Primary medication non-adherence: analysis of 195,930 electronic prescriptions

Management of drug-resistant hypertension as a heterogeneous disorder

Approximately 1.3 billion adults globally have hypertension, and are at higher risk of death associated with cardiovascular disease. Adjusted death rate primarily due to high blood pressure is 31.3 per 100,000. The prevalence of drug-resistant hypertension is estimated to be up to 20 % in hypertensive individuals, and is more common in those with chronic kidney disease and obstructive sleep apnea. It occurs in individuals on ≥3 antihypertensive drugs including a diuretic. The addition of spironolactone, as a fourth drug has been found at times to be effective in management of blood pressure. Other strategies include sequential nephron block (e.g., spironolactone + furosemide + amiloride), and use of drugs such as alpha2 agonists, endothelin antagonists, and nonsteroidal mineralocorticoid antagonists. Use of positive airway pressure and pharmacotherapy have been found to be of value in individuals with sleep apnea in lowering blood pressure. In contrast, baroreceptor stimulation and/or renal denervation combined with pharmacotherapy seem to offer little in a way of consistent efficacy of optimally lowering blood pressures. Remarkably, evidence in the literature strongly supports the view that life style changes including regular exercise and appropriate diet combined with pharmacotherapy can lead to positive outcomes in helping to significantly reduce blood pressure. There is also ample data in literature suggesting the non-compliance to antihypertensive medications as a significant barrier to lowering blood pressure in this group. Accordingly, education regarding pharmacotherapy, and appropriate exercise regimen, including changes to diet should underpin any strategy in the management of high blood pressure in this population.

Exploring adherence to antidiabetic medications in Singapore primary care: a comparison of four models of proportion of days covered

INTRODUCTION

There is currently no standardised approach to calculate and report proportion of days covered (PDC), a medication adherence measure. We aimed to assess adherence to antidiabetic medications by applying four PDC models to a primary care database and examine the factors associated with medication adherence.

METHODS

Four models were used to calculate PDC for 789 patients with diabetes mellitus (DM) using the average PDC method. Models P1 and P2 incorporated prescribed and dispensed data, whereas models D1 and D2 used dispensed data only. Models P1 and D1 used an interval-based method, whereas models P2 and D2 used a prescription-based method. Gender, age at recruitment, race, number of chronic diseases, years of DM, glycated haemoglobin (HbA1c) levels and number of antidiabetic medication classes were tested in a univariate analysis. Stepwise selection method was used in the multivariate logistic regression model.

RESULTS

The proportion of adherent patients (PDC ≥80%) was 64.1% for model P1, 73.9% for P2, 66.5% for D1, and 87.3% for D2. Patients with PDC <80% were more likely to have HbA1c ≥9% (odds ratios 2.54 [P1], 2.69 [P2], 2.48 [D1], and 3.33 [D2]). Additionally, PDC <80% was associated with Malay or Indian ethnicity and having four or more chronic diseases.

CONCLUSION

The PDC models that incorporate prescribed data and use interval-based methods may result in more patients being classified as having poor adherence. Compared to the other models, we postulate that model P2 may provide the most accurate estimate of adherence, as it takes into account the prescribers' intent by including prescribed data and changes in medication regimens by using prescription-based method.

The silent epidemic of non-adherence - insights from the 2024 a:care congress

Medication non-adherence is a global challenge with profound implications for patient health outcomes, healthcare systems, and society at large. This widespread issue leads to hundreds of thousands of preventable deaths and hospitalizations annually, and billions of dollars in avoidable healthcare costs. No country is immune to this challenge. The a:care Congress 2024, titled "Adherence is a Behavior: Do We Have the Right One?", addressed this critical issue to understand its societal and economic burden and explore the complex human behaviors driving it. The Congress examined the global impact of non-adherence and local realities, providing a health economic perspective on its consequences. Behavioral factors influencing adherence were analyzed, emphasizing the importance of understanding individual patient motivations. The role of technology and artificial intelligence in the physician-patient relationship was discussed, highlighting opportunities and challenges of integrating these tools. The patient's voice was brought to the forefront, underscoring the importance of communication and trust in the care relationship. A final multidisciplinary session explored the role of each stakeholder in improving adherence. This article provides an overview of the different sessions from the congress, focusing on the challenges associated with medication non-adherence and potential solutions. It emphasizes the need for a multidimensional approach involving all healthcare system stakeholders and the importance of prioritizing the development of new strategies to improve overall health outcomes and healthcare system efficiency.

Prevalence of diabetes mellitus and dialysis risk based on annual health checkup frequency among National Health Insurance citizens in Japan

BACKGROUND

In Japan, type 2 diabetes mellitus (T2DM) is a major health concern due to its increasing prevalence and associated complications, including diabetic nephropathy and dialysis. Although the positive relationship between annual health checkups and health outcomes is well-documented, the impact of skipping health checkups on T2DM and its progression to dialysis remains unclear. This study aimed to explore the association between the frequency of annual health checkups and DM-related indices and the potential impact of early intervention in preventing dialysis.

METHODS

The study included citizens aged ≥ 40 years from Nobeoka City, Japan (n = 22,094). Health checkup data from 2021 were analyzed, and participants were categorized into four groups based on their health checkup attendance between 2018 and 2020. Logistic regression analyses evaluated the association between health checkup frequency and DM-related indices, such as hemoglobin A1c and estimated glomerular filtration rate. These indices are used to diagnose DM and evaluate its severity. The time to dialysis for citizens without health checkups was estimated under untreated and treated scenarios using a previously published model.

RESULTS

Among the 3,472 participants who underwent health checkups in 2021, 2,098 (60.4%) were women, and 1,374 (39.6%) were men. Citizens who missed health checkups for 3 consecutive years had a higher risk of T2DM than those who had annual checkups (odds ratio = 4.69, 95% confidence interval: 2.78-7.94). No significant difference was observed in T2DM rates between those who attended once or twice and those who attended annually. Simulations for high-risk citizens showed that 32 of 39 individuals may require dialysis during their lifetime; however, early intervention could prevent dialysis in 31 of them.

CONCLUSIONS

Citizens who skipped health checkups for 3 consecutive years or longer had a higher risk of T2DM, highlighting the need for targeted public interventions to prevent DM in this population.

Adherence to oral and topical medications among dermatology patients

Poor adherence contributes to worsening of medical conditions, increased medical costs, comorbidities and mortalities. Many factors may influence adherence in dermatology. Our aim was to study the degree of adherence of dermatology patients to topical and systemic medications and to identify the relationship of adherence to patient, disease, and treatment characteristics, as well as the influence of health care providers. Seven hundred and eighteen patients of both sexes with various dermatological complaints were included. They were all subjected to Morisky 8-item Medication Adherence Scale. Topical therapy was associated with a significantly lower adherence when compared to systemic therapy (P < 0.001). Adherence to systemic medication was superior for acute compared to chronic skin diseases (P = 0.008). Reduced adherence was also observed among uneducated patients, those facing financial difficulties, individuals prescribed complex topical regimens, and those using ointments Additional factors included insufficient instructions from physicians, perceived treatment effectiveness, and the experience of side effects. Patients with psoriasis and eczema showed the lowest adherence levels to both topical and systemic treatment. Overall, adherence of dermatology patients to treatment, particularly to topical treatment, was found to be unsatisfactory. Dermatologists should assess each patient's individual adherence barriers, and the management plan should be tailored according to many factors including the patient's financial status and educational level.

Medication nonadherence - definition, measurement, prevalence, and causes: reflecting on the past 20 years and looking forwards

In 2003, Sabate's World Health Organisation report defined medication nonadherence as a phenomenon where individuals' behaviour does not correspond to prescribed treatment recommendations from their healthcare provider. This concept of nonadherence evolved beyond a categorisation of patients as adherent or nonadherent. Rather, nonadherence varies within the same individual and treatment over time, and between treatments and individuals. The type and patterns of nonadherence are key determinants of outcome with individuals with the same percentage nonadherence having different outcomes depending on their pattern of nonadherence. Often the poorest clinical outcomes occur in individuals who do not initiate medication or discontinue early, but much of the nonadherence literature remains focused on implementation. This paper provides a nuanced discussion of nonadherence which has been enabled in part by the growing availability of technologies such as electronic nonadherence monitors, new biomarkers for adherence and greater access to 'big data' (e.g., on prescription refills). These allow granular assessment of nonadherence that can be linked with biophysical markers captured using technologies such as wearables. More validated self-report measures have also become available to profile nonadherence in research and practice. Together, in-depth data on dosing and clinical measures provide an opportunity to explore complex interactions between medications, therapeutic effects and clinical outcomes. This variation in measurement and definition means that there is a more fine-grained understanding of the prevalence of nonadherence and a greater recognition of the prevalence of nonadherence, with growing evidence suggesting that approximately a fifth of patients do not initiate treatment, of those initiating treatment approximately 30%-50% of patients do not implement their treatment as prescribed and that, over long follow-up periods in some conditions 80%-100% of patients discontinue. There is potential too to better understand causes of nonadherence. New behavioural models synthesise determinants of nonadherence previously considered separately. Frameworks like the COM-B (considering individual capability, opportunity, and motivation factors) and MACO (focusing on Medication Adherence Contexts and Outcomes) emphasize the multifaceted nature of nonadherence determinants. Greater focus on dynamic processes with interplay between individual, social, and environmental influences is needed. Addressing these complexities could lead to more effective and personalised support for patients.

Primary medication adherence in Medicare beneficiaries prescribed sacubitril-valsartan or renin-angiotensin system blockers for heart failure with reduced ejection fraction

BACKGROUND

Sacubitril-valsartan is an angiotensin receptor-neprilysin inhibitor (ARNI) that is now preferred over angiotensin-converting enzyme inhibitors (ACE-Is) and angiotensin-II-receptor blockers (ARBs) for treating heart failure with reduced ejection fraction (HFrEF). Primary medication adherence to a costly brand-name ARNI, compared to inexpensive generic ACE-Is or ARBs, is unknown.

METHODS

This cohort study used a linked database of electronic health records and Medicare fee-for-service claims from a large integrated health care system in Boston to compare primary medication adherence among Medicare beneficiaries with HFrEF newly prescribed sacubitril-valsartan, those newly prescribed a generic ACE-I or ARB, and those switching from an ACE-I or ARB to sacubitril-valsartan. The primary outcome was the proportion of individuals who filled their first prescription for any ARNI, ACE-I, or ARB within 90 days; a secondary outcome was the mean number of days to first fill. We used logistic regression to adjust for variations in patient characteristics, including demographics, comorbidities, medication use, and qualification for subsidized out-of-pocket prescription drug costs.

RESULTS

Among 50 new sacubitril-valsartan prescription recipients, 33 (66%) demonstrated primary adherence at 90 days, compared to 141 of 231 (61%) new ACE-I or ARB prescription recipients (adjusted odds ratio 1.32, 95% CI, 0.63-2.73, P = .51). The mean time to first fill was 18 days for those prescribed sacubitril-valsartan and 9 days for those prescribed generic ACE-Is or ARBs (P < .001). By contrast, primary adherence at 90 days was higher (329 of 364, 90%) among those who switched from a generic ACE-I or ARB to newly prescribed sacubitril-valsartan.

CONCLUSIONS

In this small, single-center cohort study of Medicare beneficiaries with HFrEF, there was no difference in primary medication adherence among individuals newly prescribed sacubitril-valsartan and those newly prescribed generic ACE-Is or ARBs, although it took sacubitril-valsartan prescription recipients longer to fill their medication. Adherence was high among patients switching from an ACE-I or ARB to sacubitril-valsartan, suggesting that this switch was not associated with interruptions in renin-angiotensin blockade.

Approach to Estimating Adherence to Heart Failure Medications Using Linked Electronic Health Record and Pharmacy Data

BACKGROUND

Medication non-adherence, which is common in chronic diseases such as heart failure, is often estimated using proportion of days covered (PDC). PDC is typically calculated using medication fill information from pharmacy or insurance claims data, which lack information on when medications are prescribed. Many electronic health records (EHRs) have prescription and pharmacy fill data available, enabling enhanced PDC assessment that can be utilized in routine clinical care.

OBJECTIVE

To describe our approach to calculating PDC using linked EHR-pharmacy data and to compare to PDC calculated using pharmacy-only data for patients with heart failure.

METHODS

We performed a retrospective cohort study of adult patients with heart failure who were prescribed guideline-directed medical therapy (GDMT) and seen in a large health system. Using linked EHR-pharmacy data, we estimated medication adherence by PDC as the percent of days in which a patient possessed GDMT based on medication pharmacy fills over the number of days the prescription order was active. We also calculated PDC using pharmacy-only data, calculated as medications possessed over days with continued medication fills. We compared these two approaches for days observed and PDC using a paired t-test.

RESULTS

Among 33,212 patients with heart failure who were prescribed GDMT, 2226 (6.7%) never filled their medications, making them unavailable in the assessment of PDC using pharmacy-only data (n = 30,995). Linked EHR-pharmacy data had slightly longer days observed for PDC assessment (164.7 vs. 163.4 days; p < 0.001) and lower PDC (78.5 vs. 90.6, p < 0.001) as compared to assessment using pharmacy-only data.

CONCLUSIONS

Linked EHR-pharmacy data can be used to identify patients who never fill their prescriptions. Estimating adherence using linked EHR-pharmacy data resulted in a lower mean PDC as compared to estimates using pharmacy-only data.

A future of data-rich pharmacoepidemiology studies: transitioning to large-scale linked electronic health record + claims data

Electronic health record (EHR) data are seen as an important source for pharmacoepidemiology studies. In the US health-care system, EHR systems often identify only fragments of patients' health information across the care continuum, including primary care, specialist care, hospitalizations, and pharmacy dispensing. This leads to unobservable information in longitudinal evaluations of medication effects, causing unmeasured confounding, misclassification, and truncated follow-up times. A remedy is to link EHR data with longitudinal health insurance claims data, which record all encounters during a defined enrollment period across all care settings. Here we evaluate EHR and claims data sources in 3 aspects relevant to etiological studies of medical products: data continuity, data granularity, and data chronology. Reflecting on the strengths and limitations of EHR and insurance claims data, it becomes obvious that they complement each other. The combination of both will improve the validity of etiological studies and expand the range of questions that can be answered. As the research community transitions towards a future state with access to large-scale combined EHR + claims data, we outline analytical templates to improve the validity and broaden the scope of pharmacoepidemiology studies in the current environment where EHR data are available only for a subset of patients with claims data. This article is part of a Special Collection on Pharmacoepidemiology.

Non-dispensed prescriptions - A nationwide descriptive study

Background

Medication non-adherence is associated with suboptimal health outcomes, higher mortality, and increased healthcare costs.

Objective

The aim of this study was to estimate the number and share of non-dispensed prescriptions at a national level and in specific patient and medicine subgroups.

Methods

The study was a nationwide retrospective register-based study. The data consisted of prescriptions prescribed in Finland in 2020 and dispensed between 2020 and 2022. A prescription was considered non-dispensed if it had not been dispensed within the two-year validity period. For each prescription, information on the patient's birth date, sex, and income as well as details of the prescribed medicine and physician's employment sector (public/private) were collected. Distributions and odds ratios (ORs) with corresponding 95 % confidence intervals (CI) were used in the analyses.

Results

Of the 26 million prescriptions, 13.3 % were never filled. Over 1.7 million people (43.3 % of all people with prescriptions issued in 2020) had at least one non-dispensed prescription. The share of non-dispensed prescriptions was lower in men than women (12.9 % vs. 13.5 %; OR:0.95; CI:0.95-0.95). Compared to the youngest age group, the share of non-dispensed prescriptions was lower in the older age groups. The lowest share of non-dispensed medicines was in antineoplastic and immunomodulating agents (7.8 %) and in cardiovascular system medicines (8.1 %), whereas the highest was in dermatologicals (20.2 %). The proportion of non-dispensed prescriptions varied between medicine groups, from 5 % for thyroid therapy to 38 % for other nervous system drugs. The most frequently non-dispensed medications were paracetamol, ibuprofen, and salbutamol.

Conclusion

The share and number of non-dispensed prescriptions varied across therapeutic areas, medicine groups, active pharmaceutical ingredients, and patient groups. Healthcare professionals should avoid unnecessary prescribing and improve medication adherence to ensure safer and more effective care.

Does Physicians' Clinical Competence, Communication Ability, or Cultural Background Influence Potentially Inappropriate Prescribing of Benzodiazepines and Z-Drugs Among Older Adults With Insomnia?

OBJECTIVE

The objective of this study is to estimate the association between physician's age, sex, clinical and communication competencies, and cultural background on benzodiazepines and Z-drugs (BDZ) prescribing to older adults with insomnia.

METHODS

A cohort of international medical graduates (IMGs) who completed their pre-residency licensure exam in 1998-2004 were linked to all U.S. Medicare patients they provided care to in 2014-2015. Their care records in Parts A, B, and D from all physicians were extracted. The first outpatient visit for insomnia to a study IMG was identified for each patient in that period. The outcome was incident BDZ prescribing by the study physician following the visit. Main exposures were physician age, sex, citizenship at birth, and clinical and communication competency as measured on the licensure exam. The association between physician characteristics and BDZ prescribing, adjusting for physician and patient covariates, was estimated using generalized estimating equations multivariable logistic regression.

RESULTS

We analyzed 28 018 patients seen by 4069 unique physicians. IMGs born in all other regions of the world were less likely to prescribe BDZs compared to U.S.-born IMGs, with physicians from the United Kingdom being least likely (OR 0.54 [95%CI 0.34-0.85]). Neither physician's clinical competency nor communication ability were associated with BDZ prescribing (OR per 10% increase, respectively: 0.95 [95%CI 0.88-1.02] and 0.98 [95%CI 0.93-1.04]). Older physicians remain more likely to prescribe BDZ (OR per 5-year increase 1.04 [95%CI 1.00-1.08]).

CONCLUSIONS

The associations between cultural background and physician's age on BDZ prescribing highlight the potential targets for remedial solutions to reduce the use of potentially inappropriate medications.

Measurement of Completeness and Timeliness of Linked Electronic Health Record Pharmacy Data for Early Detection of Nonadherence to Breast Cancer Adjuvant Endocrine Therapy

PURPOSE

This retrospective cohort study evaluated whether linked electronic health record (EHR) pharmacy data were adequately complete and timely to detect primary nonadherence to breast cancer adjuvant endocrine therapy (AET).

MATERIALS AND METHODS

Linked EHR pharmacy data were extracted from the EHR for patients with stage 0 to III breast cancer who had their first prescription order for AET between 2016 and 2021. Patients with the first dispense event within 90 days of the prescription were classified as having sufficient or insufficient data available for early detection of primary adherence.

RESULTS

A total of 1,446 eligible patients had a first AET prescription order between 2016 and 2021; these orders were routed to 871 unique pharmacies, of which 856 (98.2%) were contracted with the linked EHR pharmacy database and 15 (1.8%) were not contracted. Among the 1,428 patients with a first prescription sent to a contract pharmacy, 164 (13%) had incomplete linked EHR pharmacy data refresh events to assess primary adherence. Among the 1,244 patients with at least 1 refresh event after their first prescription, 82% occurred within 90 days and were sufficiently timely for early detection of primary adherence. Overall, 32% of patients would benefit from an intervention to verify or improve primary adherence to AET.

CONCLUSION

Although linked EHR pharmacy data have adequate completeness of contract pharmacy data, local configurations of data refresh events tailored to medication reconciliation workflows are incomplete (13%) and insufficiently timely (32%) to fully support clinical decision support (CDS) for early detection of primary medication nonadherence. Prospective CDS interventions using linked EHR pharmacy data are possible with enhancements to the frequency and timeliness of refresh events.

Medications for Alcohol Use Disorder: Rates and Predictors of Prescription Order and Fill in Outpatient Settings

BACKGROUND

Alcohol use disorders (AUD) are prevalent and responsible for substantial morbidity and mortality; yet efficacious treatments are underused. Previous studies have identified demographic and clinical predictors of medication fills, yet these studies typically do not include patients who were prescribed a medication but did not fill it.

OBJECTIVES

To examine rates of and factors associated with prescription order and prescription fill for medications for AUD (MAUD) among individuals diagnosed with AUD in outpatient settings.

DESIGN

In a cross-sectional analysis, we used multivariate logistic regression to identify factors associated with prescription order and fill.

PATIENTS

We used data from the Optum Labs Data Warehouse that linked 2016-2021 de-identified claims and electronic health record (EHR) data, allowing us to observe prescription orders and whether they were filled. We identified 14,674 patients aged ≥ 18 who had an index outpatient encounter with an AUD diagnosis in the EHR.

KEY MEASURES

We computed the proportion for whom a MAUD prescription was ordered within 1 year of index visit, and for whom one was filled within 30 days of the order.

KEY RESULTS

5.8% of the sample had a MAUD prescription order within 1 year of their index visit. Among those with an order, 87% filled their MAUD prescription within 30 days of receipt (i.e., 5.1% of full sample). After multivariable adjustment, receipt of a MAUD prescription order was more likely for patients who were female (adjusted odds ratio (aOR) [95%CI] = 1.44 [1.24-1.67]), or had moderate or severe AUD (1.74 [1.50-2.01]). Patients receiving an order were more likely to fill it if they had a comorbid mental disorder (1.64 [1.09-2.49]).

CONCLUSIONS

The low rate of prescription orders was notable. Low use of MAUD appears to result chiefly from prescription order decisions, rather than from prescription fill decisions made by patients.

Agreement of Medication Information Derived From EHR Data Compared to Medicare Insurance Claims: An Analysis of Biologic Disease-Modifying Antirheumatic Drugs

PURPOSE

Few studies have reported the agreement between medication information derived from ambulatory EHR data compared to administrative claims for high-cost specialty drugs. We used data from a national EHR-enabled registry, the Rheumatology Informatics System for Effectiveness (RISE), with linked Medicare claims in a population of patients with rheumatoid arthritis (RA) to investigate variations in agreement for different biologic disease-modifying agents (bDMARDs) between two data sources (RISE EHR data vs. Medicare claims), categorized by drug, route of administration, and patient insurance factors (dual eligibility).

METHODS

Patients ≥ 65 years old, with ≥ 2 visits in RISE with RA ICD codes ≥ 30 days apart, and continuous enrollment in Medicare Parts B and D in 2017-2018 were included. We classified patients as bDMARD users or nonusers in Medicare claims or EHR data in 2018, and we calculated sensitivity, specificity, positive predicted value (PPV), and negative predicted value (NPV) of EHR data for identifying bDMARD users, using Medicare as the reference standard. We also calculated these metrics after stratifying by clinic-administered (Part B) versus. pharmacy-dispensed (Part D) bDMARDs and by patient dual-eligibility.

RESULTS

A total of 26 097 patients were included in the study. Using Medicare claims as the reference standard, EHR data had a sensitivity of 75.0%-90.8% for identifying patients with the same medication and route. PPV for Part B bDMARDs was higher compared with Part D bDMARDs (range 94.3%-97.3% vs. 51.0%-69.6%). We observed higher PPVs for Part D bDMARDs among patients who were dual-eligible (range 82.4%-95.1%).

CONCLUSION

The risk of misclassification of drug exposure based on EHR data sources alone is small for Medicare Part B bDMARDs but could be as high as 50% for Part D bDMARDs, in particular for patients who are not dually eligible for Medicare and Medicaid.

Health care resource utilization in Medicare beneficiaries obtaining medication synchronization

BACKGROUND

An appointment-based medication synchronization (ABMS) is a service whuch aligns patients' chronic medications to a predetermined routine pickup date and includes a comprehensive medication review or other clinical appointment at the pharmacy.

OBJECTIVE(S)

We compared healthcare utilization outcomes (outpatient, inpatient, emergency department visits, and pharmacy utilization) of Medicare beneficiaries enrolled in a med-sync program to beneficiaries not enrolled in such a program.

METHODS

This retrospective cohort study included Medicare beneficiaries obtaining medications from pharmacies providing ABMS. All Medicare inpatient, outpatient, emergency, and pharmacy claims data from 2014 to 2016 obtained from the Research Data Assistance Center. These pharmacy claims were used to create med-sync (n = 13,193) and non-med-sync cohorts (n = 156,987). All patients were followed longitudinally for 12 months before and after a 2015 index or enrollment date. Baseline characteristics were used to create a logistic regression model for propensity score matching. A 1:1 greedy nearest neighbor matching algorithm was adapted for sequentially matching both cohorts. Difference in differences (DID) was used to compare mean changes in health care utilization outcomes (outpatient, inpatient, ED visits, and pharmacy utilization) between cohorts.

RESULTS

After matching, 13,193 beneficiaries in each cohort were used for analysis. DIDs for mean of health care utilizations were statistically significantly lower in the med-sync cohort than the non-med-sync cohort for outpatient visits (DID 0.012, P = 0.0073) and pharmacy utilization (DID 0.013, P < 0.0001). There was not a statistically significant DID for inpatient and ED visits between cohorts.

CONCLUSION

Outpatient and pharmacy utilization changes were statistically significantly lower in the med-sync cohort than the non-med-sync cohort in the 12 months after enrollment. Lower pharmacy utilization could be caused by reducing duplicate prescriptions during synchronized refills or optimization of therapy during medication reviews if patients are enrolled in appointment-based model med-sync.

A consensus statement from the Japan Diabetes Society: A proposed algorithm for pharmacotherapy in people with type 2 diabetes - 2nd edition (English version)

This algorithm was issued for the appropriate use of drugs for the treatment of type 2 diabetes mellitus in Japan. The revisions include safety considerations, fatty liver disease as a comorbidity to be taken into account and the position of tirzepatide.

Initial non-adherence to lipid-lowering medication: a systematic literature review

BACKGROUND

The impact on cardiovascular health is lost when a patient does not obtain a newly prescribed lipid-lowering medication, a situation termed "initial medication nonadherence" (IMN). This research summarizes the published evidence on the prevalence, associated factors, consequences, and solutions for IMN to prescribed lipid-lowering medication in the United States.

METHODS

A systematic literature search using PubMed and Google Scholar, along with screening citations of systematic reviews, identified articles published from 2010 to 2021. Studies reporting results of IMN to lipid-lowering medications were included. Studies that evaluated non-adult or non-US populations, used weaker study designs (e.g., case series), or were not written in English were excluded.

RESULTS

There were 19 articles/18 studies that met inclusion and exclusion criteria. Estimates of the prevalence of IMN to newly prescribed lipid-lowering medications ranged from 10 to 18.2% of patients and 1.4-43.8% of prescriptions (n = 9 studies). Three studies reported prescriber and patient characteristics associated with IMN. Hispanic ethnicity, Black race, lower Charlson Comorbidity Index score and no ED visits or hospitalization were associated with IMN. Lipid lowering prescriptions from primary care providers were also associated with IMN. Four studies described patient-reported reasons for IMN, including preference for lifestyle modifications, lack of perceived need, and side effect concerns. Four intervention studies reported mixed results with automated calls, live calls, or letters. One study reported worse clinical outcomes in patients with IMN: higher levels of low-density lipoprotein and greater risk of emergency department visits.

CONCLUSIONS

Up to one-fifth of patients fail to obtain a newly prescribed lipid-lowering medication but there is limited information about the clinical consequences. Future research should assess outcomes and determine cost-effective approaches to address IMN to lipid-lowering therapy.

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

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

Nurse-led medication management as a critical component of transitional care for preventing drug-related problems

Drug-related problems (DRPs) are critical medical issues during transition from hospital to home with high prevalence. The application of a variety of interventional strategies as part of the transitional care has been studied for preventing DRPs. However, it remains challenging for minimizing DRPs in patients, especially in older adults and those with high risk of medication discrepancies after hospital discharge. In this narrative review, we demonstrated that age, specific medications and polypharmacy, as well as some patient-related and system-related factors all contribute to a higher prevalence of transitional DPRs, most of which could be largely prevented by enhancing nurse-led multidisciplinary medication reconciliation. Nurses' contributions during transitional period for preventing DRPs include information collection and evaluation, communication and education, enhancement of medication adherence, as well as coordination among healthcare professionals. We concluded that nurse-led strategies for medication management can be implemented to prevent or solve DRPs during the high-risk transitional period, and subsequently improve patients' satisfaction and health-related outcomes, prevent the unnecessary loss and waste of medical expenditure and resources, and increase the efficiency of the multidisciplinary teamwork during transitional care.

A consensus statement from the Japan Diabetes Society (JDS): a proposed algorithm for pharmacotherapy in people with type 2 diabetes-2nd Edition (English version)

The Japan Diabetes Society (JDS) adopted a sweeping decision to release consensus statements on relevant issues in diabetes management that require updating from time to time and launched a "JDS Committee on Consensus Statement Development." In March 2020, the committee's first consensus statement on "Medical Nutrition Therapy and Dietary Counseling for People with Diabetes" was published. In September 2022, a second consensus "algorithm for pharmacotherapy in people with type 2 diabetes" was proposed. In developing an algorithm for diabetes pharmacotherapy in people with type 2 diabetes, the working concept was that priority should be given to selecting such medications as would appropriately address the diabetes pathology in each patient while simultaneously weighing the available evidence for these medications and the prescribing patterns in clinical practice in Japan. These consensus statements are intended to present the committee's take on diabetes management in Japan, based on the evidence currently available for each of the issues addressed. It is thus hoped that practicing diabetologists will not fail to consult these statements to provide the best available practice in their respective clinical settings. Given that the persistent dual GIP/GLP-1 receptor agonist tirzepatide was approved in April 2023, these consensus statements have been revised1). In this revision, specifically, tirzepatide was added to the end of [likely involving insulin resistance] of "Obese patients" in Step 1: "Select medications to address the diabetes pathology involved" in Fig. 2. While the sentence, "Insulin insufficiency and resistance can be assessed by referring to the various indices listed in the JDS 'Guide to Diabetes Management.' was mentioned in the previous edition as well, "While insulin resistance is analogized based on BMI, abdominal obesity, and visceral fat accumulation, an assessment of indicators (e.g., HOMA-IR) is desirable" was added as information in order to more accurately recognize the pathology. Regarding Step 2: "Give due consideration to safety," "For renal excretion" was added to the "Rule of thumb 2: Avoid glinides in patients with renal impairment." The order of the medications in "rule of thumb 3: Avoid thiazolidinediones and biguanides in patients with heart failure (in whom they are contraindicated)." to thiazolidinediones then biguanides. In the description of the lowest part of Fig. 2, for each patient failing to achieve his/her HbA1c control goal, "while reverting to step 1" was changed to "while reverting to the opening" and "including reassessment if the patient is indicated for insulin therapy" was added. In the separate table, the column for tirzepatides was added, while the two items, "Characteristic side effects" and "Persistence of effect" were added to the area of interest. The revision also carried additional descriptions of the figure and table such as tirzepatides and "Characteristic side effects" in the statement, and while not mentioned in the proposed algorithm figure, nonalcoholic fatty liver disease (NAFLD) is covered from this revision for patients with comorbidities calling for medical attention. Moreover, detailed information was added to the relative/absolute indication for insulin therapy, the Kumamoto Declaration 2013 for glycemic targets, and glycemic targets for older people with diabetes. Again, in this revision, it is hoped that the algorithm presented here will not only contribute to improved diabetes management in Japan, but will continue to evolve into a better algorithm over time, reflecting new evidence as it becomes available.

Adherence in paediatric respiratory medicine: A review of the literature

Poor adherence is an important factor in unstable disease control and treatment failure. There are multiple ways to monitor a patient's adherence, each with their own advantages and disadvantages. The reasons for poor adherence are multi-factorial, inter-related and often difficult to target for improvement. Although practitioners can implement different methods of adherence, the ultimate aim is to improve health outcomes for the individual and the health care system. Asthma is a common airway disease, particularly diagnosed in children, often treated with inhaled corticosteroids and long-acting bronchodilators. Due to the disease's tendency for exacerbations and consequently, when severe will require unscheduled health care utilisation including hospital admissions, considerable research has been done into the effects of medication adherence on asthma control. This review discusses the difficulties in defining adherence, the reasons for and consequences of poor adherence, and the methods of recording and improving adherence in asthma patients, including an in-depth analysis of the uses of smart inhalers.

Medication regimen complexity and its impact on medication adherence in patients with multimorbidity at a comprehensive specialized hospital in Ethiopia

Background

Medication regimen complexity (MRC) is suspected to hinder medication adherence in patients with multiple illnesses. Despite this, the specific impact on Ethiopian patients with multimorbidity is unclear. This study assessed MRC and its impact on medication adherence in patients with multimorbidity.

Methods

A hospital-based cross-sectional study was conducted on patients with multimorbidity who had been followed at the University of Gondar Comprehensive and Specialized Hospital (UoGCSH), Ethiopia, from May to July 2021. Medication complexity was measured using the validated Medication Regimen Complexity Index (MRCI) tool, and the Adherence in Chronic Diseases Scale (ACDS) was used to measure medication adherence. Pearson's chi-square test was used to examine associations between MRCI levels and medication adherence. Ordinal logistic regression analysis was used to determine the impact of MRC and other associated variables on medication adherence. Statistical significance was determined using the adjusted odds ratio (AOR) at p-value <0.05 and its 95% confidence range.

Results

Out of 422 eligible patients, 416 (98.6%) were included in the study. The majority of participants (57.2%) were classified as having a high MRCI score with a mean (±SD) score of 9.7 (±3.4). Nearly half of the patients (49.3%) had low medication adherence. Patients with medium (AOR = 0.43, 95% CI: 0.04, 0.72) and higher (AOR = 0.31, 95% CI: 0.07, 0.79) MRCI levels had lower odds of medication adherence. In addition, monthly income (AOR = 4.59, 95% CI: 2.14, 9.83), follow-up durations (AOR = 2.31, 95% CI: 1.09, 4.86), number of medications (AOR = 0.63, 95% CI: 0.41, 0.97), and Charlson comorbidity index (CCI) (AOR = 0.36, 95% CI: 0.16, 0.83) were significantly associated with medication adherence.

Conclusion

Medication regimen complexity in patients with multimorbidity was found to be high and negatively impacted the levels of medication adherence. Healthcare providers and other stakeholders should seek interventions aimed at simplifying drug regimen complexity and improving adherence.

Evaluating Health Care Professionals' Readiness for e-Health Adoption in the Context of the COVID-19 Pandemic: A Georgian Perspective

Background: The COVID-19 pandemic has accelerated the adoption of Electronic health (e-Health), leveraging technologies such as telemedicine, electronic health records, artificial intelligence, and patient engagement platforms. This transformation underscores e-Health's role in providing efficient, patient-centered care. Our study explores health care professionals' readiness for these technologies, emphasizing the need for tailored education in this evolving landscape. Methods: In our study, conducted between February and March 2023, we administered a questionnaire-based survey to 500 staff members (82.4% female, 17.6% male) aged 25-70 from medical universities in Tbilisi, Georgia. The structured questionnaire covered topics such as computer literacy, telemedicine awareness, patient data security, and ethical considerations. We employed SPSS v21.0 for data analysis, encompassing descriptive statistics and thematic analysis of open-ended responses. Results: Our study included 500 participants categorized into five age groups. Notably, 31% considered themselves computer "experts," while 69% rated their skills as "intermediate" or "advanced." Furthermore, 85% used computers professionally, with 33% having practical computer training. Interestingly, 59% expressed interest in information technology training. Regarding e-Health, 15% believed it involves remote communication between health care professionals and patients, while 42% considered it "correct," and 37% "might be correct." Concerning its application in managing patients, opinions varied. In terms of e-Health's integration into Georgia's health care, responses ranged. Regarding patient data safety, participants exhibited diverse views. Finally, opinions on the necessity of informed consent for e-Health applications varied among participants. Conclusions: Our study explores health care professionals' readiness for e-Health adoption during the COVID-19 pandemic. It reveals varying computer literacy levels, a willingness to learn, differing views on e-Health applications, and mixed opinions on its integration into Georgian health care. These findings emphasize the need for clear e-Health terminology, education, tailored approaches, and a focus on data privacy and informed consent. Overall, e-Health's transformative role in modern health care is underscored.

Evidence-Based Guideline for the management of osteoporosis in men

Historically, osteoporosis has been viewed as a disease of women, with research, trials of interventions and guidelines predominantly focused as such. It is apparent, however, that this condition causes a substantial health burden in men also, and that its assessment and management must ultimately be addressed across both sexes. In this article, an international multidisciplinary working group of the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases presents GRADE-assessed recommendations for the diagnosis, monitoring and treatment of osteoporosis in men. The recommendations are based on a comprehensive review of the latest research related to diagnostic and screening approaches for osteoporosis and its associated high fracture risk in men, covering disease burden, appropriate interpretation of bone densitometry (including the use of a female reference database for densitometric diagnosis in men) and absolute fracture risk, thresholds for treatment, and interventions that can be used therapeutically and their health economic evaluation. Future work should specifically address the efficacy of anti-osteoporosis medications, including denosumab and bone-forming therapies.

Challenges in and Opportunities for Electronic Health Record-Based Data Analysis and Interpretation

Electronic health records (EHRs) have been increasingly adopted in clinical practices across the United States, providing a primary source of data for clinical research, particularly observational cohort studies. EHRs are a high-yield, low-maintenance source of longitudinal real-world data for large patient populations and provide a wealth of information and clinical contexts that are useful for clinical research and translation into practice. Despite these strengths, it is important to recognize the multiple limitations and challenges related to the use of EHR data in clinical research. Missing data are a major source of error and biases and can affect the representativeness of the cohort of interest, as well as the accuracy of the outcomes and exposures. Here, we aim to provide a critical understanding of the types of data available in EHRs and describe the impact of data heterogeneity, quality, and generalizability, which should be evaluated prior to and during the analysis of EHR data. We also identify challenges pertaining to data quality, including errors and biases, and examine potential sources of such biases and errors. Finally, we discuss approaches to mitigate and remediate these limitations. A proactive approach to addressing these issues can help ensure the integrity and quality of EHR data and the appropriateness of their use in clinical studies.

Adherence Monitoring Package (AMoPac) in patients suspected of non-response to antihypertensive treatment: perceived usefulness by general practitioners

BACKGROUND

Non-adherence to antihypertensive agents is common, mainly because of the low perceived burden of high blood pressure. General practitioners (GPs) are unable to predict whether patients are adhering to a recommended treatment. Knowledge about adherence might be of clinical interest in patients non-responding to antihypertensive treatment.

AIM

To assess the usefulness of an Adherence Monitoring Package (AMoPac) to identify non-adherence in patients non-responding to antihypertensive treatment.

METHODS

AMoPac consists of (1) 4 weeks of electronic adherence monitoring, (2) pharmacist's feedback on patient's intake behaviour and (3) adherence metrics including clinical-pharmaceutical recommendations to the GP. AMoPac-HYP ('Adherence Monitoring Package to identify non-adherence in ambulatory HYPertensive patients') is an observational study among GPs and ambulatory patients with hypertension in a real-world setting. The primary outcome was GPs' perceived usefulness of AMoPac. Secondary outcomes were (1) frequency of medication problems and prescribing errors; (2) types of pharmacist's' recommendations; (3) acceptance of the recommendations by GPs; (4) medication adherence and (5) patients' satisfaction. Outcomes are reported descriptively. Data were collected with questionnaires and electronic monitoring of medicine intake.

RESULTS

Fifteen GPs and 15 patients with hypertension participated in the AMoPac-HYP Study. Patients were on average 62 years old, and mean blood pressure was 137/83 mmHg. All GPs rated AMoPac as useful. The most frequently mentioned use was excluding non-adherence in patients with hypertension (93%). Medication problems and prescribing errors were observed in 80% of the patients. The study pharmacist recommended adherence support (N=9 patients) and treatment optimisation (N=8 patients). The recommendations were accepted and implemented in 10 of 17 cases by the GP. Patients' mean taking and timing adherence were 90% and 86%, respectively. Satisfaction with the study procedures among patients was high.

CONCLUSION

AMoPac was rated as useful for identifying and excluding non-adherence in patients with hypertension and was highly accepted among patients. Including adherence data in clinical decision-making could contribute to optimising patient care.

A Novel Home-Based Medication Management Program and Its Influence on Hospitalization Rates among Home Health Care Recipients

Patients do not take their medicine as prescribed 50% of the time, and of medication-related hospital admissions in the United States, 33% to 69% are due to poor medication adherence, at a cost of approximately $100 billion a year. Continue CareRx (CCRx) is a novel home-based medication management program that includes adherence packaging alongside medication reconciliation, review, and education by clinicians. We hypothesized that home health patients receiving the CCRx service may have a lower hospitalization rate than control home health patients. Between May 1, 2021, and March 31, 2023, 113 home health patients whose insurance covered the program were enrolled in CCRx. Home health patients not eligible for the program due to a noncovered pharmacy insurance benefit made up the control group (n = 21,304), which was matched with the CCRx group on age range (45-99 years old) and gender (67% women). Hospitalization rate was calculated in both groups and compared using generalized estimating equations analysis. The control group had a total of 7015 hospitalizations during the study period during 2,128,738 total managed days, whereas the CCRx group had 21 hospitalizations during 23,622 total managed days. These translated into rates of 1203 hospitalizations per 1000 per year for the control group, and 324 hospitalizations per 1000 per year for the CCRx group. The results showed that there was a significant main effect of group in predicting individual annual hospitalization rate (Wald χ2 = 56.415, P < .01). Specifically, being in the control group was associated with a 43.42-fold increase in the likelihood of a higher hospitalization rate (95% Wald CI for odds ratios: 7.24-230.44). Home health recipients enrolled in CCRx experienced a 73.1% lower hospitalization rate than controls. Making the program more widely available to patients receiving home health care may present a significant opportunity to reduce hospitalizations in this group.

The role of adherence in patients with chronic diseases

In the long-term management of chronic diseases, adherence and persistence to prescribed medications are continuous challenges in order to obtain all the potential benefits of drug therapies. Suboptimal drug adherence and discontinuations of therapies remain the most frequent reasons why several diseases are poorly controlled in the population. One the main issue is that physicians are relatively limited in time and tools to detect patients with a poor adherence. The present review discusses present and future strategies that are now available or are being developed to detect and to support adherence in patients with chronic diseases and provides some simple clues to identify patients at high risk of discontinuation in the clinic.

Automated Messaging Program to Facilitate Systematic Home Blood Pressure Monitoring: Qualitative Analysis of Provider Interviews

BACKGROUND

Hypertension is a leading cause of cardiovascular and kidney disease in the United States, yet blood pressure (BP) control at a population level is poor and worsening. Systematic home BP monitoring (HBPM) programs can lower BP, but programs supporting HBPM are not routinely used. The MyBP program deploys automated bidirectional text messaging for HBPM and disease self-management support.

OBJECTIVE

We aim to produce a qualitative analysis of input from providers and staff regarding implementation of an innovative HBPM program in primary care practices.

METHODS

Semistructured interviews (average length 31 minutes) were conducted with physicians (n=11), nurses, and medical assistants (n=6) from primary care settings. The interview assessed multiple constructs in the Consolidated Framework for Implementation Research domains of intervention characteristics, outer setting, inner setting, and characteristics of individuals. Interviews were transcribed verbatim and analyzed using inductive coding to organize meaningful excerpts and identify salient themes, followed by mapping to the updated Consolidated Framework for Implementation Research constructs.

RESULTS

Health care providers reported that MyBP has good ease of use and was likely to engage patients in managing their high BP. They also felt that it would directly support systematic BP monitoring and habit formation in the convenience of the patient's home. This could increase health literacy and generate concrete feedback to raise the day-to-day salience of BP control. Providers expressed concern that the cost of BP devices remains an encumbrance. Some patients were felt to have overriding social or emotional barriers, or lack the needed technical skills to interact with the program, use good measurement technique, and input readings accurately. With respect to effects on their medical practice, providers felt MyBP would improve the accuracy and frequency of HBPM data, and thereby improve diagnosis and treatment management. The program may positively affect the patient-provider relationship by increasing rapport and bidirectional accountability. Providers appreciated receiving aggregated HBPM data to increase their own efficiency but also expressed concern about timely routing of incoming HBPM reports, lack of true integration with the electronic health record, and the need for a dedicated and trained staff member.

CONCLUSIONS

In this qualitative analysis, health care providers perceived strong relative advantages of using MyBP to support patients. The identified barriers suggest the need for corrective implementation strategies to support providers in adopting the program into routine primary care practice, such as integration into the workflow and provider education.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03650166; https://tinyurl.com/bduwn6r4.

Association Between Hypnotic Use and All-Cause Mortality in Patients with Chronic Obstructive Pulmonary Disease and Insomnia

Purpose

Hypnotics are commonly prescribed in patients with COPD to manage insomnia. Given the considerable risks associated with these drugs, the aim of the study was to evaluate the risk of all-cause mortality associated with hypnotics in a cohort of veterans with COPD presenting with insomnia.

Methods

We conducted a retrospective cohort study that used Veterans Health Administration Corporate Data Warehouse with data supplemented by linkage to Medicare, Medicaid, and National Death Index data from 2010 through 2019. The primary outcome was all-cause mortality. Analyses were conducted using propensity score 1:1 matching to balance baseline characteristics.

Results

Of the 5759 veterans with COPD (mean [SD] age, 71.7 [11.2]; 92% men), 3585 newly initiated hypnotic agents during the study period. During a mean follow-up of 7.4 (SD, 2.7) years, a total of 2301 deaths occurred, with 65.2 and 48.7 total deaths per 1000 person-years among hypnotic users and nonusers, respectively. After propensity matching, hypnotic use was associated with a 22% increased risk of mortality compared with hypnotic nonusers (hazard ratio [HR] 1.22; 95% confidence interval [CI],1.11-1.35). The benzodiazepine receptor agonists (BZRAs) group experienced a higher incidence rate of all-cause mortality compared to hypnotic nonusers (Incidence rate ratio [IRR] 1.27; 95% CI, 1.14-1.43). Conversely, the mortality rate of non-BZRA hypnotics decreased after the first 2 years and was not significantly different for hypnotic nonusers (IRR 1.04; 95% CI, 0.82-1.11).

Conclusion

Among patients with COPD and insomnia, treatment with hypnotics was associated with a higher risk of all-cause mortality. The association was observed in patients prescribed BZRAs. The risk of mortality for non-BZRAs moderated after the first 2 years, indicating a class effect.

Prevalence of Nonadherence to Medications among Geriatric Patients in Al-Madinah Al-Munawara City's Hospitals, Kingdom of Saudi Arabia

Introduction

Medication adherence is a major component in the treatment of chronic patients, especially the older adults. It acts as an essential part of a successful therapeutic outcome, increasing treatment benefits, and decreasing hospital admissions, health care utilization, and cost. Limited research regarding medication adherence has been conducted nationwide; however, data among the older adults is sparse due to the lack of research on this topic. Therefore, this study aimed to determine the prevalence of medication nonadherence among older adults' Saudi patients with chronic diseases living in Al-Madinah Al-Munawwarah city.

Method

A cross-sectional study was conducted on outpatient older patients with chronic diseases who visited clinics at different hospitals in Al-Madinah Al-Munawwarah city, from March until December 2022. The questionnaire was published in a conversational Arabic dialect. The adherence level was measured by the Adherence to Refills and Medications Scale (ARMS) and the reasons for medication nonadherence were collected by using the Cluig scale.

Results

65.1% of females and 34.9% of males have participated in this study. According to the ARMS scale, 67.9% of patients had poor medication adherence and 32.1% had good medication adherence. Poor adherence was higher in females compared to males, with a p value = 0.018. For educational level, the ARMS score in graduates was higher than patients who finished middle school and illiterate patients. Based on the Cluig scale, the most common reasons for medication nonadherence were forgetfulness, feeling well, polypharmacy, and subsequent avoidance of side effects. The findings indicate the gender-based differences in the factors that associated with medication nonadherence among older adults.

Conclusion

Medication adherence is crucial especially among older adults to improve clinical outcomes. The current results highlight the prevalence of medication adherence among the older adult population. This result shows the gender-based differences in the factors associated with medication nonadherence among the older adult population.

Insights Into Metformin XR Pharmacotherapy Knowledge Among Community Pharmacists: A Cross-Sectional Study

BACKGROUND

There is a little knowledge on the extent to which healthcare providers understand and accept the professional recommendations and appropriate dosing strategy regarding metformin XR.

OBJECTIVES

To evaluate UAE community pharmacists' knowledge, attitude, and practices (KAP) concerning metformin XR.

METHODS

This is a cross-sectional research study conducted amongst licensed community pharmacists. The survey took place via a questionnaire and physical interviews were held. The survey used in this study included questions on demographics and questions on the participants' attitudes, knowledge and practices concerning metformin XR. The factors influencing KAP regarding metformin XR were examined via simple logistic regression analysis.

RESULTS

Threehundred fifty-three (n = 353) participants were recruited in the study. Independent pharmacies constituted 57.5% of this study sample and 42.5% were chain pharmacies. The average knowledge score about metformin XR tablets was 42.5% with a confidence interval (CI) of 95% [37.3%, 47.4]. Better knowledge scores on metformin XR tablets was observed in respondents aged ⩾40 years (OR 2.97, 95% CI 1.63-5.4), having greater than 10 years in terms of experience (OR 2.28; 95% CI 1.25-4.16) and pharmacist graduated from Regional or international universities (OR 2.08; 95% CI 1.34-3.24). About 78% (n = 275) of the participants believed that metformin XR tablets have better efficacy and 63.2% (n = 233) indicated that metformin IR was associated with greater adverse effects.

CONCLUSION

This study demonstrated a distinct gap in knowledge, attitude and practice pertaining to metformin XR among community pharmacists in the UAE. The community pharmacists need to enhance their practice by receiving accurate and reliable data to support their decision-making on the prescribing of metformin XR. The implementation of novel guidelines and evidence dissemination strategies may help bridge this gap.

Costs of Prescription Drugs for Children and Parental Adherence to Long-Term Medications

Importance

The adverse effects of prescription drug costs on medication adherence and health have been well described for individuals. Because many families share financial resources, high medication costs for one could lead to cost-related nonadherence in another; however, these family-level spillover effects have not been explored.

Objective

To evaluate whether the cost of a child's newly initiated medication was associated with changes in their parent's adherence to their own medications and whether that differed by likely duration of treatment.

Design, Setting, and Participants

This cohort study used interrupted time-series analysis with a propensity score-matched control group from a large national US health insurer database (2010-2020) and included children initiating medication and their linked presumed parents using long-term medications.

Exposure

The cost of the child's initiated medication. Child medication cost was classified based on highest (≥90th) or lowest (<10th) decile from out-of-pocket medication spending, stratified by whether the medication was intended for short- or long-term use. Children initiating high-cost medications (based on the highest decile) were propensity-score matched with children initiating low-cost medications.

Main Outcome and Measures

The child's parent's adherence to long-term medication assessed by the widely used proportion of days covered metric in 30-day increments before and after the child's first fill date. Parent demographic characteristics, baseline adherence, and length of treatment, and family unit size and out-of-pocket medication spending were key subgroups.

Results

Across 47 154 included pairs, the parents' mean (SD) age was 42.8 (7.7) years. Compared with a low-cost medication, initiating a high-cost, long-term medication was associated with an immediate 1.9% (95% CI, -3.8% to -0.9%) reduction in parental adherence sustained over time (0.2%; 95% CI, -0.1% to 0.4%). Similar results were observed for short-term medications (0.6% immediate change; 95% CI, -1.3% to -0.01%). Previously adherent parents, parents using treatment for longer periods, and families who spent more out-of-pocket on medications were more sensitive to high costs, with immediate adherence reductions of 2.8% (95% CI, -4.9% to -0.6%), 2.7% (95% CI, -4.7% to -0.7%), and -3.8% (95% CI, -7.2% to -0.5%), respectively, after long-term medication initiation.

Conclusions and Relevance

In this cohort study small reductions in adherence across parents with higher child drug costs were observed. Health care systems should consider child-level or even household-level spending in adherence interventions or prescription policy design.

The risk of major adverse cardiovascular events associated with the use of hypnotics in patients with insomnia

OBJECTIVES

To examine whether hypnotic use in patients with insomnia reduces major adverse cardiovascular events, including all-cause mortality and nonfatal major adverse cardiovascular events.

METHODS

Using the Veterans Affairs Corporate Data Warehouse, we conducted a retrospective cohort study of 16,064 patients who were newly diagnosed with insomnia between January 1, 2010, and December 31, 2019. A pair of 3912 hypnotic users and nonusers were selected based on a 1:1 propensity score methodology. The primary outcome was extended major adverse cardiovascular events, a composite of the first occurrence of all-cause mortality or nonfatal major adverse cardiovascular events.

RESULTS

During the median follow-up of 4.8 years, a total of 2791 composite events occurred, including 2033 deaths and 762 nonfatal major adverse cardiovascular events. Although the incidence rates of major adverse cardiovascular events were comparable between hypnotic users and nonusers in the propensity-matched cohort, users of benzodiazepines and Z-drugs had a higher risk of all-cause mortality (hazard ratio 1.47 [95% CI, 1.17-1.88] and 1.20 [95% CI, 1.03-1.39], respectively), while serotonin antagonist and reuptake inhibitors users had a survival advantage (hazard ratio 0.79 [95% CI, 0.69-0.91]) compared with nonusers. There were no differences in the risk of nonfatal major adverse cardiovascular events between all classes of hypnotics. Male patients and those aged 60 years or younger who were using benzodiazepines or Z-drugs experienced higher major adverse cardiovascular events than their counterparts.

CONCLUSIONS

In patients with newly diagnosed insomnia, treatment with hypnotics resulted in higher extended major adverse cardiovascular events but not nonfatal major adverse cardiovascular events with benzodiazepine and Z-drug users compared with nonusers. The use of serotonin antagonist and reuptake inhibitors agents had a protective effect against major adverse cardiovascular events warranting further investigation.

Prevalence and predictors of primary nonadherence to medications prescribed in primary care

BACKGROUND

Most research on medication adherence has focused on secondary nonadherence and persistence to therapy. Medication prescriptions that are never filled by patients (primary nonadherence) remain understudied in the general population.

METHODS

We linked prescribing data from primary care electronic medical records to comprehensive pharmacy dispensing claims between January 2013 and April 2019 in British Columbia (BC) to estimate primary nonadherence, defined as failure to dispense a new medication or its equivalent within 6 months of the prescription date. We used hierarchical multivariable logistic regression to determine prescriber, patient and medication factors associated with primary nonadherence among community-dwelling patients in primary care.

RESULTS

Among 150 565 new prescriptions to 34 243 patients, 17% of prescriptions were never filled. Primary nonadherence was highest for drugs prescribed mostly on an as-needed basis, including topical corticosteroids (35.1%) and antihistamines (23.4%). In multivariable analysis, primary nonadherence was lower for prescriptions issued by male prescribers (odds ratio [OR] 0.66, 95% confidence interval [CI] 0.50-0.88). Primary nonadherence decreased with patient age (OR 0.91, 95% CI 0.90-0.92 for each additional 10 years) but increased with polypharmacy among patients aged 65 years or older. Patients filled more than 82% of their medication prescriptions within 2 weeks after their primary care provider visit.

INTERPRETATION

The prevalence of primary nonadherence to new prescriptions was 17%. Interventions to address primary nonadherence could target older patients with multiple medication use and within the first 2 weeks of the prescription issue date.

Asthma and COPD: Comparison with International Guidelines and Medication Adherence in Belgium

Asthma and chronic obstructive pulmonary disease (COPD) are major chronic conditions. It is possible to limit their impact by controlling symptoms, which limits exacerbations and worsening of the disease, by choosing the appropriate treatment and ensuring that the patient adheres to it. The main purpose of this study was to assess medication adherence and persistence with inhaled medications for chronic treatment of asthma and COPD, as well as to evaluate the factors influencing this adherence. Medication adherence was measured from January 2013 to December 2016 using continuous multiple-interval measures of medication availability (CMA). Persistence was evaluated by treatment episodes (TE). We analyzed the influence of different factors on CMA such as sex, age, type of device, and the realization of the "new medicines service" (NMS), introduced in Belgium in October 2013 to support patients in adhering to their treatment. We also analyzed the consumption of these inhaled medications within the Belgian population and compared them with the Global Initiative for Asthma (GINA) and the Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommendations. Medication adherence varied greatly between the different pharmacological classes: inhaled corticosteroids (ICS) alone or in combination with long-acting beta agonists (LABA) had the lowest medication adherence and persistence, while adherence was highest for the long-acting muscarinic antagonists (LAMA) and LABA/LAMA associations. The NMS seemed to have a positive impact on medication adherence, although few patients completed the two guidance interviews offered by the service. In addition, only a minority of the targeted patients took advantage of this new service.

Estimating medication adherence from Electronic Health Records: comparing methods for mining and processing asthma treatment prescriptions

BACKGROUND

Medication adherence is usually defined as the extent of the agreement between the medication regimen agreed to by patients with their healthcare provider and the real-world implementation. Proactive identification of those with poor adherence may be useful to identify those with poor disease control and offers the opportunity for ameliorative action. Adherence can be estimated from Electronic Health Records (EHRs) by comparing medication dispensing records to the prescribed regimen. Several methods have been developed in the literature to infer adherence from EHRs, however there is no clear consensus on what should be considered the gold standard in each use case. Our objectives were to critically evaluate different measures of medication adherence in a large longitudinal Scottish EHR dataset. We used asthma, a chronic condition with high prevalence and high rates of non-adherence, as a case study.

METHODS

Over 1.6 million asthma controllers were prescribed for our cohort of 91,334 individuals, between January 2009 and March 2017. Eight adherence measures were calculated, and different approaches to estimating the amount of medication supply available at any time were compared.

RESULTS

Estimates from different measures of adherence varied substantially. Three of the main drivers of the differences between adherence measures were the expected duration (if taken as in accordance with the dose directions), whether there was overlapping supply between prescriptions, and whether treatment had been discontinued. However, there are also wider, study-related, factors which are crucial to consider when comparing the adherence measures.

CONCLUSIONS

We evaluated the limitations of various medication adherence measures, and highlight key considerations about the underlying data, condition, and population to guide researchers choose appropriate adherence measures. This guidance will enable researchers to make more informed decisions about the methodology they employ, ensuring that adherence is captured in the most meaningful way for their particular application needs.

Comparative Assessment of Diet Quality and Adherence to a Structured Nutrition and Exercise Intervention Compared with Usual Care in Pregnancy in a Randomized Trial

Background

In trials testing the efficacy of diet and exercise modifications during pregnancy on health outcomes, assessment of participant adherence to interventions of diet and exercise is rarely reported, with few standard methods existing to measure adherence.

Objective

We aimed to assess the maternal diet quality and create an algorithm to evaluate adherence to an intervention of high protein/dairy nutrition and walking exercise from early pregnancy to birth.

Methods

In Be Healthy in Pregnancy randomized trial (NCT01693510), diet quality was measured using scores from an adapted PrimeScreen food frequency questionnaire, nutrient intake assessed by 3-day diet records, and physical activity using accelerometry at 14-17 (early), 26-28 (middle), and 36-38 (late) weeks' gestation. A novel adherence score was derived by combining data for compliance with prescribed protein and energy intakes and daily step counts in the intervention group. Between-group diet quality scores and changes in adherence scores in the intervention group across pregnancy were analyzed using generalized estimating equations adjusted for prepregnancy body mass index and study site.

Results

Diet scores were similar for intervention (n = 55) and control (n = 56) groups at baseline but only the intervention group significantly improved and maintained their scores from early to middle (18.7 ± 7.6 vs. 22.9 ± 6.1; P < 0.001) and late (22.5 ± 6.9; P < 0.008) pregnancy. Protein intake was significantly (P < 0.001) higher but energy intakes were similar in the intervention group compared with those in the control group. Adherence scores for the intervention increased significantly (P < 0.01) from early (1.52 ± 0.70) to midpregnancy (1.89 ± 0.82) but declined from midpregnancy to late (1.55 ± 0.78; P < 0.0005) pregnancy primarily owing to lower step counts.

Conclusions

Adherence to an intervention may decline toward the end of pregnancy, particularly in maintaining physical activity. Creation of adherence scores is a feasible approach to measure combined intervention compliance for diet and physical activity and may increase transparency in interpreting results of randomized trials in pregnancy.This trial was registered at clinicaltrials.gov as NCT01689961 (https://clinicaltrials.gov/ct2/show/NCT01689961?cond=NCT01689961&rank=1; registered on 21 September 2012).

Factors Associated With Asthma Biologic Prescribing and Primary Adherence Among Adults in a Large Health System

BACKGROUND

The availability of asthma biologics may not benefit all patients equally.

OBJECTIVE

We sought to identify patient characteristics associated with asthma biologic prescribing, primary adherence, and effectiveness.

METHODS

A retrospective, observational cohort study of 9,147 adults with asthma who established care with a Penn Medicine asthma subspecialist was conducted using Electronic Health Record data from January 1, 2016, to October 18, 2021. Multivariable regression models were used to identify factors associated with (1) receipt of a new biologic prescription; (2) primary adherence, defined as receiving a dose in the year after receiving the prescription, and (3) oral corticosteroid (OCS) bursts in the year after the prescription.

RESULTS

Factors associated with a new prescription, which was received by 335 patients, included being a woman (odds ratio [OR] 0.66; P = .002), smoking currently (OR 0.50; P = .04), having an asthma hospitalization in the prior year (OR 2.91; P < .001), and having 4+ OCS bursts in the prior year (OR 3.01; P < .001). Reduced primary adherence was associated with Black race (incidence rate ratio 0.85; P < .001) and Medicaid insurance (incidence rate ratio 0.86; P < .001), although most in these groups, 77.6% and 74.3%, respectively, still received a dose. Nonadherence was associated with patient-level barriers in 72.2% of cases and health insurance denial in 22.2%. Having more OCS bursts after receiving a biologic prescription was associated with Medicaid insurance (OR 2.69; P = .047) and biologic days covered (OR 0.32 for 300-364 d vs 14-56 d; P = .03).

CONCLUSIONS

In a large health system, primary adherence to asthma biologics varied by race and insurance type, whereas nonadherence was primarily explained by patient-level barriers.

Adjuvant chemotherapy non-adherence, patient-centered communication, and patient-level factors in elderly breast and colon cancer patients

BACKGROUND

We examined patient-level factors (patient characteristics, disease and treatment factors, and patient experience), patient-centered communication (PCCM), and non-adherence to adjuvant chemotherapy (AC) guidelines among breast and colon cancer patients to inform AC adherence promotion and improve clinical outcomes.

METHODS

Descriptive statistics for patient-level factors, PCCM, and AC non-adherence (primary non-adherence, non-persistence at 3 and 6 months) were obtained. Multiple logistic regression models were used to estimate AC non-adherence after accounting for the identified patient-level factors.

RESULTS

The majority of the sample (n = 577) were White (87%), breast cancer patients (87%), and reported PCCM (provider communication score ≥ 90%, 73%, provider communication score = 100%, 58%). All three levels of AC nonadherence were significantly higher in breast cancer patients (69%, 81%, and 89% for primary non-adherence, and non-persistence at 3 and 6 months, respectively) than colon cancer patients (43%, 46%, and 62%, respectively). Male sex, survey assistance, and low/average ratings of a personal doctor, specialist, and healthcare were associated with lower PCCM. Older age, breast cancer diagnosis, and diagnosis group following 2007-2009 increased the likelihood of all three levels of AC non-adherence. Comorbidities and PCCM-90 were exclusively associated with non-persistence at 3 months.

CONCLUSIONS

Adjuvant chemotherapy non-adherence varied by cancer diagnosis and treatment factors. The relationship between PCCM and AC non-adherence differed by level of PCCM, time period, and the presence of comorbidities. AC guideline adherence, communication, and value-concordant treatment should be assessed and compared simultaneously to improve our understanding of their interrelationships.

Relationship Between the Effect of Roxadustat and Comorbid Diabetes in Non-dialyzed Chronic Kidney Disease Patients: A Retrospective Observational Study

Introduction The dose of roxadustat, a hypoxia-inducible factor prolyl hydroxylase (HIF-PH) inhibitor, required to treat anemia, the hemoglobin level and the rate of hemoglobin target achievement were retrospectively investigated in non-dialyzed chronic kidney disease (CKD) patients with and without type 2 diabetes. Methods As the full analysis set, 25 subjects (10 with diabetes and 15 without diabetes) were observed over six months among 44 non-dialyzed CKD patients who received roxadustat. The target hemoglobin level was set at 110-130 g/L. Results The comorbidities of diabetes and body weight at baseline were significantly associated with each dose of roxadustat at six months and the change in each dose of roxadustat from the initiation of roxadustat treatment. There was no significant difference in the amount of increase in the hemoglobin level (14±11 g/L vs. 15±8 g/L) and the rate of hemoglobin target achievement (70% vs. 67%) between patients with and without diabetes. Each dose of roxadustat gradually decreased in patients without diabetes, whereas it increased in those with diabetes. Each dose of roxadustat was significantly higher in patients with diabetes than in those without diabetes at 3 (60±21 mg vs. 42±14 mg) and 6 (61±22 mg vs. 41±14 mg) months after the initiation of roxadustat treatment. Conclusion Roxadustat is useful for the treatment of anemia in both CKD patients with and without diabetes. However, the dose required to achieve the target hemoglobin level may be higher in patients with diabetes than in those without diabetes.

Treatment With Opioids Is Not Associated With Poor Outcomes Among Older Adults With Lumbar Spinal Stenosis Receiving Epidural Injections

STUDY DESIGN

Secondary analysis of a randomized controlled trial.

OBJECTIVE

To assess how baseline treatment with opioids is associated with pain and function in older adults with lumbar spinal stenosis who receive epidural injections.

SUMMARY OF BACKGROUND DATA

Data were obtained from the Lumbar Epidural Steroid injections for Spinal Stenosis trial, a double-blind, multisite, randomized controlled trial.

METHODS

Baseline treatment with opioids was assessed from electronic medical record prescription pharmacy data or from health utilization records collected from patients. We calculated adjusted changes in back pain numerical rating scale, leg pain numerical rating scale, and back-related disability (Roland Morris Disability Questionnaire scores) from baseline to three weeks and to six weeks among patients treated and not treated with opioids at baseline using generalized linear regression.

RESULTS

Baseline treatment with opioids was not significantly associated with back pain intensity (adjusted difference in means at three weeks of follow-up between patients treated with opioids at baseline versus not [±95% CI, 0.1 (-0.7, 0.7)], leg pain intensity [-0.2 (-0.9, 0.4)], or back-related function [-0.8 (-2.1, 0.4)]. We found similar results at six weeks of follow-up.

CONCLUSIONS

Among older adults with lumbar spinal stenosis who are receiving epidural injections, those treated with opioids at baseline had similar outcomes to those who were not.

The Impact of Electronic Health Record Interventions on Patient Access to Post-Hospital Discharge Prescriptions

Purpose: Assess the impact of electronic health record interventions on patient access to post-hospital discharge prescriptions. Methods: Five interventions were implemented in the electronic health record to improve patient access to prescriptions after discharge from hospital: electronic prior authorization, alternative medication suggestions, order sets, mail order pharmacy alerts, and medication interchange instructions. This was a retrospective cohort study of patient responses from discharges during 6 months before the first intervention implementation and 6 months after the last intervention implementation documented in the electronic health record and a transition-in-care platform. Primary endpoint was the proportion of discharges with patient-reported issues that would have been prevented by the studied interventions out of number of discharges with at least one prescription, analyzed using Chi-squared test (level of significance .05). Results: Discharges with patient-reported issues that would have been prevented by the studied interventions decreased from 1.68 to 1.07 out of 1000 discharges with prescriptions (P < .001). Conclusion: Interventions in the electronic health record reduced barriers faced by patients to picking up prescriptions post-discharge from hospital, potentially leading to improved patient satisfaction and improved health outcomes. Important factors to consider for electronic health record intervention implementation are workflow development and intrusiveness of clinical decision support. Multiple targeted electronic health record interventions can improve patients' access to prescriptions after discharge from hospital.

Oversight of in-office dispensing and samples in dermatology

The provision of samples and in-office dispensing of products and medications to patients are important, yet often controversial, practices in dermatology. Opinions on the practices of sampling and in-office dispensing vary greatly among dermatologists. Ultimately, there are several advantages and disadvantages associated with each practice, and common topics of discussion include ethics, costs, safety, and adherence. Many of the concerns associated with the practices of sampling and dispensing in dermatology may be mitigated by careful consideration and action by prescribers. Providers should be aware of their current practices surrounding these issues and, if used, methods by which these practices can be improved to optimize patient care. With careful consideration, it may be possible to practice sampling and dispensing of products and medications safely, ethically, and to the patients' advantage as an integral part of the dermatology practice.

Disparities in Medicare beneficiaries' receiving medication synchronization

BACKGROUND

Medication synchronization (med-sync) aligns patients' monthly or quarterly chronic medications to a predetermined single pickup date at a community pharmacy. The study objective was to examine med-sync enrollment disparities based on Medicare beneficiaries' predisposing, enabling, and need characteristics.

METHODS

This was a retrospective cohort study using a Medicare dataset of beneficiaries receiving medications from pharmacies that self-identified as providing med-sync. Medicare beneficiaries who were continuously enrolled in fee-for-service medical and pharmacy benefits during the study period (2014-2016) were included. Study cohorts (med-sync and non-med-sync patients) were defined, and bivariate and multivariable logistic regression analyses were performed. Andersen's Health Services Utilization Model guided our inclusion of predisposing, enabling, and need characteristics to examine for association with med-sync enrollment.

RESULTS

A total of 170,180 beneficiaries were included, of which 13,193 comprised the med-sync cohort and 156,987 comprised the non-med-sync cohort. Bivariate logistic regression analysis revealed statistically significant differences (P < 0.05) in cohorts based on age, geographic region, type of residence, number of unique chronic medications, comorbidities, outpatient visits, and inpatient hospitalizations. Beneficiaries had higher odds of being enrolled in med-sync with increasing age (adjusted odds ratio [AOR] 1.003 [95% CI 1.001-1.005]) and if they resided in the Northeast (AOR 1.094 [95% CI 1.018-1.175]), South (AOR 1.109 [95% CI 1.035-1.188]), and West (AOR 1.113 [95% CI 1.020-1.215]) than those in the Midwest. Beneficiaries residing in nonmetro areas had lower odds of enrollment (AOR 0.914 [95% CI 0.863-0.969]) than those in metro areas. Beneficiaries with previous fewer inpatient hospitalizations (AOR 0.945 [95% CI 0.914-0.977]) were more likely to be enrolled, and those with more outpatient visits (AOR 1.003 [95% CI 1.001-1.004]) were more likely to be enrolled. Those taking a higher number of oral chronic medications (AOR 1.005 [95% CI 1.002-1.008]) had greater odds of enrollment in med-sync.

CONCLUSIONS

Med-sync program expansion opportunities exist to address potential enrollment disparities based on age, geographic region, metropolitan area, and prior health utilization. Further studies are needed to develop and examine strategies among pharmacies to improve med-sync enrollment outreach to these subgroups of patients.

Formulary & benefit and real-time pharmacy Benefit: Electronic standards delivering value to prescribers and pharmacists

The use of standard transactions in the electronic sharing of prescription-related information among payers, prescribers and pharmacists aids in the delivery of effective, safe, and affordable medication therapy to patients. Integral to electronic medication management (eMM) in this environment is the availability of data to aid in the determination of the most appropriate medication for a patient considering benefits coverage restrictions, therapeutic effectiveness, and cost. Key elements of this formulary decision support are the National Council for Prescription Drug Programs Formulary & Benefit (F&B) standard and the related Real-time Pharmacy Benefit (RTPB) standard. In this article, we review the foundational role of F&B in the electronic prescribing of medications, the value it delivers to prescribers, and dispensing pharmacists. The combination of F&B and RTPB to enhance the quality of information available in eMM is also discussed with evidence presented on how these standards help to minimize manual tasks and rework in the pharmacy, optimize time to therapy, lower patient out-of-pocket costs, and result in the dispensing of prescriptions less likely to be abandoned. We conclude with a view of the future of F&B to support new eMM requirements.

Disagreement between pharmacy claims and direct interview to identify patients with non-adherence to chronic cardiometabolic medications

BACKGROUND

Accurate methods of identifying patients with suboptimal adherence to cardiometabolic medications are needed, and each approach has benefits and tradeoffs.

METHODS

We used data from a large trial of patients with poorly controlled cardiometabolic disease and evidence of medication non-adherence measured using pharmacy claims data whose adherence was subsequently assessed during a telephone consultation with a clinical pharmacist. We then evaluated if the pharmacist assessment agreed with the non-adherence measured using claims. When pharmacist and claims assessments disagreed, we identified reasons why claims were insufficient and used multivariable modified Poisson regression to identify patient characteristics associated with disagreement.

RESULTS

Of 1,069 patients identified as non-adherent using claims (proportion of days covered [PDC] <80%), 646 (60.4%) were confirmed as non-adherent on pharmacist interview. For the 423 patients (39.6%) where the interview disagreed with the claims, the most common reasons were paying cash or using an alternate insurance (36.6%), medication discontinuation or regimen change (32.8%), and recently becoming adherent (26.7%). Compared to patients whose claims and interview both showed non-adherence, patients whose interview disagreed with claims were less likely to miss outpatient office visits (RR:0.91, 95%CI:0.85-0.97) and more likely to have a baseline PDC above the median (RR:1.35, 95%CI:1.10-1.64).

CONCLUSIONS

Among patients identified as non-adherent by claims, 39.6% were observed to be adherent when assessed during pharmacist consultation. This discrepancy was largely driven by paying out-of-pocket, using alternative insurance, or medication discontinuation or change. These findings have important implications for using pharmacy claims to identify and intervene upon medication non-adherence.

A Pilot Study Exploring the Impact of a Primary Medication Non-Adherence Intervention among Four Chronic Disease States in One Regional Division of a Large Community Pharmacy Chain

There is a 12.2% rate of primary medication non-adherence (PMN) among community pharmacy patients. The Pharmacy Quality Alliance (PQA) has developed a standardized definition of PMN to aid stakeholders in addressing PMN. However, little research had been conducted to date on how to address PMN. The objective of the study was to determine the impact of an evidence-based adherence intervention program on PMN rates among four chronic disease states and to identify and characterize factors associated with PMN. Patients at risk of PMN were randomized into a control or intervention group. Those in the intervention group received a live call from a pharmacist to determine reason for and to discuss solutions to overcome PMN. Subjects included adult patients with newly prescribed medications used to treat diabetes, hypertension, hyperlipidemia, and/or chronic obstructive pulmonary disease (COPD). This study occurred in six pharmacies across one regional division of a national supermarket, community pharmacy chain. Prescriptions were considered newly initiated when the same drug, or its generic equivalent, had not been filled during the preceding 180 days. Prescriptions were considered at risk if they had not been obtained by day 7 of it being filled. Prescriptions were considered PMN if the patient had not obtained it, or an appropriate alternative, within 30 days after it was prescribed. During the 4-month intervention period, 203 prescriptions were included in the study with 94 in the intervention group and 109 in the control group. There was a 9% difference (p = 0.193) in PMN between the intervention group (44 patients, 47%) and the control group (61 patients, 56%). The therapeutic class most at risk of PMN was statins (34%). Cost (26%) and confusion/miscommunication (15%) were the most common reasons for PMN within the intervention group. Among the four chronic disease states studied, the intervention had the largest impact on hypertension. The PMN intervention did not significantly decrease PMN rates.

Utilization of remote e-prescription (Anat) in Saudi Arabia during COVID-19: Factors associated with primary adherence and antibiotic prescription

Background

The COVID-19 pandemic has affected healthcare systems globally. Various health care technologies have been used to mitigate the risk of disease transmission. Telemedicine is one such technology, and remote consulting and prescribing comprise one of its key aspects. In Saudi Arabia, telephone health services have been widely used through the free Medical Consultation Call Center (937). This platform facilitates medical consultations for all citizens, residents, and visitors. After consultations, healthcare providers are able to issue authenticated e-prescriptions using the Anat platform.

Objectives

To explore the utilization of the Anat remote prescription system in Saudi Arabia during the COVID-19 pandemic and to identify the factors associated with antibiotic prescription and primary medication adherence.

Methods

This retrospective analysis included data from the Anat e‑prescription system using a stratified random sample of 25000 prescriptions issued in Saudi Arabia in 2020. Predictive factors related to the patients, practitioners, and prescriptions were identified through bivariate and multivariate logistic regression analyses.

Results

Out of 25,000 e-prescriptions, 8885 were dispensed, resulting in a 35.5% primary medication adherence rate. The significant predictors of primary adherence were children, respiratory diseases, and antibacterial drugs. In addition, antibiotics made up 32.1% of the e-prescriptions. The prescription of antibiotics was significantly associated with male sex, children, genitourinary system diseases, and being treated by radiologists.

Conclusions

Almost two thirds 62.2% of e-prescriptions were undispensed, with antibiotic eprescriptions at 32.1%. Findings emphasize the need to enhance primary medication adherence and antibiotic prescription interventions. These findings could aid decision-makers in improving patient-centered e-prescribing practices.