Predictors of medication adherence: fact or artifact

Psychosocial characteristics are associated with adherence to dietary, drugs and physical activity recommendations amongst cardiovascular disease patients in Lebanon

Cardiovascular diseases are increasing at an alarming rate worldwide, reaching epidemic proportions in countries of the Eastern Mediterranean Region, including Lebanon. Despite the growing number of patients suffering from cardiovascular diseases in Lebanon, there is scarce data on whether cardiac patients adhere to therapeutic dietary guidelines, drug prescriptions, and physical activity recommendations and whether such adherence differs according to sociodemographic, lifestyle, or psychosocial characteristics. A cross-sectional study was conducted among 367 Lebanese adult cardiovascular disease patients admitted for hospitalization at various hospital sites in Lebanon. Electronic medical records and a multi-component questionnaire were used to collect information on patients' characteristics. Dietary assessment was performed using a culture-specific validated food frequency questionnaire, and physical activity levels were assessed using the international physical activity questionnaire (IPAQ). Mental well-being was assessed based on the validated five-item well-being index (WHO-5), and drug adherence was evaluated using the Morisky medication adherence scale (MMAS-8). The majority of the patients were males (67.8%), overweight or obese (74%), smokers (62.1%), and unemployed or retired (54.5%). Almost 35% of the patients were lonely, and nearly one fourth were at a high risk of poor mental health. Approximately 43%, 70%, and 52% of the patients were found to have poor adherence to diet, drug, and physical activity recommendations, respectively. A lower sense of mental well-being was a significant predictor of low dietary and drug adherence. Surprisingly, overweight and obesity were associated with higher odds of dietary adherence. Male gender was positively associated with physical activity while loneliness was inversely associated with physical activity. This study showed that adherence to diet, drug, and physical activity recommendations was low in this patient population and identified several non-clinical characteristics that may affect adherence. These findings highlighted the need for considering patients' psychosocial characteristics in the treatment of patients with cardiovascular diseases.

A Comparison of Adherence and CD4 Cell Count with Respect to Virologic Failure Among HIV-Infected Adults Under Combination Antiretroviral Therapy (cART) at Felege Hiwot Teaching and Specialized Hospital, Bahir Dar, Ethiopia

Background

Medication adherence plays a significant in the success of combination antiretroviral therapy (cART). Therefore, the current investigation was conducted with the objective of comparing adherence and CD4 cell count with respect to virologic failure among HIV-infected adults under cART.

Methods

A retrospective study design was conducted on 792 randomly selected HIV-infected adult patients who initiated first-line cART enrolled in the first 10 months of 2012 and followed up to August 2018 by using a simple random sampling technique based on their identification number.

Results

The main outcome for the current investigation was the virologic failure which was decreased with successive visits. The area under the receiver operating characteristic curve for adherence and CD4 cell count change were 0.68 and 0.63 with χ² = 21.2; p-value <0.001 for the 12-month assessment. Similarly, these areas for the 36th and 60th month assessments were 0.71 and 0.66, with χ² = 23.2; p-value <0.001, and 0.73 and 0.71 with χ² = 24.3; p-value <0.001 for adherence and CD4 cell count, respectively.

Conclusion

Pill count adherence was more accurate compared to CD4 cell count change for assessing virologic responses. Therefore, because of its easy access, simple use, cost-effectiveness, and accuracy, the adherence to cART was in favor of CD4 cell count change for monitoring the healthcare quality of HIV-infected patients.

Electronic monitoring of adherence to once-daily and twice-daily direct oral anticoagulants in patients with atrial fibrillation: Baseline data from the SMAAP-AF trial

BACKGROUND

Nonadherence diminishes the efficacy of direct oral anticoagulants (DOACs) in patients with nonvalvular atrial fibrillation (NVAF). This report presents the baseline survey results regarding medication adherence among NVAF patients who were treated with once-daily edoxaban or twice-daily apixaban from a randomized control trial of the effect of an educational intervention on DOAC adherence.

METHODS

We prospectively studied 301 NVAF patients who were treated with edoxaban (n = 175) or apixaban (n = 126) during the 12-week observation period. Adherence was measured with an electronic monitoring system and is expressed as the percentage of days with the correct doses in the measurement period (days). Adherence to DOAC therapy was defined based on the standard threshold (≥80%) or a strict threshold (≥90%).

RESULTS

Of the 301 patients, 33 had incomplete data or protocol deviations, leaving 268 patients (edoxaban 158 and apixaban 110) for the per-protocol baseline analysis. There was no difference in adherence (threshold ≥80%) between the groups (edoxaban 95% vs apixaban 91%, P = .2), but there was a lower proportion of patients with strict adherence (threshold ≥90%) among apixaban users than among edoxaban users (edoxaban 87% vs apixaban 76%, P = .02). Multivariate analysis showed a negative relationship between apixaban use and an adherence rate ≥90% (odds ratio 0.49, 95% confidence interval [CI]: 0.25-0.94).

CONCLUSIONS

Our study showed that the proportion of DOAC users with adherence (≥80%) did not differ between the groups, but the proportion of patients with strict adherence (≥90%) was lower among those using apixaban than among those using edoxaban.

TEOS: A framework for constructing operational definitions of medication adherence based on Timelines-Events-Objectives-Sources

AIMS

Managing adherence to medications is a priority for health systems worldwide. Adherence research is accumulating, yet the quality of the evidence is reduced by various methodological limitations. In particular, the heterogeneity and low accuracy of adherence measures have been highlighted in many literature reviews. Recent consensus-based guidelines advise on best practices in defining adherence (ABC) and reporting of empirical studies (EMERGE). While these guidelines highlight the importance of operational definitions in adherence measurement, such definitions are rarely included in study reports. To support researchers in their measurement decisions, we developed a structured approach to formulate operational definitions of adherence.

METHODS

A group of adherence and research methodology experts used theoretical, methodological and practical considerations to examine the process of applying adherence definitions to various research settings, questions and data sources. Consensus was reached through iterative review of discussion summaries and framework versions.

RESULTS

We introduce TEOS, a four-component framework to guide the operationalization of adherence concepts: (1) describe treatment as four simultaneous interdependent timelines (recommended and actual use, conditional on prescribing and dispensing); (2) locate four key events along these timelines to delimit the three ABC phases (first and last recommended use, first and last actual use); (3) revisit study objectives and design to fine-tune research questions and assess measurement validity and reliability needs, and (4) select data sources (e.g., electronic monitoring, self-report, electronic healthcare databases) that best address measurement needs.

CONCLUSION

Using the TEOS framework when designing research and reporting explicitly on these components can improve measurement quality.

The Feasibility of a Using a Smart Button Mobile Health System to Self-Track Medication Adherence and Deliver Tailored Short Message Service Text Message Feedback

BACKGROUND

As many as 50% of people experience medication nonadherence, yet studies for detecting nonadherence and delivering real-time interventions to improve adherence are lacking. Mobile health (mHealth) technologies show promise to track and support medication adherence.

OBJECTIVE

The study aimed to evaluate the feasibility and acceptability of using an mHealth system for medication adherence tracking and intervention delivery. The mHealth system comprises a smart button device to self-track medication taking, a companion smartphone app, a computer algorithm used to determine adherence and then deliver a standard or tailored SMS (short message service) text message on the basis of timing of medication taking. Standard SMS text messages indicated that the smartphone app registered the button press, whereas tailored SMS text messages encouraged habit formation and systems thinking on the basis of the timing the medications were taken.

METHODS

A convenience sample of 5 adults with chronic kidney disease (CKD), who were prescribed antihypertensive medication, participated in a 52-day longitudinal study. The study was conducted in 3 phases, with a standard SMS text message sent in phases 1 (study days 1-14) and 3 (study days 46-52) and tailored SMS text messages sent during phase 2 (study days 15-45) in response to participant medication self-tracking. Medication adherence was measured using: (1) the smart button and (2) electronic medication monitoring caps. Concordance between these 2 methods was evaluated using percentage of measurements made on the same day and occurring within ±5 min of one another. Acceptability was evaluated using qualitative feedback from participants.

RESULTS

A total of 5 patients with CKD, stages 1-4, were enrolled in the study, with the majority being men (60%), white (80%), and Hispanic/Latino (40%) of middle age (52.6 years, SD 22.49; range 20-70). The mHealth system was successfully initiated in the clinic setting for all enrolled participants. Of the expected 260 data points, 36.5% (n=95) were recorded with the smart button and 76.2% (n=198) with electronic monitoring. Concordant events (n=94), in which events were recorded with both the smart button and electronic monitoring, occurred 47% of the time and 58% of these events occurred within ±5 min of one another. Participant comments suggested SMS text messages were encouraging.

CONCLUSIONS

It was feasible to recruit participants in the clinic setting for an mHealth study, and our system was successfully initiated for all enrolled participants. The smart button is an innovative way to self-report adherence data, including date and timing of medication taking, which were not previously available from measures that rely on recall of adherence. Although the selected smart button had poor concordance with electronic monitoring caps, participants were willing to use it to self-track medication adherence, and they found the mHealth system acceptable to use in most cases.

Adherence to Pharmacological Smoking Cessation Interventions: A Literature Review and Synthesis of Correlates and Barriers

Introduction

Efficacious pharmacological interventions for smoking cessation are available, but poor adherence to these treatments may limit these interventions overall impact. To improve adherence to smoking cessation interventions, it is first necessary to identify and understand smoker-level characteristics that drive nonadherence (ie, nonconformance with a provider's recommendation of timing, dosage, or frequency of medication-taking during the prescribed length of time).

Methods

We present a literature review of studies examining correlates of, or self-reported reasons for, nonadherence to smoking cessation pharmacotherapies. Studies were identified through PubMed-using MeSH terms, Embase-using Emtree terms, and ISI Web of Science.

Results and Conclusions

This literature review included 50 studies that examined nonpreventable (eg, sociodemographics) and preventable (eg, forgetfulness) factors associated with adherence to smoking cessation medication and suggestions for overcoming some of the identified barriers. Systematic study of this topic would be facilitated by consistent reporting of adherence and correlates thereof in the literature, development of consistent definitions of medication adherence across studies, utilization of more objective measures of adherence (eg, blood plasma levels vs. self-report) in addition to reliance on self-reported adherence.

Implications

This article provides the most comprehensive review to date on correlates of adherence to pharmacological smoking cessation interventions. Challenges and specific gaps in the literature that should be a priority for future research are discussed. Future priorities include additional research, particularly among vulnerable populations of smokers, developing standardized definitions of adherence and methods for measuring adherence, regular assessment of cessation pharmacotherapy adherence in the context of research and clinical practice, and development of novel treatments aimed at preventable barriers to medication adherence.

The association between self-reported varenicline adherence and varenicline blood levels in a sample of cancer patients receiving treatment for tobacco dependence

Introduction

The degree to which smokers quit successfully with varenicline is strongly associated with their adherence to the medication regimen. Thus, measuring varenicline adherence to identify smokers needing additional intervention is a priority. Few studies, however, have examined the validity of self-reported varenicline adherence, using a biological assessment of adherence as a reference. No study has examined this issue among cancer patients trying to quit smoking, who may show unique patterns of adherence given their medical comorbidity.

Methods

This study used data from 76 cancer patients who received varenicline and provided self-reported varenicline adherence data (pill count) and a blood sample to determine varenicline metabolites 4 weeks after initiating varenicline.

Results

Receiver operating characteristic (ROC) curve analyses of plasma varenicline levels showed that 4 ng/ml was the optimal cut-point for differentiating adherence with significant (p's < 0.04) area under the curve values, ranging from 0.73–0.80 for 3-day, 7-day, and 4-week self-reported pill count; specificity values ranged from 0.63–0.78 and sensitivity values ranged from 0.82–0.94. Using this cut-point, adherence was high (88%). However, plasma varenicline levels were weakly correlated with 3-day and 4-week pill count and total pill count (12 weeks) was not correlated with plasma varenicline levels. Patients with head and neck cancer, gastrointestinal cancer, and more advanced disease showed lower varenicline adherence and lower plasma varenicline.

Conclusions

Using the 4 ng/ml cut-point, this study suggests validity of short-term self-reported varenicline adherence among cancer patients undergoing tobacco dependence treatment in contrast to studies in the general population, which supported 12-week pill count.

•

First study of the validity of self-reported varenicline use among cancer patients

•

Identified cut-point for varenicline plasma adherence

•

Supports the validity of short-term self-reported varenicline adherence

•

Cancer-related variables influence varenicline adherence

•

Varenicline adherence may be higher among cancer patients

Examining Factors Associated With Nonadherence And Identifying Providers Caring For Nonadherent Subgroups

Objectives

To examine racial/ethnic and regional differences in medication adherence in patients with diabetes taking oral anti-diabetic, anti-hypertensive, and cholesterol lowering medications and to identify the pharmacies and prescribers who serve these communities.

Methods

Administrative claims data was analyzed for members enrolled in a large health plan in Hawaii (2008-2010) with diabetes mellitus who were taking three types of medications: 1) oral anti-diabetic medications; 2) anti-hypertensive medications; 3) cholesterol lowering medications (n=5136). The primary outcome was medication adherence based on medication possession ratios. Multivariable logistic regression models were estimated to examine the association between race/ethnicity and region to adherence to each drug class separately, followed by non-adherence to all three. Covariates included age, gender, education level, chronic conditions, copayment level, and number of prescribers and pharmacies from which the patients received their medications.

Key Findings

After adjustment for other factors, Filipinos [OR=0.58, 95%CI(0.45,0.74)], Native Hawaiians [OR=0.74, 95%CI(0.56,0.98)], and people of other race [OR=0.67, 95%CI(0.55,0.82)] were significantly less adherent to anti-diabetic and anti-hypertensive medications than Japanese. For cholesterol-lowering medications, all racial and ethnic groups were significantly less adherent than Japanese, except mixed race. We also found that different racial/ethnic groups tended to use different pharmacies and prescribers, particularly in rural areas.

Conclusion

Adherence differed by race/ethnicity as well as age and region. Qualitative research involving subgroups (e.g. Filipinos, Native Hawaiians, people under age 50) is needed to identify how to adapt and enhance the effects of interventions shown to be efficacious in prior studies.

Determinants of community pharmacists' quality of care: a population-based cohort study using pharmacy administrative claims data

OBJECTIVE

To determine if a prototype pharmacists' services evaluation programme that uses linked community pharmacy claims and health administrative data to measure pharmacists' performance can be used to identify characteristics of pharmacies providing higher quality of care.

DESIGN

Population-based cohort study using community pharmacy claims from 1 November 2009 to 30 June 2010.

SETTING

All community pharmacies in Quebec, Canada.

PARTICIPANTS

1742 pharmacies dispensing 8 655 348 antihypertensive prescriptions to 760 700 patients.

PRIMARY OUTCOME MEASURE

Patient adherence to antihypertensive medications.

PREDICTORS

Pharmacy level: dispensing workload, volume of pharmacist-provided professional services (eg, refusals to dispense, pharmacotherapy recommendations), pharmacy location, banner/chain, pharmacist overlap and within-pharmacy continuity of care. Patient level: sex, age, income, patient prescription cost, new/chronic therapy, single/multiple antihypertensive medications, single/multiple prescribers and single/multiple dispensing pharmacies. Dispensing level: prescription duration, time of day dispensed and antihypertensive class. Multivariate alternating logistic regression estimated predictors of the primary outcome, accounting for patient and pharmacy clustering.

RESULTS

9.2% of dispensings of antihypertensive medications were provided to non-adherent patients. Male sex, decreasing age, new treatment, multiple prescribers and multiple dispensing pharmacies were risk factors for increased non-adherence. Pharmacies that provided more professional services were less likely to dispense to non-adherent hypertensive patients (OR: 0.60; 95% CI: 0.57 to 0.62) as were those with better scores on the Within-Pharmacy Continuity of Care Index. Neither increased pharmacists' services for improving antihypertensive adherence per se nor increased pharmacist overlap impacted the odds of non-adherence. However, pharmacist overlap was strongly correlated with dispensing workload. There was significant unexplained variability among pharmacies belonging to different banners and chains.

CONCLUSIONS

Pharmacy administrative claims data can be used to calculate pharmacy-level characteristics associated with improved quality of care. This study supports the importance of pharmacist's professional services and continuity of pharmacist's care.

Adherence to medication and characteristics of Japanese patients with non-valvular atrial fibrillation

BACKGROUND

Adherence to medication plays an important role in the prevention of morbidity and mortality in non-valvular atrial fibrillation (NVAF) patients. The aim of this study is to assess adherence to medication and risk factors for non-adherence in Japanese NVAF patients who are prescribed anticoagulants.

METHODS

A total of 378 outpatients with NVAF who completed self-reported questionnaires were analyzed in this prospective study (mean age 69±12 years; 26% female). Self-reported adherence to cardiovascular drugs including anticoagulants was measured with a modified Siegal scale. Depression was defined as a Patient Health Questionnaire-9 score of ≥10. Univariate and multivariate analyses were performed on several variables to analyze factors affecting non-adherence.

RESULTS

In total, 291 (77%) of our patients received warfarin, and the remainder received direct oral anticoagulants. Fifty-two (14%) patients were defined as non-adherent. Univariate analyses showed that age <65 years, ≥2 times daily dosing of cardiovascular drugs and employment, but not depression, were significantly associated with non-adherence, 1.87 (95% CI: 1.01-3.42, p=0.04), 2.97 (95% CI: 1.64-5.49, p<0.01), 2.11 (95% CI: 1.16-3.93, p=0.01), and 0.74 (95% CI: 0.26-2.64), respectively. Multivariate analysis showed that only ≥2 times daily dosing was a significant independent risk factor (HR 3.06, 95% CI: 1.67-5.69, p<0.01).

CONCLUSIONS

Our study showed that the prevalence of non-adherence to medications was 14% in NVAF patients. Frequent daily dosing was an independent risk factor for non-adherence to medication (UMIN-CTR No. UMIN 000023514).

Treatment adherence and illness self-management: introduction to the special issue

The current issue is devoted broadly to research on treatment adherence and chronic illness self-management behavior. As the prevalence of chronic illness increases, the pervasive problem of treatment nonadherence is increasingly viewed as having a major impact on treatment outcomes, public health and healthcare costs, making this issue particularly timely. Sixteen articles spanning an array of topics are presented; articles include empirical studies, statistical simulations, systematic reviews, and theoretical commentaries. Studies conducted with diverse patient populations (e.g., chronic headache, diabetes, end-stage renal disease, HIV, hypertension, severe obesity), samples (e.g., adolescents, ethnic/racial minorities, low-income adults, parents, spousal dyads), and designs (e.g., cross-sectional, longitudinal assessment, randomized controlled trial), are represented. This issue highlights psychosocial factors associated with nonadherence, promising interventions to promote adherence, and state-of-the art methods for the study of illness self-management. We hope these articles engender even more high quality, methodologically rigorous research in this important subfield of behavioral medicine.