A systematic review of the barriers affecting medication adherence in patients with rheumatic diseases

Serial mediation of illness perception and beliefs about medicines in the relationship between patient satisfaction and medication adherence: An evaluation of self-regulatory model in rheumatoid arthritis and ankylosing spondylitis patients

This study examined the effect of patient satisfaction on medication adherence through serial mediation of Self Regulatory Model (SRM) components which are illness perception and beliefs about medicines in patients with rheumatoid arthritis (RA) and ankylosing spondylitis (AS). The 222 outpatients (nRA = 112; nAS = 110) were administered a sociodemographic form, the Medication Adherence Report Scale, the Brief Illness Perception Questionnaire, the Short Assessment of Patient Satisfaction, and the Beliefs about Medicines Questionnaire. The results showed that SRM components fully mediated the relationship between patient satisfaction and medication adherence. This proposed model had acceptable and better fit indices than the alternative model where patient satisfaction was introduced as a direct predictor. Furthermore, patient satisfaction, illness perception, and beliefs about medicines had an extremely good relationship, so these may be interpreted as variables of a latent construct of the illness experience which deserves further research in these group of patients.

A Web-Based Patient Empowerment to Medication Adherence Program for Patients With Rheumatoid Arthritis: Feasibility Randomized Controlled Trial

BACKGROUND

Living with a chronic illness such as rheumatoid arthritis (RA) requires medications and therapies, as well as long-term follow-up with multidisciplinary clinical teams. Patient involvement in the shared decision-making process on medication regimens is an important element in promoting medication adherence. Literature review and needs assessment showed the viability of technology-based interventions to equip patients with knowledge about chronic illness and competencies to improve their adherence to medications. Thus, a web-based intervention was developed to empower patients living with RA to adhere to their disease-modifying antirheumatic drugs (DMARDs) medication regimen.

OBJECTIVE

This study aims to discuss the intervention mapping process in the design of a web-based intervention that supports patient empowerment to medication adherence and to evaluate its feasibility among patients living with RA.

METHODS

The theory-based Patient Empowerment to Medication Adherence Programme (PE2MAP) for patients with RA was built upon the Zimmerman Psychological Empowerment framework, a web-based program launched through the Udemy website. PE2MAP was developed using a 6-step intervention mapping process: (1) needs assessment, (2) program objectives, (3) conceptual framework to guide the intervention, (4) program plan, (5) adoption, and (6) evaluation involving multidisciplinary health care professionals (HCPs) and a multimedia team. PE2MAP is designed as a 4-week web-based intervention program with a complementary RA handbook. A feasibility randomized controlled trial was completed on 30 participants from the intervention group who are actively taking DMARD medication for RA to test the acceptability and feasibility of the PE2MAP.

RESULTS

The mean age and disease duration of the 30 participants were 52.63 and 8.50 years, respectively. The feasibility data showed 87% (n=26) completed the 4-week web-based PE2MAP intervention, 57% (n=17) completed all 100% of the contents, and 27% (n=8) completed 96% to 74% of the contents, indicating the overall feasibility of the intervention. As a whole, 96% (n=24) of the participants found the information on managing the side effects of medications, keeping fit, managing flare-ups, and monitoring joint swelling/pain/stiffness as the most useful contents of the intervention. In addition, 88% (n=23) and 92% (n=24) agreed that the intervention improved their adherence to medications and management of their side effects, including confidence in communicating with their health care team, respectively. The dos and do nots of traditional Chinese medicine were found by 96% (n=25) to be useful. Goal setting was rated as the least useful skill by 6 (23.1%) of the participants.

CONCLUSIONS

The web-based PE2MAP intervention was found to be acceptable, feasible, and effective as a web-based tool to empower patients with RA to manage and adhere to their DMARD medications. Further well-designed randomized controlled trials are warranted to explore the effectiveness of this intervention in the management of patients with RA.

Assessment and Prediction of Adherence to Methotrexate Using Three Self-Report Questionnaires in Patients with Rheumatoid Arthritis

Introduction: Methotrexate (MTX) reduces rheumatoid arthritis activity and ameliorates the long-term functional status in these patients. To achieve this aim, patients need to take their medication regularly. Nevertheless, non-adherence to MTX still remains a considerable issue in the management of rheumatoid arthritis. Objective: This study aimed to estimate the adherence to methotrexate in patients with rheumatoid arthritis and to identify specific non-adherence risk factors. Methods: A cross-sectional study included 111 patients (mean age 56.2 ± 10.6 years, 78.4% female, and mean disease duration 6 years (3-13)). Three adherence self-assessment questionnaires were used: the Compliance-Questionnaire-Rheumatology (CQR19), the Medication Adherence Reports Scale (MARS-5), and the Visual Analogue Scale (VAS). We also collected demographic data, disease and treatment characteristics, and anxiety/depression estimation results (Hospital Anxiety and Depression Scale, HADS). Results: Adherence was identified in 48.6% of patients (COR19), 70.3% of patients (MARS-5), and 82.9% of patients (VAS questionnaire). All three questionnaires displayed a significant positive mutual correlation: CQR19 with MARS-5 and VAS (r = 0.364, r = 0.329, respectively, p < 0.001 for both) and between the VAS and MARS-5 scores (r = 0.496, p < 0.001). A significant positive prediction was shown for urban residence (0.347 (0.134-0.901), p = 0.030) using the MARS-5, female sex (0.264 (0.095-0.730), p = 0.010) according to the CQR19, and for a dose of methotrexate (0.881 (0.783-0.992), p = 0.036) using the VAS, while negative predictions were shown for comorbidity number (3.062 (1.057-8.874), p = 0.039) and depression (1.142 (1.010-1.293), p = 0.035) using the MARS-5 and for older age (1.041 (1.003-1.081), p = 0.034) according to the CQR19. The use of steroids was a significant positive predictor in all three questionnaires and remained an independent predictor for methotrexate adherence in the multivariate logistic regression. Conclusions: We showed non-adherence to methotrexate in a significant number of patients using all three questionnaires. Concomitant steroid therapy emerged as an independent positive predictor for adherence.

Development and validation of a nomogram model for medication non-adherence in patients with chronic kidney disease

OBJECTIVE

The high prevalence of medication non-adherence in patients with chronic kidney disease places a tremendous burden on healthcare resources. The study was designed to develop and validate a nomogram model of medication non-adherence in patients with chronic kidney disease in China.

METHODS

A multicenter cross-sectional study was conducted. 1206 chronic kidney disease patients were consecutively enrolled from Be Resilient to Chronic Kidney Disease (registration number: ChiCTR2200062288) between September 2021 and October 2022 in four tertiary hospitals in China. The Chinese version of four-item Morisky Medication Adherence Scale was used to assess the medication adherence of the patients and associated factors consisted of socio-demographic information, self-designed medication knowledge questionnaire, the 10-item Connor-Davidson Resilience Scale, the Beliefs about Medicine questionnaire, the Acceptance Illness Scale, and the Family Adaptation Partnership Growth and Resolve Index. Least Absolute Shrinkage and Selection Operator regression was performed to select significant factors. Concordance index, Hosmer-Lemeshow test and decision curve analysis were estimated.

RESULTS

The prevalence of medication non-adherence was 63.8%. Area under the curves ranged from 0.72 to 0.96 in internal and external validation sets. The predicted probabilities of the model were consistent with those of the actual observations by Hosmer-Lemeshow test (all P > .05). The final model included educational level, occupational status, duration of chronic kidney disease, medication beliefs (perceptions of the need to take medications and concerns about adverse effects), and illness acceptance (adaptation and acceptance of the disease).

CONCLUSIONS

There is a high prevalence of medication non-adherence among Chinese patients with chronic kidney disease. A nomogram model based on five factors has been successfully developed and validated and could be incorporated into long-term medication management.

Treat-to-target in rheumatoid arthritis: a real-world study of the application and impact of treat-to-target within the wider context of patient management, patient centricity and advanced therapy use in Europe

BACKGROUND

While treat-to-target (T2T) is endorsed for the management of rheumatoid arthritis (RA), data on the degree of implementation in clinical practice are limited. This study investigated the use of T2T for RA in a real-world setting across Europe.

METHODS

The Adelphi RA Disease-Specific Programme was a point-in-time survey of rheumatologists and their consulting patients with RA conducted between January and October 2020 in Belgium, France, Germany, Italy, Spain and the UK. Rheumatologists completed an attitudinal survey, and a record form for their next 10-12 consulting patients, who were invited to voluntarily complete a patient-reported questionnaire. Data collected included clinical characteristics, treatment patterns and attitudes towards T2T.

RESULTS

Overall, 316 rheumatologists provided data for 3120 patients, of whom 1108 completed the questionnaire. While 86.1% of rheumatologists estimated using T2T principles in clinical practice, only 66.6% of patients were reported by their physician to be managed using a T2T approach. Achieving disease remission was the most commonly reported treatment goal identified by rheumatologists (79.7%), followed by symptom control (47.8%) and reducing impact on quality of life (44.5%). 40.8% of rheumatologists and their patients were in agreement that a treatment goal had been set. When there was agreement on treatment goals, we observed better patient satisfaction, engagement and treatment success.

CONCLUSIONS

Despite recommendations, the T2T approach in RA appears to be suboptimally implemented in clinical practice. This highlights the importance of patient-centricity in the decision-making process to define meaningful targets and select appropriate treatments to improve disease outcomes.

“Medicines is all that I can sometimes offer them”: challenges of providing primary diabetes care to persons with disabilities in Tamil Nadu

Background

Persons with disabilities have a higher risk for and poorer outcomes of type 2 diabetes. Primary health care providers face several challenges in providing primary diabetes care for them. This study was conducted to explore the challenges faced by primary health care providers in delivering primary diabetes services to persons with disabilities.

Methods

We performed a qualitative research study by conducting in-depth interviews among 13 primary health care providers including medical officers, staff nurses, community health workers and a physiotherapist. We adopted a descriptive qualitative research approach to data collection and analysis.

Results

Primary health care providers often could only prescribe medications to persons with diabetes by proxy due to poor accessibility of the facilities. They felt that these patients also had poor compliance to treatment. They felt that the lack of standard guidelines for diet and exercise for persons with disabilities prevented them from giving them appropriate advice on the same and even if they did, persons with disabilities would find it very difficult to adopt dietary changes and physical activity as they were dependent on others for even their daily activities. They also felt that they couldn’t perform annual screening tests due to lack of accessibility to higher facilities. Some primary care providers did local innovations such as formation of peer support groups, utilization of resources of other programs to reach out to persons with disabilities and innovative physical activity techniques to care for persons with disabilities. They recommended that there is a need for specific guidelines for management of diabetes among persons with disabilities, treatment of chronic diseases among persons with disabilities must be incentivized and there must be intersectoral coordination between social welfare department and health department to achieve the goal of care for persons with disabilities.

Conclusions

Primary health care providers faced substantial challenges in providing primary diabetes care for persons with disabilities. There is a need for an effective public health policy to address these challenges.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08246-1.

Patient-reported adherence to physical exercises of patients with ankylosing spondylitis

Introduction

Studies on adherence to exercise therapy of patients with ankylosing spondylitis (AS) are rare, and the criteria for adherence to exercise are inconsistent. This study aimed to quantify patient-reported adherence to exercise therapy of Chinese outpatients with AS and investigate the factors related to poor adherence.

Methods

The subjects’ sociodemographic, disease-related, radiographic, and laboratory parameters were collected. Patients’ adherence to exercise therapy was assessed using the Exercise Attitude Questionnaire (EAQ) with a 4-point Likert scale. All cases were grouped as good adherence and poor adherence using a cutoff score of 60, according to a previous study. Univariate analysis was conducted to assess the intergroup differences. Then, we built a multivariate logistic regression model to identify possible significant factors related to poor adherence to exercise therapy.

Results

A total of 185 outpatients completed the questionnaire. The mean EAQ score was 49.4 (IQR, 40.7–59.3) and 146 patients (78.9%) were considered to have poor adherence, and 39 patients (21.1%) were considered to have good adherence. The rates of current nonsteroidal anti-inflammatory drugs (NSAIDs), conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), and tumor necrosis factor-α inhibitor (TNF-i) use were significantly higher in the poor adherence group (p=0.001, p=0.027, p=0.018, respectively). Our multivariate logistic regression model revealed that the only significant associated factor was current use of NSAIDs (OR=3.517; p=0.016; 95% CI, 1.259–9.827).

Conclusions

Outpatients with AS had an unacceptable level of adherence to exercise therapy, and current use of NSAIDs was a significantly associated factor.

Key Points • Outpatients with AS had an unacceptable level of adherence to exercise therapy. • Current use of NSAIDs exerted a negative impact on patients’ adherence to exercise therapy.

An Overview on Causes of Nonadherence in the Treatment of Rheumatoid Arthritis: Its Effect on Mortality and Ways to Improve Adherence

Rheumatoid arthritis is one of the most prevalent musculoskeletal disorders that, when insufficiently treated, results in detrimental sequelae including joint damage and reduced quality of life. Poor patient adherence to medication is a significant blockade to effective management. The purpose of this review is to highlight and discuss the factors responsible for defiance of antirheumatic medication and ways to overcome these barriers. Education level, health literacy, cohabitation status, multi-morbidities, complicated drug regimen, intermittent co-payments, prescribed regimen adverse effects, and cognitive impairment are a few among many common barrier factors leading to poorer outcomes in rheumatoid arthritis. While there is an abundance of inhibitory factors leading to worsening disease progression, they each can be easily dealt with an effective approach at the beginning or during the treatment course to ensure a better outcome.

Radiographic changes in the temporomandibular joint related to medication in rheumatic diseases

OBJECTIVES

The purpose of this study was to assess radiographical changes on temporomandibular joint (TMJ) in relation the autoimmune rheumatic diseases and the medicines that treat this diseases with cone beam computed tomography(CBCT).

METHODS

65 people with rheumatoid diseases were included in the study and divided into five subgroups according to drugs they used. Condyle height (CH), anteroposterior dimension (APD), mesiolateral dimension (MLD) and superior joint space (SJS) were measured in order to evaluate mandibular condyle dimensions. Further, were evaluated in terms of osteoarthritic changes such as erosion, flattening, osteophyte and subchondral cyst in the mandibular condyle. TMJ measurements were compared between study-control groups and subgroups by using Student's t-test, Mann-Whitney-U test, one-way analysis of variance (ANOVA) and Kruskal-Wallis test. The association between osteoarthritic features, rheumatoid status was tested by using χ2 test. Observers were blinded to all groups. Cohen κ values (0853-0945) and Spearman's correlation coefficient (0.959-0.997) indicated high interexaminer reliability.

RESULTS

Condylar dimentions were significantly lower in CH and SJS in rheumatic diseases group (p < 0.001), however APD (p = 0,681) and MLD (p = 0,757) was not different significantly. Osteoarthritic changes such as erosion (p < 0.001), flattening (p = 0.005), osteophyte (p = 0.001) and subchondral cyst (p = 0.001) were significantly higher in the patient group. None of the parameters were different significantly according to subgroups determined according to drugs used(p > 0.05).

CONCLUSIONS

Degenerative changes may cause decrease in condyle size and changes in condyle position. It is a process that can continue despite the use of antirheumatic or immunosuppressive drugs. All of these can become the source of possible TMJ problems.

An Adaptable Framework for Factors Contributing to Medication Adherence: Results from a Systematic Review of 102 Conceptual Frameworks

OBJECTIVE

To summarize the available conceptual models for factors contributing to medication adherence based on the World Health Organization (WHO)'s five dimensions of medication adherence via a systematic review, identify the patient groups described in available conceptual models, and present an adaptable conceptual model that describes the factors contributing to medication adherence in the identified patient groups.

METHODS

We searched PubMed®, Embase®, CINAHL®, and PsycINFO® for English language articles published from inception until 31 March 2020. Full-text original publications in English that presented theoretical or conceptual models for factors contributing to medication adherence were included. Studies that presented statistical models were excluded. Two authors independently extracted the data.

RESULTS

We identified 102 conceptual models, and classified the factors contributing to medication adherence using the WHO's five dimensions of medication adherence, namely patient-related, medication-related, condition-related, healthcare system/healthcare provider-related, and socioeconomic factors. Eight patient groups were identified based on age and disease condition. The most universally addressed factors were patient-related factors. Medication-related, condition-related, healthcare system-related, and socioeconomic factors were represented to various extents depending on the patient group. By systematically examining how the WHO's five dimensions of medication adherence were applied differently across the eight different patient groups, we present a conceptual model that can be adapted to summarize the common factors contributing to medication adherence in different patient groups.

CONCLUSION

Our conceptual models can be utilized as a guide for clinicians and researchers in identifying the facilitators and barriers to medication adherence and developing future interventions to improve medication adherence.

PROTOCOL REGISTRATION

PROSPERO Identifier: CRD42020181316.

Electronic Monitoring Feedback for Improving Medication Adherence and Clinical Outcomes in Early Rheumatoid Arthritis: A Randomized Clinical Trial

BACKGROUND

Non-adherence to medication (range 30-107%) is a major issue in patients with rheumatoid arthritis (RA). Previous research has shown that electronic monitoring feedback (EMF) might be an effective strategy to improve medication adherence in chronic conditions. Therefore, this study investigated the effectiveness of electronic monitoring feedback in patients with early RA to improve medication adherence and clinical outcomes compared to usual care.

METHODS

An open-label randomized clinical trial was performed to compare EMF with standard care during a 12-month follow-up period on two sites of the Sint Maartenskliniek (Nijmegen and Boxmeer) in the Netherlands. Patients were eligible if they: (1) had a (working) diagnosis of early RA, (2) were currently using methotrexate, (3) were aged ≥18 years, and (4) had a life expectancy of ≥12 months. Primary outcome was the difference in proportion of non-adherent patients measured with the Compliance Questionnaire on Rheumatology after 12 months. Secondary outcomes were beliefs about medicines, medication adherence measured with the MMAS-8®, patients' health status, prescription of biologic DMARDs, and disease activity after 12 months.

RESULTS

Of the 367 initially-invited patients, 93 patients with early RA agreed to participate in this study. No significant difference was found in the proportion of non-adherent patients between the intervention arm and the usual care arm after 12 months follow-up (60.0% and 61.3%, p=0.93, respectively). Patients in the intervention arm tended to discontinue methotrexate earlier than patients in the usual care arm (median time in weeks: 15.7 (9.1-33.6) and 21.9 (19-28.4), respectively, p=0.31), whereas patients in the usual care arm tended to initiate biologic DMARDs earlier than those in the intervention arm (median time in weeks: 11.9 (5.7-22) and 17 (9.9-40.9), respectively, p=0.55).

CONCLUSION

This study illustrates the challenge of targeting non-adherence with EMF in patients with early RA and shares important lessons learned about designing adherence intervention trials with respect to study attrition, accounting for drug survival, intervention fidelity, intervention uptake, and technical aspects.

Assessment of impact of the COVID-19 pandemic from the perspective of patients with rheumatic and musculoskeletal diseases in Europe: results from the REUMAVID study (phase 1)

Aim

To assess the impact of the COVID-19 pandemic on patients with rheumatic and musculoskeletal diseases (RMDs).

Methods

REUMAVID is a cross-sectional study using an online survey developed by an international multidisciplinary patient-led collaboration across seven European countries targeting unselected patients with RMDs. Healthcare access, daily activities, disease activity and function, well-being (WHO Five Well-Being Index (WHO-5)), health status, anxiety/depression (Hospital Anxiety and Depression Scale (HADS)) and access to information were evaluated. Data were collected in April–July 2020 (first phase).

Results

Data from the first phase included 1800 patients with 15 different RMDs (37.2% axial spondyloarthritis, 29.2% rheumatoid arthritis, 17.2% osteoarthritis and others). Mean age was 53, 80% female and 49% had undertaken university studies. During the beginning of the pandemic, 58.4% had their rheumatology appointment cancelled and 45.6% reported not having received any information relating to the possible impact of SARS-CoV-2 infection in their RMDs, with the main source being patient organisations (27.6%).

Regarding habits, 24.6% increased smoking, 18.2% raised their alcohol consumption, and 45.6% were unable to continue exercising. Self-reported disease activity was high (5.3±2.7) and 75.6% reported elevated pain. Half the patients (49.0%) reported poor well-being (WHO-5) and 46.6% that their health had changed for the worse during lockdown. According to HADS, 57.3% were at risk of anxiety and 45.9% of depression.

Conclusion

Throughout the first wave of the COVID-19 pandemic, patients with RMDs have experienced disruption in access to healthcare services, poor lifestyle habits and negative effects on their overall health, well-being and mental health. Furthermore, information on COVID-19 has not reached patients appropriately.

Medication Management Frameworks in the Context of Self-Management: A Scoping Review

PURPOSE

Many individuals take multiple prescribed and unprescribed medications, also known as polypharmacy, which can be problematic. Improving medication self-management is important; however, most medication management frameworks focus on adherence and limit the integration of the core components of self-management. Therefore, the objective of this scoping review was to identify what is reported in the literature on medication management frameworks or models within the context of self-management.

METHODS

Electronic databases (Medline, Embase, CINAHL and Cochrane Library) and grey literature (healthcare and government organization websites) were searched for articles that described a framework or model developed or adapted for medication management, included components of self-management and was published from January 2000 to January 2020. During the screening of titles and abstracts, 5668 articles were reviewed, 5242 were excluded and 426 were then assessed at the full-text level. Thirty-nine articles met the eligibility criteria and were included in the review.

RESULTS

About half of the frameworks were newly developed (n=20), while the other half were adapted from, or applied, a previous model or framework (n=19). The majority of frameworks focused on medication adherence and most of the self-management domains were categorized as medical management, followed by emotional and role management.

CONCLUSION

Medication self-management is a complex process and often impacts multiple areas of an individual's life. It is important for future frameworks to incorporate a comprehensive, holistic conceptualization of self-management that is inclusive of the three self-management domains - medical, emotional and role management.

Barriers, facilitators, and interventions for medication adherence across chronic conditions with the highest non-adherence rates: a scoping review with recommendations for intervention development

Medication non-adherence (MNA) constitutes a complex health problem contributing to increased economic burden and poor health outcomes. The Medication Adherence Model (MAM) supports that numerous processes are involved in medication adherence (MA). Based on the MAM and guidelines of the World Health Organization (WHO), this scoping review aimed to identify the barriers and facilitators associated with MA, and the behavioral health interventions and techniques among chronic conditions presenting with high non-adherence rates (asthma, cancer, diabetes, epilepsy, HIV/AIDS, and hypertension). PubMed, PsycINFO, and Scopus databases were screened, and 243 studies were included. A mixed methods approach was used to collate the evidence and interpret findings. The most commonly reported barriers to MA across conditions were younger age, low education, low income, high medication cost, side effects, patient beliefs/perceptions, comorbidities, and poor patient-provider communication. Additionally, digitally delivered interventions including components such as medication and condition education, motivational interviewing (MI), and reinforcement and motivational messages led to improvements in MA. This review highlights the importance of administrating multicomponent interventions digitally and personalized to the patients' individual needs and characteristics, responding to the adherence barriers faced. This is the first review examining and synthesizing evidence on barriers and facilitators to MA and behavioral health interventions used for improving MA across chronic conditions with the highest non-adherence rates and providing recommendations to researchers and clinicians. Stakeholders are called to explore methods overcoming barriers identified and developing effective multicomponent interventions that can reduce the high rates of MNA.

Prevention, screening, assessing and managing of non-adherent behaviour in people with rheumatic and musculoskeletal diseases: systematic reviews informing the 2020 EULAR points to consider

OBJECTIVE

To analyse how non-adherence to prescribed treatments might be prevented, screened, assessed and managed in people with rheumatic and musculoskeletal diseases (RMDs).

METHODS

An overview of systematic reviews (SR) was performed in four bibliographic databases. Research questions focused on: (1) effective interventions or strategies, (2) associated factors, (3) impact of shared decision making and effective communication, (4) practical things to prevent non-adherence, (5) effect of non-adherence on outcome, (6) screening and assessment tools and (7) responsible healthcare providers. The methodological quality of the reviews was assessed using AMSTAR-2. The qualitative synthesis focused on results and on the level of evidence attained from the studies included in the reviews.

RESULTS

After reviewing 9908 titles, the overview included 38 SR on medication, 29 on non-pharmacological interventions and 28 on assessment. Content and quality of the included SR was very heterogeneous. The number of factors that may influence adherence exceed 700. Among 53 intervention studies, 54.7% showed a small statistically significant effect on adherence, and all three multicomponent interventions, including different modes of patient education and delivered by a variety of healthcare providers, showed a positive result in adherence to medication. No single assessment provided a comprehensive measure of adherence to either medication or exercise.

CONCLUSIONS

The results underscore the complexity of non-adherence, its changing pattern and dependence on multi-level factors, the need to involve all stakeholders in all steps, the absence of a gold standard for screening and the requirement of multi-component interventions to manage it.

Differential Diagnoses and Clinical Implications of Medication Nonadherence in Older Patients with Chronic Kidney Disease: A Review

Older adults with chronic kidney disease (CKD) often have many comorbidities, which requires them to take multiple medications. As the number of daily medications prescribed increases, the risk for polypharmacy increases. Understanding and improving medication adherence in this patient population is vital to avoiding the drug-related adverse events of polypharmacy. The primary objective of this review is to summarize the existing literature and to understand the factors leading to medication nonadherence in older patients with CKD. In this review, we discuss the prevalence of polypharmacy, the current lack of consensus on the incidence of medication nonadherence, the heterogeneity of assessing medication adherence, and the most common differential diagnoses for medication nonadherence in this population. Specifically, the most common differential diagnoses for medication nonadherence in older adults with CKD are (1) medication complexity; (2) cognitive impairment; (3) low health literacy; and (4) systems-based barriers. We provide tailored strategies to address these differential diagnoses and subsequently improve medication adherence. The clinical implications include deprescribing to decrease medication complexity and polypharmacy, utilizing a team-based approach to identify and support patients with cognitive impairment, enriching communication between health providers and patients with low health literacy, and improving health care access to address systems-based barriers. Further research is needed to determine the effects of addressing these differential diagnoses and medication adherence in older adults with CKD.

Development of an Item Bank to Measure Medication Adherence: Systematic Review

Background

Medication adherence is important in managing the progression of chronic diseases. A promising approach to reduce cognitive burden when measuring medication adherence lies in the use of computer‐adaptive tests (CATs) or in the development of shorter patient-reported outcome measures (PROMs). However, the lack of an item bank currently hampers this progress.

Objective

We aim to develop an item bank to measure general medication adherence.

Methods

Using the preferred reporting items for systematic review and meta-analysis (PRISMA), articles published before October 2019 were retrieved from PubMed, Embase, CINAHL, the Cochrane Library, and Web of Science. Items from existing PROMs were classified and selected (“binned” and “winnowed”) according to standards published by the Patient-Reported Outcomes Measurement Information System (PROMIS) Cooperative Group.

Results

A total of 126 unique PROMs were identified from 213 studies in 48 countries. Items from the literature review (47 PROMs with 579 items for which permission has been obtained) underwent binning and winnowing. This resulted in 421 candidate items (77 extent of adherence and 344 reasons for adherence).

Conclusions

We developed an item bank for measuring general medication adherence using items from validated PROMs. This will allow researchers to create new PROMs from selected items and provide the foundation to develop CATs.

Self-reported medication adherence in differentiated thyroid cancer survivors: Role of illness perception and medication beliefs

BACKGROUND

To investigate medication adherence (MA) to Levothyroxine in differentiated thyroid cancer survivors and analyze the related factors for nonadherence.

METHODS

The Medication Adherence Report Scale (MARS), Hospital Anxiety and Depression Scale (HAD), Brief Illness Perception Questionnaire (B-IPQ), and Beliefs about Medicines Questionnaire (BMQ) were used to assess MA.

RESULTS

Nonadherence was reported in 77 of 197 patients (39.1%). Socioeconomic status and education levels were found to be significantly related to MA. The HAD scores, all items of B-IPQ, and BMQ were associated with MA and showed a correlation with the MARS scores. The primary predictors of MA were greater confidence in treatment modality (odds ratio [OR]: 0.48, 95% confidence interval (CI): 0.37-0.63) and greater belief that the medication had minimal risk of harm (OR: 3.35, 95% CI: 1.50-7.49).

CONCLUSIONS

Special attention should be paid to educational programs for differentiated thyroid carcinoma patients concerning the effectiveness and low risk of harm of medication in order to improve MA.

Factors affecting medication adherence among pre-dialysis chronic kidney disease patients: a systematic review and meta-analysis of literature

BACKGROUND

Medication adherence plays an essential role in slowing the progression of chronic kidney disease (CKD). This review aims to summarise factors affecting medication adherence among these pre-dialysis CKD patients.

METHODS

A systematic review of the literature was performed in Medline®, Embase®, SCOPUS® and CINAHL®. Peer-reviewed, English language articles which evaluated factors associated with medication adherence among pre-dialysis CKD patients were included. Meta-analysis was performed to assess the pooled medication adherence rates across studies. Factors identified were categorised using the World Health Organization's five dimensions of medication adherence (condition, patient, therapy, health-system, and socio-economic domains).

RESULTS

Of the 3727 articles reviewed, 18 articles were included. The pooled adherence rate across studies was 67.4% (95% CI 61.4-73.3%). The most studied medication class was anti-hypertensives (55.6%). A total of 19 factors and 95 sub-factors related to medication adherence were identified. Among condition-related factors, advanced CKD was associated with poorer medication adherence. Patient-related factors that were associated with lower medication adherence included misconceptions about medication and lack of perceived self-efficacy in medication use. Therapy-related factors which were associated with poorer medication adherence included polypharmacy while health system-based factors included loss of confidence in the physician. Socioeconomic factors such as poor social support and lower education levels were associated with poorer medication adherence.

CONCLUSION

Factors associated with poor medication adherence among pre-dialysis CKD patients were highlighted in this review. This will aid clinicians in designing interventions to optimise medication adherence among pre-dialysis CKD patients.

Which Matters More for Medication Adherence Among Disabled People in Shanghai, China: Family Support or Primary Health Care?

Most disabled people have poor health status. They often have multiple diseases requiring continual medication. This study aimed to explore the factors associated with medication adherence among disabled people, with a particular focus on the factors associated with family and primary health care support. A questionnaire survey was conducted among 226 disabled individuals. The analysis was performed using an ordered logistic regression model, including 4 categories of predictor variables. We found that the community health service center played a positive role in improving medication adherence, whereas the role played by the participant’s family was more complicated. Specifically, those obtaining a brochure were more likely to have higher medication adherence (odds ratio [OR] = 2.732, 95% confidence interval [CI] = 1.349-5.532). Compared with those who were married, widowed participants (OR = 0.207, 95% CI = 0.069-0.620) and divorced participants (OR = 0.330, 95% CI = 0.057-1.914) had lower odds of having greater adherence, whereas the odds of having greater adherence for single participants were 1.679 times the same odds for married participants (OR = 1.679, 95% CI = 0.668-4.224). The odds of having greater medication adherence for participants receiving help with prescriptions from a family member were almost 60% lower than these odds for those who did not receive this kind of help (OR = 0.460, 95% CI = 0.216-0.979). Thus, the role played by participants’ family members was both protective and damaging, whereas the role of the community health service center was clearer. These findings merit further exploration.

Self-Reported Medication Adherence in Patients With Ankylosing Spondylitis: The Role of Illness Perception and Medication Beliefs

Objectives

This study aims to investigate medication adherence in Turkish patients with ankylosing spondylitis (AS) and analyze the related factors for non-adherence.

Patients and methods

Ninety-nine patients with AS (60 males, 39 females; mean age 41.3±8.4 years; range, 18 to 66 years) were included in the study. Sociodemographic and clinical data were collected. Disease activity (Bath Ankylosing Spondylitis Disease Activity Index, C-reactive protein, and erythrocyte sedimentation rate), functional status (Bath Ankylosing Spondylitis Functional Index), spinal pain and fatigue (visual analog scale), quality of life (Ankylosing Spondylitis Quality of Life), and depression and anxiety (Hospital Anxiety and Depression Scale) were evaluated. Adherence to anti-rheumatic drugs was elicited using the Compliance Questionnaire on Rheumatology (CQR). Medication beliefs were assessed using the Beliefs about Medicines Questionnaire (BMQ), and illness perception using the Brief Illness Perception Questionnaire (B-IPQ).

Results

Non-adherence was reported in 64 patients (64.6%). No significant relationship between demographic, clinical, or psychological factors and adherence was found, except for disease duration (p=0.031). High B-IPQ treatment follow-up, illness coherence, and BMQ-Specific necessity scores were associated with good adherence (p=0.007, p=0.039, and p=0.002, respectively). BMQ-General overuse and harm scores showed an inverse correlation with the CQR score (p=0.005 r=-0.278; p=0.029 r=-0.219, respectively). Longer disease duration [odds ratio (OR): 0.98, 95% confidence interval (CI): 0.97-0.99] and higher B-IPQ item-1 score regarding the effect of the illness on the individual's life (OR: 0.58, 95% CI: 0.42- 0.81) were important predictors of low adherence.

Conclusion

Nearly three out of five AS patients were identified as at risk for non-adherence with the CQR. Medication adherence is influenced by the patient’s beliefs about medicines and illness perceptions, and these may be key targets for future interventions to improve medication adherence.

Qualitative Exploration of Triangulated, Shared Decision-Making in Rheumatoid Arthritis

OBJECTIVE

Treat-to-target implementation in rheumatoid arthritis (RA) requires a shared decision-making (SDM) process. However, ability to pay is a major determinant of patient choice, but how this factor affects SDM is under-explored.

METHODS

Visits at 4 RA clinics during which patients faced a decision to change their treatment were audiotaped between May 2016 and June 2017. Audiotapes were transcribed verbatim and analyzed using qualitative framework analysis.

RESULTS

A total of 156 visits were analyzed. Most patients with RA, except those with effective insurance coverage, had deliberations disrupted or sidelined by third-party insurance providers having power to authorize the preferred disease-modifying antirheumatic drug choice. This triangulated SDM complicated efficiency in deliberations and timely treatment and was a barrier to shared engagement about health risks and symptom improvement typically found in patient-provider dyads.

CONCLUSION

Rheumatology care providers should aim to incorporate treatment costs and ability to pay into their deliberations so that individualized out-of-pocket estimates can be considered during triangulated SDM at the point-of-care.