = 20), nurses (n = 10), pharmacists (n = 11), doctors (n = 10) and policy makers (n = 5) were individually interviewed using a semi-structured topic guide. Purposive sampling was used. Interviews were transcribed verbatim and analysed using thematic analysis. Main outcome measure Perspective of stakeholders on the current and future role of pharmacists. Results All participants perceived pharmacists to be suppliers of medication, although there was some recognition of roles in providing medication advice. Nonetheless, these stakeholders were eager for pharmacists to expand their non-dispensing roles towards counselling, creating awareness and screening of osteoporosis. Interviewed pharmacists referred to their current role as 'robotic dispensers' and unanimously agreed to spread out to osteoporosis management role. Conclusion Under stakeholders there is a willingness to expand the role of pharmacists in Malaysia to non-dispensing roles, particularly in osteoporosis screening and management.
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Affiliation(s)
- L S Toh
- Division of Pharmacy, School of Medicine, University of Tasmania, Sandy Bay Campus, Pharmacy Building Churchill Avenue, Tasmania, 7005, Australia. .,School of Pharmacy, University of Nottingham, Jalan Broga, 43500, Semenyih, Selangor, Malaysia.
| | - P S M Lai
- University of Malaya Primary Care Research Group (UMPCRG), Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - S Othman
- University of Malaya Primary Care Research Group (UMPCRG), Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - A Shah
- Division of Pharmacy, School of Medicine, University of Tasmania, Sandy Bay Campus, Pharmacy Building Churchill Avenue, Tasmania, 7005, Australia
| | - C P L Dang
- Division of Pharmacy, School of Medicine, University of Tasmania, Sandy Bay Campus, Pharmacy Building Churchill Avenue, Tasmania, 7005, Australia
| | - B Y Low
- School of Pharmacy, University of Nottingham, Jalan Broga, 43500, Semenyih, Selangor, Malaysia
| | - K T Wong
- School of Pharmacy, University of Nottingham, Jalan Broga, 43500, Semenyih, Selangor, Malaysia
| | - C Anderson
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, NG7 2RD, UK
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12
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Spence M, Makarem A, Reyes S, Nguyen C. Evaluation of an Outpatient Pharmacy Clinical Services Program on Adherence and Fractures among Patients with Osteoporosis. JOURNAL OF CONTEMPORARY PHARMACY PRACTICE 2017. [DOI: 10.37901/jcphp16-00032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Hall SF, Edmonds SW, Lou Y, Cram P, Roblin DW, Saag KG, Wright NC, Jones MP, Wolinsky FD. Patient-reported reasons for nonadherence to recommended osteoporosis pharmacotherapy. J Am Pharm Assoc (2003) 2017; 57:503-509. [PMID: 28602783 PMCID: PMC5515491 DOI: 10.1016/j.japh.2017.05.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 04/27/2017] [Accepted: 05/03/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES As many as one-half of patients recommended for osteoporosis pharmacotherapy do not take their medications. To identify intervention targets, we examined patient characteristics associated with nonadherence to recommended pharmacotherapy and their reasons for nonadherence. METHODS Data come from the Patient Activation after DXA Result Notification (PAADRN) study, a randomized controlled trial of 7749 patients aged 50 years or older presenting for dual-energy X-ray absorptiometry (DXA) at 3 health centers in the United States. We focused on the 790 patients who reported receiving a recommendation for new pharmacotherapy at baseline. Using Pearson chi-squared tests for categorical variables, 2-sample t tests for continuous variables, and multivariable multinomial logistic regression, we compared those who reported starting the recommended medication (adherers) with temporary nonadherers and nonadherers on demographics, health habits, DXA impression, 10-year probability of fracture using the assessment tool, and osteoporosis knowledge, and we examined their stated reasons for nonadherence. RESULTS Mean age was 66.8 years (SD = 8.9); 87.2% were women, and 84.2% were white. One-fourth of patients (24.8%) reported that they did not start their recommended pharmacotherapy. In the unadjusted analyses, the only factor significantly associated with nonadherence was osteoporosis knowledge, with those having better knowledge being less likely to take their medications (P < 0.05). The most common reasons for nonadherence were fear of adverse effects (53.3%), a dislike of taking medicine (25.3%), and the belief that the medication would not help their condition (16.7%). CONCLUSION One in 4 patients recommended for osteoporosis pharmacotherapy declined treatment because they feared potential adverse effects, did not like taking medicine, or believed that the medication would not help their condition. Improved patient counseling on the potential adverse effects of osteoporosis treatment and the risk-benefit ratio for these medications may increase adherence.
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14
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Melton BL, Lai Z. Review of community pharmacy services: what is being performed, and where are the opportunities for improvement? INTEGRATED PHARMACY RESEARCH AND PRACTICE 2017; 6:79-89. [PMID: 29354554 PMCID: PMC5774328 DOI: 10.2147/iprp.s107612] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective The aim of this review was to assess pharmacist and pharmacy services being provided and identify opportunities to improve patient satisfaction. Methods Studies published between January 2006 and July 2016 examining patient satisfaction with pharmacy and pharmacist services, which were written in English, were identified in PubMed. Studies were excluded if they only looked at pharmacy student-provided services. Key findings A total of 50 studies were ultimately included in the review. Of these studies, 28 examined services traditionally provided by community pharmacists such as dispensing and counseling, while 16 examined a new in-person service being offered by a pharmacy, and the remaining six involved a new technology-assisted service. While study findings were generally positive for patient satisfaction of pharmacy services, several opportunities were identified for pharmacies to improve. Conclusion Overall, patient satisfaction is high across pharmacy services; however, this satisfaction is related to prior patient exposure to services and their level of expectation. Pharmacists have multiple opportunities to improve the services they provide, and there are additional services pharmacists may consider offering to expand their role within the health care system.
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Affiliation(s)
- Brittany L Melton
- Department of Pharmacy Practice, University of Kansas, Lawrence, KS, USA
| | - Zoe Lai
- Department of Pharmacy Practice, University of Kansas, Lawrence, KS, USA
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15
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Danila MI, Outman RC, Rahn EJ, Mudano AS, Thomas TF, Redden DT, Allison JJ, Anderson FA, Anderson JP, Cram PM, Curtis JR, Fraenkel L, Greenspan SL, LaCroix AZ, Majumdar SR, Miller MJ, Nieves JW, Safford MM, Silverman SL, Siris ES, Solomon DH, Warriner AH, Watts NB, Yood RA, Saag KG. A multi-modal intervention for Activating Patients at Risk for Osteoporosis (APROPOS): Rationale, design, and uptake of online study intervention material. Contemp Clin Trials Commun 2016; 4:14-24. [PMID: 27453960 PMCID: PMC4955389 DOI: 10.1016/j.conctc.2016.06.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 06/09/2016] [Accepted: 06/22/2016] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To develop an innovative and effective educational intervention to inform patients about the need for osteoporosis treatment and to determine factors associated with its online uptake. METHODS Postmenopausal women with a prior fracture and not currently using osteoporosis therapy were eligible to be included in the Activating Patients at Risk for OsteoPOroSis (APROPOS). Four nominal groups with a total of 18 racially/ethnically diverse women identified osteoporosis treatment barriers. We used the Information, Motivation, Behavior Skills conceptual model to develop a direct-to-patient intervention to mitigate potentially modifiable barriers to osteoporosis therapy. The intervention included videos tailored by participants' race/ethnicity and their survey responses: ranked barriers to osteoporosis treatment, deduced barriers to treatment, readiness to behavior change, and osteoporosis treatment history. Videos consisted of "storytelling" narratives, based on osteoporosis patient experiences and portrayed by actresses of patient-identified race/ethnicity. We also delivered personalized brief phone calls followed by an interactive voice-response phone messages aimed to promote uptake of the videos. RESULTS To address the factors associated with online intervention uptake, we focused on participants assigned to the intervention arm (n = 1342). These participants were 92.9% Caucasian, with a mean (SD) age 74.9 (8.0) years and the majority (77.7%) had some college education. Preference for natural treatments was the barrier ranked #1 by most (n = 130; 27%), while concern about osteonecrosis of the jaw was the most frequently reported barrier (at any level; n = 322; 67%). Overall, 28.1% (n = 377) of participants in the intervention group accessed the videos online. After adjusting for relevant covariates, the participants who provided an email address had 6.07 (95% CI 4.53-8.14) higher adjusted odds of accessing their online videos compared to those who did not. CONCLUSION We developed and implemented a novel tailored multi-modal intervention to improve initiation of osteoporosis therapy. An email address provided on the survey was the most important factor independently associated with accessing the intervention online. The design and uptake of this intervention may have implications for future studies in osteoporosis or other chronic diseases.
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Affiliation(s)
| | - Ryan C. Outman
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Amy S. Mudano
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - Jeroan J. Allison
- University of Massachusetts Medical School, Worcester, MA 01655, USA
| | - Fred A. Anderson
- University of Massachusetts Medical School, Worcester, MA 01655, USA
| | | | | | | | | | | | - Andrea Z. LaCroix
- Group Health Cooperative, Seattle, WA 98112, USA
- University of California San Diego, La Jolla, CA 92093, USA
| | | | - Michael J. Miller
- The University of Oklahoma Health Sciences Center, Tulsa, OK 74135, USA
| | | | - Monika M. Safford
- University of Alabama at Birmingham, Birmingham, AL, USA
- Weill Cornell Medical Center, New York, NY 10065, USA
| | | | - Ethel S. Siris
- Columbia University Medical Center, New York, NY 10032, USA
| | | | | | - Nelson B. Watts
- Mercy Health Osteoporosis and Bone Health Services, Cincinnati, OH 45236, USA
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Driesenaar JA, De Smet PAGM, van Hulten R, Hu L, van Dulmen S. Communication during counseling sessions about inhaled corticosteroids at the community pharmacy. Patient Prefer Adherence 2016; 10:2239-2254. [PMID: 27843303 PMCID: PMC5098562 DOI: 10.2147/ppa.s108006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Pharmaceutical care is one of the major tasks of pharmacists, which aims to improve patient outcomes. Counseling patients with asthma or chronic obstructive pulmonary disease about their use of inhaled corticosteroids (ICS) might enhance medication adherence and symptom control. Therefore, effective pharmacist-patient communication is very important. In this regard, both affective communication, for handling emotions, and instrumental communication, for exchanging biomedical and lifestyle information, are relevant. Until now, only few studies have explored pharmacist-patient communication, and further insight is needed in this regard. The aim of this study is to investigate how pharmacists and pharmacy technicians communicate about ICS with patients with asthma and/or chronic obstructive pulmonary disease, what topics are discussed by them, and whether pharmacists and pharmacy technicians differ in their communication during counseling sessions. METHODS Patients aged ≥18 years who had used ICS for at least 1 year and filled at least two ICS prescriptions in the preceding year were recruited through 12 pharmacies. Participants had one counseling session with a pharmacist or a pharmacy technician, which was video-recorded. The process and content of the provider-patient communication were analyzed using the Roter interaction analysis system, adapted to the pharmaceutical setting. RESULTS A total of 169 sessions were recorded and analyzed. The communication appeared largely instrumental. Lifestyle, psychosocial issues, and ICS adherence were not discussed in detail. The pharmacists had longer conversations and more affective talk than the pharmacy technicians. CONCLUSION Pharmacists and pharmacy technicians may need to pay more attention to ICS adherence, lifestyle, and psychosocial topics. They differed in their communication; the pharmacists exhibited more affective behavior and discussed medical and therapeutic issues more extensively compared to the pharmacy technicians. Educational courses for pharmacists and pharmacy technicians could focus more on the discussion of adherence, lifestyle, and psychosocial topics with patients.
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Affiliation(s)
- Jeanine A Driesenaar
- NIVEL, Netherlands institute for health services research, Utrecht, the Netherlands
| | - Peter AGM De Smet
- Department of Clinical Pharmacy, Radboud University Medical Center, Nijmegen, the Netherlands
- IQ Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Rolf van Hulten
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, the Netherlands
- Department of Pharmacotherapy and Pharmaceutical Care, University of Groningen, Groningen, the Netherlands
| | - Litje Hu
- NIVEL, Netherlands institute for health services research, Utrecht, the Netherlands
| | - Sandra van Dulmen
- NIVEL, Netherlands institute for health services research, Utrecht, the Netherlands
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands
- Faculty of Health Sciences, University College of Southeast Norway, Drammen, Norway
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Sodihardjo-Yuen F, van Dijk L, Wensing M, De Smet PAGM, Teichert M. Use of pharmacy dispensing data to measure adherence and identify nonadherence with oral hypoglycemic agents. Eur J Clin Pharmacol 2016; 73:205-213. [PMID: 27796465 PMCID: PMC5226973 DOI: 10.1007/s00228-016-2149-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 10/13/2016] [Indexed: 11/27/2022]
Abstract
Purpose A framework for calculation of adherence for oral hypoglycemic agents (OHAs) based on data from health-insurance claims is available. Pharmacy dispensing data aid identification of nonadherent patients in pharmacy practices. However, use of these data for calculation of OHA adherence requires additional methodological categories. We examined the impact of different methodological choices on estimation of OHA adherence using pharmacy dispensing data. Methods Four methodological categories were added to the framework available to be used for adherence calculation with pharmacy dispensing data. Three adherence measures were defined to supply pharmacists with significant information on OHA use of their patients: (i) percentage of days covered by use periods of dispensed medication (PDC), (ii) mean rate of adherent patients with a PDC ≥80 % (MRAP80), and (iii) mean number of nonadherent patients (MNNP80) per pharmacy with a PDC <80 %. A basic scenario was developed from 16 methodological categories. Consequences of choices for different parameters within these categories on the scores of the three adherence measures were calculated from dispensing data between July 2013 and July 2014. Results Data were available for 604,500 OHA users in 1737 community pharmacies in the Netherlands. For the basic scenario, mean PDC for OHA was 88.3 %. MRAP80 was 80.3 %, which corresponded to an average of 69 nonadherent patients per pharmacy. Different choices for parameter values resulted in score variations for PDC of 85.0–91.8 %, for MRAP80 of 75.3–86.1 %, and between 49 and 92 MNNP80 per pharmacy. Conclusion Sixteen methodological categories specified calculation of OHA adherence based on pharmacy dispensing data. Adherence scores expressed as percentages were relatively robust to variation in parameter values, but differed substantially for the absolute numbers of nonadherent patients per pharmacy. Electronic supplementary material The online version of this article (doi:10.1007/s00228-016-2149-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Liset van Dijk
- Netherlands Institute for Health Services Research, Utrecht, the Netherlands
| | - Michel Wensing
- Radboud Institute for Health Sciences, Department of IQ Healthcare, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Peter A G M De Smet
- Royal Dutch Pharmacists Association, 2514 JL, The Hague, the Netherlands
- Radboud Institute for Health Sciences, Department of IQ Healthcare, Radboud University Medical Centre, Nijmegen, the Netherlands
- Radboud Institute for Health Sciences, Department of Clinical Pharmacy, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Martina Teichert
- Royal Dutch Pharmacists Association, 2514 JL, The Hague, the Netherlands
- Radboud Institute for Health Sciences, Department of IQ Healthcare, Radboud University Medical Centre, Nijmegen, the Netherlands
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, the Netherlands
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18
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Nik J, Lai PSM, Ng CJ, Emmerton L. A qualitative study of community pharmacists' opinions on the provision of osteoporosis disease state management services in Malaysia. BMC Health Serv Res 2016; 16:448. [PMID: 27577560 PMCID: PMC5006277 DOI: 10.1186/s12913-016-1686-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 08/17/2016] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND Osteoporosis has significant impact on healthcare costs and quality of life. Amongst the models for collaborative disease state management services published internationally, there is sparse evidence regarding the role of community pharmacists in the provision of osteoporosis care. Hence, the aim of our study was to explore community pharmacists' opinions (including the barriers and facilitators) and scope of osteoporosis disease state management services by community pharmacists in Malaysia, informing a vision for developing these services. METHODS Semi-structured individual interviews and focus groups discussions were conducted with community pharmacists from October 2013 to July 2014. Three trained researchers interviewed the participants. Interviews were recorded and transcribed verbatim. Data were analyzed thematically using an interpretative description approach. RESULTS Nineteen community pharmacists with 1-23 years of experience were recruited (in depth interviews: n = 9; focus group discussions: n = 10). These participants reflected on their experience with osteoporosis-related enquiries, which included medication counseling, bone density screening and referral of at-risk patients. Key barriers were the lack of numerous factors: public awareness of osteoporosis, accurate osteoporosis screening tools for community pharmacists, pharmacists' knowledge on osteoporosis disease and medications, time to counsel patients about bone health, collaboration between pharmacists and doctors, and support from the government and professional body. The pharmacists wanted more continuing education on osteoporosis, osteoporosis awareness campaigns, a simple, unbiased osteoporosis education material, and inter-professional collaboration practices with doctors, and pharmacists' reimbursement for osteoporosis care. CONCLUSIONS The involvement of community pharmacists in the provision of osteoporosis disease state management was minimal. Only ad-hoc counseling on osteoporosis prevention was performed by community pharmacists. Development and trial of collaborative osteoporosis disease state management services in community pharmacy could be facilitated by training, support and remuneration.
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Affiliation(s)
- Jah Nik
- Department of Primary Care Medicine, University Malaya Primary Care Research Group (UMPCRG), Faculty of Medicine, University of Malaya, Kuala Lumpur, 50603 Malaysia
| | - Pauline Siew Mei Lai
- Department of Primary Care Medicine, University Malaya Primary Care Research Group (UMPCRG), Faculty of Medicine, University of Malaya, Kuala Lumpur, 50603 Malaysia
| | - Chirk Jenn Ng
- Department of Primary Care Medicine, University Malaya Primary Care Research Group (UMPCRG), Faculty of Medicine, University of Malaya, Kuala Lumpur, 50603 Malaysia
| | - Lynne Emmerton
- School of Pharmacy, Curtin University, GPO Box U1987, Perth, WA 6845 Australia
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Hanemaaijer S, Sodihardjo F, Horikx A, Wensing M, De Smet PAGM, Bouvy ML, Teichert M. Trends in antithrombotic drug use and adherence to non-vitamin K oral anticoagulants in the Netherlands. Int J Clin Pharm 2015; 37:1128-35. [PMID: 26243531 PMCID: PMC4619456 DOI: 10.1007/s11096-015-0174-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Accepted: 07/23/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND Non-vitamin K oral anticoagulants (NOACs) became available in the Netherlands in 2008, providing another antithrombotic treatment besides vitamin K antagonists (VKAs) and antiplatelet agents (APAs). OBJECTIVE To describe the patterns of antithrombotic drug use between 2008 and 2013 by examination of dispensing data form community pharmacies in the Netherlands; to determine the concomitant use of NOACs with VKAs and APAs and switching between the drug classes; and to compare adherence to NOACs with adherence to APAs. SETTING An observational retrospective study was conducted using routinely collected dispensing data from Dutch community pharmacies. METHODS For each calendar year, the numbers of NOAC, VKA, and APA users were calculated. Adherence was determined for NOACs and APAs by the percentage of days covered by medication (PDC). Information on the prescribed daily dose of VKAs was unavailable. MAIN OUTCOME MEASURES Comparison of age, sex, and co-medications of users of the three drug classes; concomitant use of different antithrombotic drug classes and switching between these in each year; and mean PDC and percentages of all users with a PDC above 80 %. RESULTS NOAC use increased during the study period to 29,687 users in 2013. In that year there were 484,024 VKA users and 1313,032 APA users. Compared with users of VKAs, NOAC users were slightly younger and more frequently used antiarrhythmic drugs and beta blockers as co-medications. Substantial numbers of patients were dispensed potentially harmful combinations in 2013: 820 subjects were dispensed NOACs together with VKAs, and 684 subjects were dispensed NOACs, VKAs, and APAs concomitantly. Mean adherence to NOACs was 84.2 % compared with 87.3 % to APA. One in four NOAC users had a PDC lower than 80 % compared with one in five APA users. CONCLUSION Our findings show increasing use of NOACs by outpatients. The number of patients taking potentially harmful combinations of antithrombotic drugs was substantial. Adherence to NOACs in daily practice may be suboptimal to prevent thrombotic events.
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Affiliation(s)
- Susan Hanemaaijer
- Royal Dutch Pharmacists Association (KNMP), 2514JL, The Hague, The Netherlands
- Division of Pharmacoepidemiology and Clinical Pharmacology, Faculty of Science, Utrecht Institute of Sciences, Utrecht University, PO Box 80082, 3508 TB, Utrecht, The Netherlands
| | - Fong Sodihardjo
- Royal Dutch Pharmacists Association (KNMP), 2514JL, The Hague, The Netherlands
| | - Annemieke Horikx
- Royal Dutch Pharmacists Association (KNMP), 2514JL, The Hague, The Netherlands
| | - Michel Wensing
- Department of IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Centre, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Peter A G M De Smet
- Royal Dutch Pharmacists Association (KNMP), 2514JL, The Hague, The Netherlands
- Department of Clinical Pharmacy, Radboud University Medical Centre, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Marcel L Bouvy
- Division of Pharmacoepidemiology and Clinical Pharmacology, Faculty of Science, Utrecht Institute of Sciences, Utrecht University, PO Box 80082, 3508 TB, Utrecht, The Netherlands
| | - Martina Teichert
- Royal Dutch Pharmacists Association (KNMP), 2514JL, The Hague, The Netherlands.
- Department of IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Centre, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
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Costa E, Giardini A, Savin M, Menditto E, Lehane E, Laosa O, Pecorelli S, Monaco A, Marengoni A. Interventional tools to improve medication adherence: review of literature. Patient Prefer Adherence 2015; 9:1303-14. [PMID: 26396502 PMCID: PMC4576894 DOI: 10.2147/ppa.s87551] [Citation(s) in RCA: 179] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Medication adherence and persistence is recognized as a worldwide public health problem, particularly important in the management of chronic diseases. Nonadherence to medical plans affects every level of the population, but particularly older adults due to the high number of coexisting diseases they are affected by and the consequent polypharmacy. Chronic disease management requires a continuous psychological adaptation and behavioral reorganization. In literature, many interventions to improve medication adherence have been described for different clinical conditions, however, most interventions seem to fail in their aims. Moreover, most interventions associated with adherence improvements are not associated with improvements in other outcomes. Indeed, in the last decades, the degree of nonadherence remained unchanged. In this work, we review the most frequent interventions employed to increase the degree of medication adherence, the measured outcomes, and the improvements achieved, as well as the main limitations of the available studies on adherence, with a particular focus on older persons.
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Affiliation(s)
- Elísio Costa
- UCIBIO, REQUIMTE, Faculty of Pharmacy, University of Porto, Porto, Portugal
| | - Anna Giardini
- Psychology Unit, Salvatore Maugeri Foundation, IRCCS, Scientific Institute of Montescano (PV), Pavia, Italy
| | - Magda Savin
- European Association of Pharmaceutical Full-line Wholesalers, Brussels, Belgium
| | - Enrica Menditto
- CIRFF/Center of Pharmacoeconomics, School of Pharmacy, University of Naples FedericoII, Nápoles, Italy
| | - Elaine Lehane
- Catherine McAuley School of Nursing and Midwifery, Brookfield Health Sciences Complex, University College Cork, Cork, Ireland
| | - Olga Laosa
- Centro de Investigación Clínica del Anciano Fundación para la Investigación Biomédica, Hospital Universitario de Getafe, Madrid, Spain
| | - Sergio Pecorelli
- Italian Medicines Agency – AIFA, Rome, Italy
- University of Brescia, Brescia, Italy
| | | | - Alessandra Marengoni
- Department of Clinical and Experimental Science, University of Brescia, Brescia, Italy
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21
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Klop C, Welsing PMJ, Elders PJM, Overbeek JA, Souverein PC, Burden AM, van Onzenoort HAW, Leufkens HGM, Bijlsma JWJ, de Vries F. Long-term persistence with anti-osteoporosis drugs after fracture. Osteoporos Int 2015; 26:1831-40. [PMID: 25822104 PMCID: PMC4469296 DOI: 10.1007/s00198-015-3084-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Accepted: 02/19/2015] [Indexed: 11/07/2022]
Abstract
UNLABELLED Long-term persistence with anti-osteoporosis drugs and determinants for discontinuation among fracture patients were examined. Persistence was 75.0 and 45.3 % after 1 and 5 years, respectively. Those aged ≥80 years were at increased risk of early discontinuation. Within 1 year after discontinuation, 24.3 % restarted therapy, yet 47.0 % persisted for 1 year. INTRODUCTION The risk of osteoporotic fracture can effectively be reduced with use of anti-osteoporosis drugs. However, little is known about persistence with these drugs after fracture where subsequent fracture risk is high. The aims were to determine long-term persistence with anti-osteoporosis drugs among fracture patients, including its determinants, and to describe restart and subsequent persistence. METHODS A cohort study was conducted within the Dutch PHARMO Database Network. Patients aged ≥50 years (n = 961) who received anti-osteoporosis drugs within 1 year after fracture, but not in the preceding year, were included (2002-2011). Persistence (defined as the proportion on treatment) and the proportion restarting after discontinuation were estimated using Kaplan-Meier analyses. Time-dependent Cox regression was used to identify determinants of non-persistence including age, sex, initial dosage regime, fracture type, comorbidities, and drug use. RESULTS Persistence with anti-osteoporosis drugs was 75.0 % (95 % confidence interval (CI) 72.0-77.7) and 45.3 % (95 % CI 40.4-50.0) after 1 and 5 years, respectively. A significant determinant of non-persistence was age ≥80 years (reference 50-59 years: adjusted hazard ratio [adj. HR] 1.65; 95 % CI 1.15-2.38). This effect was not constant over time (≤360 days following initiation: adj. HR 2.07; 95 % CI 1.27-3.37; >360 days: adj. HR 1.08; 95 % CI 0.62-1.88). Within 1 year after discontinuation, 24.3 % (95 % CI 20.1-29.2) restarted therapy, yet 47.0 % persisted for 1 year. CONCLUSIONS This study identified suboptimal persistence with anti-osteoporosis drugs among fracture patients. Major target groups for measures aimed to improve persistence may be those aged >80 years and those restarting therapy.
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Affiliation(s)
- C Klop
- Utrecht Institute for Pharmaceutical Sciences, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, Netherlands
| | - P M J Welsing
- Department of Rheumatology and Clinical Immunology, University Medical Center, Utrecht, Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, Netherlands
| | - P J M Elders
- Department of General Practice and Elderly Care, VU University Medical Centre, Amsterdam, Netherlands
| | - J A Overbeek
- PHARMO Institute for Drug Outcomes Research, Utrecht, Netherlands
| | - P C Souverein
- Utrecht Institute for Pharmaceutical Sciences, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, Netherlands
| | - A M Burden
- Utrecht Institute for Pharmaceutical Sciences, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, Netherlands
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - H A W van Onzenoort
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre+, Maastricht, Netherlands
- Department of Pharmacy, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - H G M Leufkens
- Utrecht Institute for Pharmaceutical Sciences, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, Netherlands
| | - J W J Bijlsma
- Department of Rheumatology and Clinical Immunology, University Medical Center, Utrecht, Netherlands
| | - F de Vries
- Utrecht Institute for Pharmaceutical Sciences, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, Netherlands.
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre+, Maastricht, Netherlands.
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, Southampton, UK.
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