Medication (Re)fill Adherence Measures Derived from Pharmacy Claims Data in Older Americans: A Review of the Literature

Medications Adherence and Associated Factors Among Patients with Stroke in Iraq

Purpose

Stroke poses significant challenges to affected individuals, their families, and healthcare systems, with adherence to medications being a pivotal determinant of health outcomes. In this study, we aim to evaluate the medication adherence of stroke patients living in Iraq, and explore how patients' demographic and clinical details relate to their adherence levels. Furthermore, we seek to assess the self-care practices used by stroke patients and their adherence to them.

Patients and Methods

We carried out a cross-sectional correlational study conducted from November 2022 to April 2023, stroke patients diagnosed in seven hospitals across Baghdad and Al-Mothanna governorate were recruited, with diagnoses confirmed by physicians and senior neurologists using MRI and/or CT scans. Patients' adherence to medications, demographic data, clinical characteristics, and self-care activities were analyzed using descriptive statistics and regression analyses.

Results

Of the 200 participants, mean age was 58.27 years, with males constituting 53.5%. About 40.5% had a hemorrhagic stroke, and 59.5% an ischemic stroke. The mean adherence score was 13.36 (SD= 4.658) out of a possible 28. Factors significantly correlated with medication adherence included age, monthly income, time since having a stroke, and education level. Adherence was also significantly linked to having diabetes mellitus or high blood pressure. The assessment of participants' self-care activities and medication adherence revealed that responses to questions about healthcare habits varied, with "None" being the most common response for most items. Notably, we found no significant association between adherence and factors such as gender, marital status, living place, and smoking status.

Conclusion

Medication adherence remains suboptimal among stroke patients in Iraq. Various demographic and clinical factors play a role in influencing adherence. The conformity to medication regimens and factors associated with it among individuals who have suffered a stroke in Iraq is vital.

Investigating adherence to tyrosine kinase inhibitors in renal cancer

INTRODUCTION

Tyrosine kinase inhibitors (TKIs) have been used as the first-line treatment for many patients with renal cell carcinoma (RCC), the seventh most common cancer in the United Kingdom. However, suboptimal adherence to TKIs can result in poor clinical prognosis. This study quantified RCC patients' adherence to TKIs and explored factors associated with suboptimal adherence.

METHOD

This retrospective cohort study was conducted at a specialist oncology tertiary hospital in Northwest England, using pharmacy dispensing records between November 2021 and March 2022. TKI prescriptions dispensed to patients with RCC were extracted to calculate the persistency gaps (≥7 or ≥14 days) and medication possession ratio (MPR). Multilevel regression analysis was conducted to associate MPR and persistency gaps with specific patient-related and TKI-related factors. This study did not require ethics approval.

RESULTS

Of the 2225 prescriptions dispensed to 109 patients, 469 (23.4%) and 274 (13.7%) persistency gaps of ≥7 and ≥14 days were identified. About 75% and 92% of patients had a persistency gap of ≥7 days within the first 90 days and 180 days. The length of time since the first TKI prescription (p < 0.001) and the use of sunitinib(p = 0.003) were significantly associated with the number of prescription gaps of ≥7 days. Moreover, the median MPR was 95.6% (interquartile range: 90.7%, 100.1%). Similarly, the length of time since the first TKI prescription was dispensed (p < 0.001) and the use of sunitinib (p = 0.034) were significantly associated with MPR.

DISCUSSION AND CONCLUSION

This single-centre study found that patients with RCC generally adhere to TKIs (MPR > 90%), but many patients experienced a persistency gap. The crucial window to mitigate TKI utilisation is within 180 days after the initial dispensing of TKIs. Further large-scale studies are required to comprehensively investigate other factors associated with adherence to TKIs and develop interventions to improve adherence and medication use problems.

Formative Perceptions of a Digital Pill System to Measure Adherence to Heart Failure Pharmacotherapy: Mixed Methods Study

BACKGROUND

Heart failure (HF) affects 6.2 million Americans and is a leading cause of hospitalization. The mainstay of the management of HF is adherence to pharmacotherapy. Despite the effectiveness of HF pharmacotherapy, effectiveness is closely linked to adherence. Measuring adherence to HF pharmacotherapy is difficult; most clinical measures use indirect strategies such as calculating pharmacy refill data or using self-report. While helpful in guiding treatment adjustments, indirect measures of adherence may miss the detection of suboptimal adherence and co-occurring structural barriers associated with nonadherence. Digital pill systems (DPSs), which use an ingestible radiofrequency emitter to directly measure medication ingestions in real-time, represent a strategy for measuring and responding to nonadherence in the context of HF pharmacotherapy. Previous work has demonstrated the feasibility of using DPSs to measure adherence in other chronic diseases, but this strategy has yet to be leveraged for individuals with HF.

OBJECTIVE

We aim to explore through qualitative interviews the facilitators and barriers to using DPS technology to monitor pharmacotherapy adherence among patients with HF.

METHODS

We conducted individual, semistructured qualitative interviews and quantitative assessments between April and August 2022. A total of 20 patients with HF who were admitted to the general medical or cardiology service at an urban quaternary care hospital participated in this study. Participants completed a qualitative interview exploring the overall acceptability of and willingness to use DPS technology for adherence monitoring and perceived barriers to DPS use. Quantitative assessments evaluated HF history, existing medication adherence strategies, and attitudes toward technology. We analyzed qualitative data using applied thematic analysis and NVivo software (QSR International).

RESULTS

Most participants (12/20, 60%) in qualitative interviews reported a willingness to use the DPS to measure HF medication adherence. Overall, the DPS was viewed as useful for increasing accountability and reinforcing adherence behaviors. Perceived barriers included technological issues, a lack of need, additional costs, and privacy concerns. Most were open to sharing adherence data with providers to bolster clinical care and decision-making. Reminder messages following detected nonadherence were perceived as a key feature, and customization was desired. Suggested improvements are primarily related to the design and usability of the Reader (a wearable device).

CONCLUSIONS

Overall, individuals with HF perceived the DPS to be an acceptable and useful tool for measuring medication adherence. Accurate, real-time ingestion data can guide adherence counseling to optimize adherence management and inform tailored behavioral interventions to support adherence among patients with HF.

Polypharmacy and medication fill nonadherence in a population-based sample of adolescent and young adult cancer survivors, 2008-2017

PURPOSE

We examined the association between polypharmacy-an established risk factor for nonadherence in the elderly-and medication fill nonadherence in a large national sample of adolescent and young adult cancer survivors (AYAs) in the USA.

METHODS

We pooled data (2008-2017) from the Medical Expenditure Panel Survey. We defined polypharmacy as ≥ 3 unique medications prescribed, based on self-report and pharmacy data, and medication fill nonadherence as self-reported delay or inability to obtain a necessary medication. We estimated prevalence of medication fill nonadherence among AYAs (age 18-39 years with a cancer history). We used logistic regression to estimate the association between (1) polypharmacy and medication fill nonadherence in AYAs, and (2) total number of medications prescribed and medication fill nonadherence, controlling for sex, number of chronic conditions, disability, and survey year.

RESULTS

AYAs (n = 598) were predominantly female (76.2%), age 30-39 years (64.9%), and non-Hispanic White (72.1%). Nearly half were poor (19.0%) or near-poor/low income (21.6%). One in ten AYAs reported medication fill nonadherence (9.75%). Of these, more than 70% cited cost-related barriers as the reason. AYAs with polypharmacy had 2.49 times higher odds of medication fill nonadherence (95%CI 1.11-5.59), compared to those without polypharmacy. Odds of medication fill nonadherence increased by 16% with each additional medication prescribed (AOR 1.16, 95% CI 1.07-1.25).

CONCLUSIONS

Polypharmacy may be an important risk factor for medication fill nonadherence in AYAs in the USA.

IMPLICATIONS FOR CANCER SURVIVORS

Improving AYAs' medication adherence requires eliminating cost-related barriers, particularly for those with polypharmacy.

Clinical pharmacist practitioners on primary care teams play an important role in caring for complex patients with diabetes

PURPOSE

To evaluate whether clinical pharmacist practitioners (CPPs) are being utilized to care for patients with complex medication regimens and multiple chronic illnesses, we compared the clinical complexity of diabetes patients referred to CPPs in team primary care and those in care by other team providers (OTPs).

METHODS

In this cross-sectional comparison of patients with diabetes in the US Department of Veterans Affairs (VA) healthcare system in the 2017-2019 period, patient complexity was based on clinical factors likely to indicate need for more time and resources in medication and disease state management. These factors include insulin prescriptions; use of 3 or more other diabetes medication classes; use of 6 or more other medication classes; 5 or more vascular complications; metabolic complications; 8 or more other complex chronic conditions; chronic kidney disease stage 3b or higher; glycated hemoglobin level of ≥10%; and medication regime nonadherence.

RESULTS

Patients with diabetes referred to one of 110 CPPs for care (n = 12,728) scored substantially higher (P < 0.001) than patients with diabetes in care with one of 544 OTPs (n = 81,183) on every complexity measure, even after adjustment for age, sex, race, and marital status. Based on composite summary scores, the likelihood of complexity was 3.42 (interquartile range, 3.25-3.60) times higher for those in ongoing CPP care (ie, those with 2 or more visits) versus OTP care. Patients in CPP care also were, on average, younger, more obese, and had more prior outpatient visits and hospital stays.

CONCLUSION

The greater complexity of patients with diabetes seen by CPPs in primary care suggests that CPPs are providing valuable services in comprehensive medication and disease management of complex patients.

Assessment of Medication Adherence Using Pharmacy Data Before and After Percutaneous Coronary Intervention

Objective

Adherence to anti-platelet medications is critical following coronary stenting, but prior studies indicate that clinician assessment and patient self-assessment of adherence are poorly correlated with future medication-taking behavior. We therefore sought to determine if integrated pharmacy data can be used to identify patients at high risk of non-adherence after percutaneous coronary interventions (PCI).

Methods

Using Veteran Affairs (VA) Clinical Assessment, Reporting, and Tracking (CART) data linked with pharmacy records, we assessed adherence to cardiovascular medications from 2012 to 2018. Adherence was defined as the proportion of days covered (PDC) ≥ 0.80. We assessed the association of pre-PCI adherence with post-PCI adherence to P2Y12 inhibitors and clinical outcomes using logistic regression and Cox proportional hazard models, respectively.

Results

Among 56,357 patients, 66.0% filled at least 1 cardiovascular medication within VA for the year prior to PCI and were evaluable for adherence. Pre-PCI non-adherence was 20.7%, and non-adherent patients were more likely to be younger and present non-electively. Non-adherent patients were less likely to adhere to P2Y12 inhibitor therapy after PCI (Adjusted OR 0.45 C.I. 0.41-0.46), compared with adherent patients, and had a higher adjusted risk of mortality (HR 1.17 C.I. 1.03-1.33).

Conclusion

Adherence to cardiovascular medications prior to PCI can be assessed for most patients using pharmacy data, and past adherence is associated with future adherence and mortality after PCI. Use of integrated pharmacy data to identify high-risk patients could improve outcomes and cost-effectiveness of adherence interventions.

Psychometric Properties of a Machine Learning-Based Patient-Reported Outcome Measure on Medication Adherence: Single-Center, Cross-Sectional, Observational Study

BACKGROUND

Medication adherence plays a critical role in controlling the evolution of chronic disease, as low medication adherence may lead to worse health outcomes, higher mortality, and morbidity. Assessment of their patients' medication adherence by clinicians is essential for avoiding inappropriate therapeutic intensification, associated health care expenditures, and the inappropriate inclusion of patients in time- and resource-consuming educational interventions. In both research and clinical practices the most extensively used measures of medication adherence are patient-reported outcome measures (PROMs), because of their ability to capture subjective dimensions of nonadherence. Machine learning (ML), a subfield of artificial intelligence, uses computer algorithms that automatically improve through experience. In this context, ML tools could efficiently model the complexity of and interactions between multiple patient behaviors that lead to medication adherence.

OBJECTIVE

This study aimed to create and validate a PROM on medication adherence interpreted using an ML approach.

METHODS

This cross-sectional, single-center, observational study was carried out a French teaching hospital between 2021 and 2022. Eligible patients must have had at least 1 long-term treatment, medication adherence evaluation other than a questionnaire, the ability to read or understand French, an age older than 18 years, and provided their nonopposition. Included adults responded to an initial version of the PROM composed of 11 items, each item being presented using a 4-point Likert scale. The initial set of items was obtained using a Delphi consensus process. Patients were classified as poorly, moderately, or highly adherent based on the results of a medication adherence assessment standard used in the daily practice of each outpatient unit. An ML-derived decision tree was built by combining the medication adherence status and PROM responses. Sensitivity, specificity, positive and negative predictive values (NPVs), and global accuracy of the final 5-item PROM were evaluated.

RESULTS

We created an initial 11-item PROM with a 4-point Likert scale using the Delphi process. After item reduction, a decision tree derived from 218 patients including data obtained from the final 5-item PROM allowed patient classification into poorly, moderately, or highly adherent based on item responses. The psychometric properties were 78% (95% CI 40%-96%) sensitivity, 71% (95% CI 53%-85%) specificity, 41% (95% CI 19%-67%) positive predictive values, 93% (95% CI 74%-99%) NPV, and 70% (95% CI 55%-83%) accuracy.

CONCLUSIONS

We developed a medication adherence tool based on ML with an excellent NPV. This could allow prioritization processes to avoid referring highly adherent patients to time- and resource-consuming interventions. The decision tree can be easily implemented in computerized prescriber order-entry systems and digital tools in smartphones. External validation of this tool in a study including a larger number of patients with diseases associated with low medication adherence is required to confirm its use in analyzing and assessing the complexity of medication adherence.

Adherence to colchicine prophylaxis among patients with familial Mediterranean fever treated with interleukin-1 inhibitors

OBJECTIVE

Interleukin-1 (IL-1) inhibitors are approved for treating familial Mediterranean fever (FMF) that is resistant to colchicine. However, continued concomitant treatment with colchicine is imperative, as it is the only drug proven to prevent secondary amyloidosis. We aimed to compare the adherence to colchicine between patients with colchicine-resistant FMF (crFMF) who were treated with IL-1 inhibitors and patients with colchicine-sensitive FMF (csFMF) who were treated only with colchicine.

METHODS

The databases of Maccabi Health Services, a 2.6-million-member state-mandated health provider in Israel were searched for patients with FMF diagnosis. The medication possession ratio (MPR), calculated from the day of the first colchicine purchase (index date) until the last colchicine purchase was the main outcome measure. Patients with crFMF were matched in a 1:4 ratio to patients with csFMF.

RESULTS

The final cohort included 4526 patients. Of them, 108 (2.4%) were with crFMF, and were matched to 432 with csFMF. The total mean MPR in each of the matched groups was similar (78.9 ± 41.4 and 82.5 ± 80.6, respectively, P = 0.5). Statistically significant differences in MPR were not found between the groups according to age or duration of colchicine use. However, adherence to colchicine was insufficient (MPR<80%) among more than 50% of the patients in both groups.

CONCLUSION

In contrast to initial concerns, adherence to colchicine was similar between patients with crFMF and csFMF. However, in both groups, adherence to colchicine was poor. Education of both caregivers and patients is essential to increase adherence.

Objective Assessment of Adherence and Inhaler Technique among Asthma and COPD Patients in London: A Study in Community Pharmacies Using an Electronic Monitoring Device

BACKGROUND

The INhaler Compliance Assessment (INCA^TM) device is an electronic monitoring device (EMD) that assesses both patient's adherence and inhaler technique (IT). This study aimed, first, to assess the value of using the INCA^TM device as an objective measure during medicine use review (MUR) consultations provided by community pharmacists (CPs) on patients' adherence and IT. Second, we aimed to explore patients' perceptions about the INCA^TM device.

METHODS

A mixed methods approach was used, involving two phases. Phase one was a service evaluation in independent community pharmacies in London with a before-and-after study design. The service included provision of an MUR consultation to asthma and COPD patients using objective feedback about adherence and IT generated with the INCA^TM device. Descriptive and inferential statistics were performed using SPSS. Phase two involved semi-structured interviews with respiratory patients. Thematic analysis was performed to generate key findings.

MAIN FINDINGS

Eighteen patients participated in the study (12 COPD and 6 asthma). The results showed significant improvement in the INCA^TM actual adherence from 30% to 68% (p = 0.001) and significant reduction in IT error rate from 51% to 12% (p = 0.002) after conducting the service. Analysis of the interviews revealed patients' positive attitudes in terms of the perceived benefits of the technology and a desire for future use and recommendation for others. Patients had also positive attitudes towards the consultations provided.

CONCLUSION

Embedding an objective measure about adherence and IT during CPs' consultations showed a significant improvement in patients' adherence and IT and was accepted by patients as well.

Predictors of adherence and the role of primary non-adherence in antihormonal treatment of breast cancer

BACKGROUND

Antihormonal treatment for hormone receptor (HR) positive breast cancer has highly beneficial effects on both recurrence rates and survival. We investigate adherence and persistence in this group of patients.

METHODS

The study population comprised 1192 patients with HR-positive breast cancer who were prescribed adjuvant antihormonal treatment from 2004 to 2013. Adherence was defined as a medical possession ratio (MPR) of ≥80.

RESULTS

Of the 1192 included patients, 903 (75.8%) were adherent and 289 (24.2%) were non-adherent. Primary non-adherence was seen in 101 (8.5%) patients. The extremes of age (< 40 and ≥ 80 years) were associated with poor adherence. Patients with metastasis to axillary lymph nodes and those who received radiotherapy and/or chemotherapy were more likely to be adherent. Better adherence was also shown for those who switched medication at 2 years after diagnosis. Primary non-adherence seems to be associated with cancers with a good prognosis.

CONCLUSION

Adherence to antihormonal therapy for breast cancer is suboptimal. Primary non-adherence occurs among patients with a relatively good prognosis. Non-adherent patients tend to terminate their antihormonal therapy in the initial part of the treatment period. Targeted interventions to improve adherence should be focused on the first part of the treatment period.

Antihypertensive and Statin Medication Adherence Among Medicare Beneficiaries

INTRODUCTION

Medication adherence is important for optimal management of chronic conditions, including hypertension and hypercholesterolemia. This study describes adherence to antihypertensive and statin medications, individually and collectively, and examines variation in adherence by demographic and geographic characteristics.

METHODS

The 2017 prescription drug event data for beneficiaries with Medicare Part D coverage were assessed. Beneficiaries with a proportion of days covered ≥80% were considered adherent. Adjusted prevalence ratios were estimated to quantify the associations between demographic and geographic characteristics and adherence. Adherence estimates were mapped by county of residence using a spatial empirical Bayesian smoothing technique to enhance stability. Analyses were conducted in 2019‒2021.

RESULTS

Among the 22.5 million beneficiaries prescribed antihypertensive medications, 77.1% were adherent; among the 16.1 million prescribed statin medications, 81.9% were adherent; and among the 13.5 million prescribed antihypertensive and statin medications, 70.3% were adherent to both. Adherence varied by race/ethnicity: American Indian/Alaska Native (adjusted prevalence ratio=0.83, 95% confidence limit=0.82, 0.842), Hispanic (adjusted prevalence ratio=0.90, 95% confidence limit=0.90, 0.91), and non-Hispanic Black (adjusted prevalence ratio=0.87, 95% confidence limit=0.86, 0.87) beneficiaries were less likely to be adherent than non-Hispanic White beneficiaries. County-level adherence ranged across the U.S. from 25.7% to 88.5% for antihypertensive medications, from 36.0% to 93.8% for statin medications, and from 20.8% to 92.9% for both medications combined and tended to be the lowest in the southern U.S.

CONCLUSIONS

This study highlights opportunities for efforts to remove barriers and support medication adherence, especially among racial/ethnic minority groups and within the regions at greatest risk for adverse cardiovascular outcomes.

Medication adherence and persistence among patients with non-small cell lung cancer receiving tyrosine kinase inhibitors and estimation of the economic burden associated with the unused medicines

BACKGROUND

Non-small cell lung cancer (NSCLC) is a leading cause of cancer deaths. Its treatment includes specific oral tyrosine kinases inhibitors (TKIs).

OBJECTIVES

To estimate adherence and persistence among patients receiving TKIs and to assess the economic burden of the unused medicines in Alsace (France).

METHOD

This retrospective study was carried out using the Insurance Healthcare database.

MAIN OUTCOME MEASURES

Adherence was calculated using medication possession ratio (MPR), persistence using estimated level of persistence with therapy (ELPT) and economic impact using prescription refill data.

RESULTS

242 patients were receiving TKIs. The most common TKIs prescribed were erlotinib (75.6%, n = 183) and crizotinib (12.8%, n = 31). Total of 149 patients were included in the adherence analysis. Overall MPR was 0.98. 180 patients were included in the persistence analysis. Almost half of patients had stopped treatment at 60 days and only 38.3% (n = 69) were still persistent with the therapy at 120 days. The expenses related to unused TKIs amounted to €356,392 and were related majorly to treatment discontinuation followed by overlapping refills, patient deaths and dose- or drug-switching, respectively.

CONCLUSIONS

Our data indicated overall adherence medicines above the acceptable limit of 0.80 but also pointed out a significant decline in persistence over time. The resulting economic losses justify the need for physicians and pharmacists to closely monitor their patients to ensure continuity of treatment. To limit the cost associated with unused medicines, interventions such as app-based monitoring, dispensing TKIs per unit over shorter periods and not only on monthly intervals could be implemented.

A systematic review and meta-analysis on impact of suboptimal use of antidepressants, bisphosphonates, and statins on healthcare resource utilisation and healthcare cost

BACKGROUND

Depression, osteoporosis, and cardiovascular disease impose a heavy economic burden on society. Understanding economic impacts of suboptimal use of medication due to nonadherence and non-persistence (non-MAP) for these conditions is important for clinical practice and health policy-making.

OBJECTIVE

This systematic literature review aims to assess the impact of non-MAP to antidepressants, bisphosphonates and statins on healthcare resource utilisation and healthcare cost (HRUHC), and to assess how these impacts differ across medication classes.

METHODS

A systematic literature review and an aggregate meta-analysis were performed. Using the search protocol developed, PubMed, Cochrane Library, ClinicalTrials.gov, JSTOR and EconLit were searched for articles that explored the relationship between non-MAP and HRUHC (i.e., use of hospital, visit to healthcare service providers other than hospital, and healthcare cost components including medical cost and pharmacy cost) published from November 2004 to April 2021. Inverse-variance meta-analysis was used to assess the relationship between non-MAP and HRUHC when reported for at least two different populations.

RESULTS

Screening 1,123 articles left 10, seven and 13 articles on antidepressants, bisphosphonates, and statins, respectively. Of those, 27 were rated of good quality, three fair and none poor using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. In general, non-MAP was positively associated with HRUHC for all three medication classes and most prominently for bisphosphonates, although the relationships differed across HRUHC components and medication classes. The meta-analysis found that non-MAP was associated with increased hospital cost (26%, p = 0.02), outpatient cost (10%, p = 0.01), and total medical cost excluding pharmacy cost (12%, p<0.00001) for antidepressants, and increased total healthcare cost (3%, p = 0.07) for bisphosphonates.

CONCLUSIONS

This systematic literature review is the first to compare the impact of non-MAP on HRUHC across medications for three prevalent conditions, depression, osteoporosis and cardiovascular disease. Positive relationships between non-MAP and HRUHC highlight inefficiencies within the healthcare system related to non-MAP, suggesting a need to reduce non-MAP in a cost-effective way.

Self-reported medication adherence and pharmacy refill adherence among persons with ischemic stroke: a cross-sectional study

Purpose

To describe and compare self-reported medication adherence assessed with the 5-item version of Medication Adherence Report Scale (MARS-5) and pharmacy refill adherence based on data from the Swedish Prescribed Drug Register (SPDR) among persons with ischemic stroke, and to investigate independent predictors associated with respective assessments.

Methods

A study questionnaire was sent to persons with ischemic stroke registered in the Swedish Stroke Register between Dec 2011 and March 2012, and who lived at home 3 months after discharge. The primary outcome was dichotomized to adherent/non-adherent based on MARS-5 and SPDR and analyzed with multivariable logistic regression. Adherence according to MARS-5 was defined as score 23 or higher (out of 25). Adherence according to SPDR was defined as at least one filled statin prescription recorded in SPDR in each 6-month interval during 2 years of follow-up.

Results

Of 420 participants, 367 (87%) and 329 (78%) were adherent according to MARS-5 and SPDR, respectively, and 294 (70%) participants were adherent according to both assessments. A significant association was shown between medication adherence according to the two assessments (p = 0.020). Independent predictors associated with medication adherence according to MARS-5 were female sex, while factors associated with SPDR were male sex and being younger.

Conclusions

The majority of participants were classified as adherent, 87% according to MARS-5 and 78% based on data from SPDR. However, only 70% were adherent according to both MARS-5 and SPDR, and different predictors were associated with the different measurements, suggesting that these assessments are measuring different aspects of adherence.

Supplementary information

The online version contains supplementary material available at 10.1007/s00228-022-03284-4.

Precision Medicine for Hypertension Patients with Type 2 Diabetes via Reinforcement Learning

Precision medicine is a new approach to understanding health and disease based on patient-specific data such as medical diagnoses; clinical phenotype; biologic investigations such as laboratory studies and imaging; and environmental, demographic, and lifestyle factors. The importance of machine learning techniques in healthcare has expanded quickly in the last decade owing to the rising availability of vast multi-modality data and developed computational models and algorithms. Reinforcement learning is an appealing method for developing efficient policies in various healthcare areas where the decision-making process is typically defined by a long period or a sequential process. In our research, we leverage the power of reinforcement learning and electronic health records of South Koreans to dynamically recommend treatment prescriptions, which are personalized based on patient information of hypertension. Our proposed reinforcement learning-based treatment recommendation system decides whether to use mono, dual, or triple therapy according to the state of the hypertension patients. We evaluated the performance of our personalized treatment recommendation model by lowering the occurrence of hypertension-related complications and blood pressure levels of patients who followed our model’s recommendation. With our findings, we believe that our proposed hypertension treatment recommendation model could assist doctors in prescribing appropriate antihypertensive medications.

Delta T, a Useful Indicator for Pharmacy Dispensing Data to Monitor Medication Adherence

INTRODUCTION

Calculating patients' medication availability from dispensing or refill data is a common method to estimate adherence. The most often used measures, such as the medication possession ratio (MPR), average medication supplies over an arbitrary period. Averaging masks the variability of refill behavior over time.

GOAL

To derive a new absolute adherence estimate from dispensing data.

METHOD

Dispensing histories of patients with 19 refills of direct oral anticoagulants (DOAC) between 1 January 2008 and 31 December 2017 were extracted from 39 community pharmacies in Switzerland. The difference between the calculated and effective refill day (ΔT) was determined for each refill event. We graphed ΔT and its dichotomized version (dΔT) against the MPR, calculated mean ΔT and mean dΔT per refill, and applied cluster analysis.

RESULTS

We characterized 2204 refill events from 116 DOAC patients. MPR was high (0.975 ± 0.129) and showed a positive correlation with mean ΔT. Refills occurred on average 17.8 ± 27.9 days "too early", with a mean of 75.8 ± 20.2 refills being "on time". Four refill behavior patterns were identified including constant gaps within or at the end of the observation period, which were critical.

CONCLUSION

We introduce a new absolute adherence estimate ΔT that characterizes every refill event and shows that the refill behavior of DOAC patients is dynamic.

Developing real-world evidence from real-world data: Transforming raw data into analytical datasets

Development of evidence-based practice requires practice-based evidence, which can be acquired through analysis of real-world data from electronic health records (EHRs). The EHR contains volumes of information about patients-physical measurements, diagnoses, exposures, and markers of health behavior-that can be used to create algorithms for risk stratification or to gain insight into associations between exposures, interventions, and outcomes. But to transform real-world data into reliable real-world evidence, one must not only choose the correct analytical methods but also have an understanding of the quality, detail, provenance, and organization of the underlying source data and address the differences in these characteristics across sites when conducting analyses that span institutions. This manuscript explores the idiosyncrasies inherent in the capture, formatting, and standardization of EHR data and discusses the clinical domain and informatics competencies required to transform the raw clinical, real-world data into high-quality, fit-for-purpose analytical data sets used to generate real-world evidence.

Adherence and persistence in the use of statins and ezetimibe over 8 years in a real-life study

BACKGROUND

Adherence and persistence to treatment are crucial in statin therapy as they are synonymous with efficacy and quality of care. The aim of this study was the real-life assessment of adherence and persistence over eight years in treatment-naive patients receiving atorvastatin, lovastatin, simvastatin, pravastatin, ezetimibe.

METHODS

Adherence to treatment was calculated using the 'proportion of days covered' method and persistence as the difference between the start and end of the therapy under study.

RESULTS

Treatment adherence was consistently above 85% for all drugs under study in each year. Treatment persistence was shown to half halved already from the first year.

CONCLUSION

Adherent patients had a higher persistence than non-adherent patients.

Providers' mediating role for medication adherence among cancer survivors

Background

We conducted a mediation analysis of the provider team’s role in changes to chronic condition medication adherence among cancer survivors.

Methods

We used a retrospective, longitudinal cohort design following Medicare beneficiaries from 18-months before through 24-months following cancer diagnosis. We included beneficiaries aged ≥66 years newly diagnosed with breast, colorectal, lung or prostate cancer and using medication for non-insulin anti-diabetics, statins, and/or anti-hypertensives and similar individuals without cancer from Surveillance, Epidemiology, and End Results-Medicare data, 2008–2014. Chronic condition medication adherence was defined as a proportion of days covered ≥ 80%. Provider team structure was measured using two factors capturing the number of providers seen and the historical amount of patient sharing among providers. Linear regressions relying on within-survivor variation were run separately for each cancer site, chronic condition, and follow-up period.

Results

The number of providers and patient sharing among providers increased after cancer diagnosis relative to the non-cancer control group. Changes in provider team complexity explained only small changes in medication adherence. Provider team effects were statistically insignificant in 13 of 17 analytic samples with significant changes in adherence. Statistically significant provider team effects were small in magnitude (<0.5 percentage points).

Conclusions

Increased complexity in the provider team associated with cancer diagnosis did not lead to meaningful reductions in medication adherence. Interventions aimed at improving chronic condition medication adherence should be targeted based on the type of cancer and chronic condition and focus on other provider, systemic, or patient factors.

Association between adherence to oral therapies in cancer patients and clinical outcome: A systematic review of the literature

AIMS

Adherence to therapy is a key factor in successful treatment. The aim of this systematic review is to assess the extent to which patients with better adherence to oral therapy have better clinical outcomes among cancer patients.

METHODS

All studies published in PubMed up to 20 October 2020, which considered the use of oral anticancer drugs for cancer patients and which correlated treatment adherence with a clinical outcome, were considered.

RESULTS

From the 42 studies considered in the systematic review, 14 were for oncological indications and 28 for haematological indications. There was considerable variance in calculation methods, outcomes considered, and in the definitions of adherence. However, it emerged that most studies reported a significant correlation between adherence to therapy and clinical outcome.

CONCLUSION

As adherence to therapy is a key factor in achieving a better clinical outcome, future studies with large samples, robust endpoints and the use of at least two methods of assessing adherence would be desirable in order to produce more robust evidence.

Influence of the implementation of a multidisciplinary consultation program on adherence to the first ever course of oral antineoplastic treatment in patients with cancer

PURPOSE

To evaluate adherence (as measured by the medication possession ratio) to the first ever course of oral antineoplasic treatment in cancer patients before and after the implementation of a multidisciplinary consultation program (involving an oncologist, a pharmacist, and a nurse) and to investigate the program's impact on adverse events and drug-related problems.

PATIENTS AND METHODS

In a retrospective single-center study, we compared the medication possession ratio 2 months after treatment initiation in a control group (before multidisciplinary consultation program implementation) versus an interventional group (after multidisciplinary consultation program implementation).

RESULTS

Two months after oral antineoplasic treatment initiation, the mean ± standard deviation medication possession ratio did not differ significantly when comparing the interventional (multidisciplinary consultation program) group (n = 33; 0.99 ± 0.06) with the control group (n = 64; 0.94 ± 0.16) (p = 0.062). Patients in the multidisciplinary consultation program group had fewer adverse events in general (41, vs 109 in the control group; p = 0.048) and digestive adverse events in particular (6 vs 29, respectively; p = 0.007). A total of 53 and 40 drug-related problems were identified in the control and multidisciplinary consultation program groups, respectively (p = 0.074).

CONCLUSIONS

Implementation of an multidisciplinary consultation program was not associated with a significant difference in drug adherence (as assessed by the medication possession ratio), which was good before and after implementation. The multidisciplinary consultation program was associated with a lower incidence of adverse events.

Importance of medication adherence in treatment needed diabetic retinopathy

We aim to investigate the role of medication adherence history in treatment needed diabetic retinopathy (TNDR). We conducted a retrospective nested case–control study using 3 population-based databases in Taiwan. The major one was the 2-million-sample longitudinal health and welfare population-based database from 1997 to 2017, a nationally representative random sample of National Health Insurance Administration enrolled beneficiaries in 2010 (LHID2010). The national death registry and national cancer registry were also checked to verify the information. The outcome was defined as the TNDR. The Medication possession ratio (MPR) was defined as the ratio of total days of diabetes mellitus (DM) medication supply divided by total observation days. MPR ≥ 80% was proposed as good medication adherence. The association of MPR and the TNDR was analyzed. Other potential confounders and MPR ratio were also evaluated. A total of (n = 44,628) patients were enrolled. Younger aged, male sex and patients with less chronic illness complexity or less diabetes complication severity tend to have poorer medication adherence. Those with severe comorbidity or participating pay-for-performance program (P4P) revealed better adherence. No matter what the characteristics are, patients with good MPR showed a significantly lower likelihood of leading to TNDR after adjustment with other factors. The protection effect was consistent for up to 5 years. Good medication adherence significantly prevents treatment needed diabetic retinopathy. Hence, it is important to promote DM medication adherence to prevent risks of diabetic retinopathy progression, especially those who opt to have low medication adherence.

Non-Adherence to Appointments is a Strong Predictor of Medication Non-Adherence and Outcomes in Kidney Transplant Recipients

BACKGROUND

Non-adherence is an important aspect of transplantation that affect outcomes. This study aims to investigate the impact of non-adherence to laboratory and clinic appointments on medication non-adherence and outcomes in kidney transplant (KT) recipients.

METHODS

We analyzed KT recipients between 2005-14 with a detailed review of the medical records for non-adherence to laboratory and clinic appointments, as well as medication regimens. Baseline characteristics and clinical outcomes were compared between adherent and non-adherent groups.

RESULTS

A total of 1413 KT recipients were included: 754 who were adherent and 659 who were non-adherent. Non-adherent recipients tend to be younger, African American, and have private insurance. Adherent patients tend to have a history of DM, heart disease, and receive an ECD kidney. Non-adherence to appointments was a strong predictor of medication non-adherence (OR 3.1), acute rejection (OR 1.4), and subsequent rejection episodes (OR 3.3 and 8.1 respectively for ≥ 1 and ≥ 2 rejection episodes). Subset analysis of patients who had early non-adherence within 1-year post-transplant showed predominance of younger, African American patients. The same patients had higher prevalence of medication non-compliance, overall and ≥ 1-year post-transplant, and mean number of readmissions. Kaplan-Meier analysis showed a trend towards lower graft survival in this group.

CONCLUSIONS

Early non-adherence to laboratory and clinic appointments is a strong predictor of late medication non-adherence, acute rejection, and graft loss. Targeting patients that demonstrate early non-adherence to appointments with focused interventions may help improve kidney transplant outcomes in this high risk group.

Assessment of compliance with oral nutritional supplementation and exploration of barriers and facilitators for patients after gastrectomy: A mixed-methods study

AIMS

To evaluate the compliance of patients after gastrectomy in taking oral nutritional supplementation and to explore the promoting and hindering factors.

DESIGN

A mixed-methods design with an explanatory sequential approach was employed.

METHODS

We conducted a 12-week longitudinal study to evaluate the oral nutritional supplementation compliance of 122 patients after gastric cancer surgery and the factors that affected their compliance. After the quantitative phase, we selected the interview subjects and developed the interview outline based on the analysis of the quantitative results. In-depth interviews (n = 15) were conducted to explain and supplement the quantitative phase results. Data were collected from October 2019 to May 2020.

RESULTS

The average overall compliance rate of oral nutritional supplementation in patients with gastric cancer over 12 weeks was 30.59%. Adverse reactions to oral nutritional supplementation, the identity of the main caregivers and the patient's financial ability were independent factors that affected patient compliance. In subsequent interviews, we extracted four themes: social support plays an important role in patients taking oral nutritional supplementation, adverse reactions discourage patients from continuing to take oral nutritional supplementation, patients' attitudes affect their motivation to take oral nutritional supplementation, and the different needs of patients for oral nutritional supplementation affect patient compliance.

CONCLUSION

Patients' compliance with oral nutritional supplementation after gastric cancer surgery is very low. Health education should pay more attention to the management of adverse reactions and the role of patients' peers and family members. Oral nutritional supplementation products should be diversified to provide patients with more choices.

IMPACT

This study clarifies the factors that hinder and promote oral nutritional supplementation compliance and provides an important reference for the establishment and revision of health education strategies for patients after gastric cancer surgery.

Adverse drug event rates in pediatric pulmonary hypertension: a comparison of real-world data sources

Objective

Real-world data (RWD) are increasingly used for pharmacoepidemiology and regulatory innovation. Our objective was to compare adverse drug event (ADE) rates determined from two RWD sources, electronic health records and administrative claims data, among children treated with drugs for pulmonary hypertension.

Materials and Methods

Textual mentions of medications and signs/symptoms that may represent ADEs were identified in clinical notes using natural language processing. Diagnostic codes for the same signs/symptoms were identified in our electronic data warehouse for the patients with textual evidence of taking pulmonary hypertension-targeted drugs. We compared rates of ADEs identified in clinical notes to those identified from diagnostic code data. In addition, we compared putative ADE rates from clinical notes to those from a healthcare claims dataset from a large, national insurer.

Results

Analysis of clinical notes identified up to 7-fold higher ADE rates than those ascertained from diagnostic codes. However, certain ADEs (eg, hearing loss) were more often identified in diagnostic code data. Similar results were found when ADE rates ascertained from clinical notes and national claims data were compared.

Discussion

While administrative claims and clinical notes are both increasingly used for RWD-based pharmacovigilance, ADE rates substantially differ depending on data source.

Conclusion

Pharmacovigilance based on RWD may lead to discrepant results depending on the data source analyzed. Further work is needed to confirm the validity of identified ADEs, to distinguish them from disease effects, and to understand tradeoffs in sensitivity and specificity between data sources.

Prevalence of statin utilization and adherence among privately insured subjects in the Commonwealth of Puerto Rico

BACKGROUND: Puerto Ricans are the Hispanic subgroup with the highest adjusted prevalence of statin-eligible patients. However, no study has described statin utilization and adherence among subjects living on the island of Puerto Rico. OBJECTIVES: To (a) estimate the prevalence of beneficiaries with diabetes aged between 40 and 75 years; (b) estimate the prevalence of statin utilization among beneficiaries with diabetes; and (c) estimate secondary adherence to statins among beneficiaries with diabetes. METHODS: With pharmacy claims data from a commercial pharmacy benefit manager (PBM) in the Commonwealth of Puerto Rico, this study used a retrospective longitudinal design to analyze all pharmacy claims generated by 115,674 beneficiaries aged between 40 and 75 years with continuous enrollment during 2018. Beneficiaries with diabetes were defined by having ≥ 2 pharmacy claims for antidiabetic agents during 2018. Statin utilization was defined by having ≥ 1 pharmacy claim for statins among beneficiaries with diabetes. The proportion of days covered (PDC) was used to measure secondary adherence to statins. Parametric and nonparametric statistics were used to describe statin utilization and adherence. RESULTS: The prevalence of beneficiaries with diabetes was 7.8%. Of the 8,975 beneficiaries with diabetes, 5,129 (57.1%) received ≥ 1 prescription for a statin. Older males with diabetes were more likely to receive prescriptions for statins. The median PDC for the 4,553 beneficiaries with ≥ 2 prescriptions for statins was 63.4%; 3,306 (72.6%) beneficiaries filled their statin prescriptions for a 30-day supply only; and 1,252 (27.5%) beneficiaries had a PDC ≥ 80%. The highest PDC (92.3%) was observed for beneficiaries who received statins for a 90-day supply only. CONCLUSIONS: This is the first study that has measured statin utilization and adherence among patients with diabetes living in Puerto Rico. The utilization and adherence to statins among privately insured beneficiaries with diabetes in Puerto Rico are suboptimal. Future studies should focus on understanding the reasons for the suboptimal use of statins and on potential interventions at the beneficiary and provider level to increase statin utilization. DISCLOSURES: No outside funding supported this study. The authors have no conflicts of interest or financial disclosures to disclose related to this study.

Testing for Primary Aldosteronism and Mineralocorticoid Receptor Antagonist Use Among U.S. Veterans : A Retrospective Cohort Study

BACKGROUND

Primary aldosteronism is a common cause of treatment-resistant hypertension. However, evidence from local health systems suggests low rates of testing for primary aldosteronism.

OBJECTIVE

To evaluate testing rates for primary aldosteronism and evidence-based hypertension management in patients with treatment-resistant hypertension.

DESIGN

Retrospective cohort study.

SETTING

U.S. Veterans Health Administration.

PARTICIPANTS

Veterans with apparent treatment-resistant hypertension (n = 269 010) from 2000 to 2017, defined as either 2 blood pressures (BPs) of at least 140 mm Hg (systolic) or 90 mm Hg (diastolic) at least 1 month apart during use of 3 antihypertensive agents (including a diuretic), or hypertension requiring 4 antihypertensive classes.

MEASUREMENTS

Rates of primary aldosteronism testing (plasma aldosterone-renin) and the association of testing with evidence-based treatment using a mineralocorticoid receptor antagonist (MRA) and with longitudinal systolic BP.

RESULTS

4277 (1.6%) patients who were tested for primary aldosteronism were identified. An index visit with a nephrologist (hazard ratio [HR], 2.05 [95% CI, 1.66 to 2.52]) or an endocrinologist (HR, 2.48 [CI, 1.69 to 3.63]) was associated with a higher likelihood of testing compared with primary care. Testing was associated with a 4-fold higher likelihood of initiating MRA therapy (HR, 4.10 [CI, 3.68 to 4.55]) and with better BP control over time.

LIMITATIONS

Predominantly male cohort, retrospective design, susceptibility of office BPs to misclassification, and lack of confirmatory testing for primary aldosteronism.

CONCLUSION

In a nationally distributed cohort of veterans with apparent treatment-resistant hypertension, testing for primary aldosteronism was rare and was associated with higher rates of evidence-based treatment with MRAs and better longitudinal BP control. The findings reinforce prior observations of low adherence to guideline-recommended practices in smaller health systems and underscore the urgent need for improved management of patients with treatment-resistant hypertension.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Treatment prescription, adherence, and persistence after the first hospitalization for heart failure: A population-based retrospective study on 100785 patients

BACKGROUND

This study evaluates, in a real-world setting, to what extent the recommended therapies by international guidelines, are prescribed after a first hospitalization for heart failure (HF), and to analyse adherence and persistence, and the effect of treatment adherence on mortality and re-hospitalization.

METHODS

From the Lombardy healthcare administrative database, we analysed patients discharged after their incident HF, from 2000 to 2012. Adherence was defined as the proportion of days covered (PDC) ≥80% adjusted for hospitalizations and persistence as the absence of discontinuation of therapy for >30 days. A logit model was used to determine the effect of patients' adherence on mortality and readmissions.

RESULTS

Of 100422 HF patients (52% males, age 75 ± 12 years), 86846 (87%) had a prescription for angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACE/ARBs), 64135 (64%) for beta-blockers (BB), and 36893 (37%) for mineralocorticoid receptor antagonists (MRAs), as mono-, bi- or tri-therapy. In patients on monotherapy, PDC was 78 ± 22% for ACE/ARBs, 69 ± 29% for BB and 54 ± 29% for MRAs; in those on bi-therapy, PDC was 63 ± 31% for ACEI/ARBs+BB, 41 ± 29% for ACEI/ARBs+MRAs, and 40 ± 26% for MRAs+BB; for patients on tri-therapy, PDC was 42 ± 28%. Medication persistence was present in 47% of patients treated with ACEI/ARBs, in 35% of patients treated with BB and in 14% of patients treated with MRAs. Re-hospitalizations and in mortality were significantly reduced in adherent patients (p < 0.000).

CONCLUSIONS

Polypharmacy is associated with an increased rate of non-adherence and non-persistence in incident HF. Non-adherence is associated with an increased risk of mortality and re-hospitalizations.

In-hospital myocardial infarction and adherence to evidence-based drug therapies: a real-world evaluation

OBJECTIVES

This study aimed to measure adherence to chronic polytherapy following an acute myocardial infarction (AMI) and to find out associations between adherence and the setting of AMI onset (in vs out of hospital) as well as other determinants.

DESIGN

Retrospective follow-up study.

SETTING

Population living in the Lazio Region, Italy.

PARTICIPANTS

This study included 25 779 hospitalised patients with a first diagnosis of AMI in 2012-2016, after the exclusion of those with hospital admission for AMI or related causes in the previous 5 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

Patients were classified as in-hospital AMI (IH-AMI) or out of hospital AMI (OH-AMI) according to present-on-admission codes. Adherence was measured based on prescription claims during a 6-month follow-up after hospital discharge, using medication possession ratio (MPR). Adherence to chronic polytherapy was defined as MPR ≥75% to at least 3 of the following medications: antithrombotics, betablockers, ACE inhibitors/angiotensin receptor blockers and statins.

RESULTS

Among the entire cohort, 1 044 (4%) patients suffered IH-AMI. Overall, 15 440 (60%) patients were deemed adherent to chronic polytherapy. Female gender, older age, mental disorders, renal disease, asthma and ongoing concomitant treatments were factors associated with poor adherence. By contrast, patients with more severe AMI and those already taking evidence-based (E-B) drugs were more likely to be adherent. A strong association between the setting of AMI onset and adherence was observed: IH-AMI patients were 46% less likely to be adherent to E-B medications during their 6-month follow-up as compared with OH-AMI patients (OR 0.54; 95% CI 0.47 to 0.62; p<0.001).

CONCLUSION

Pharmacotherapy is not consistent with clinical guidelines, especially for IH-AMI patients. Our findings provide evidence on a previously unidentified groups of patients at risk for poor adherence, who might benefit from greater medical attention and dedicated healthcare interventions.

Patient-reported barriers to statin adherence: Excerpts from a motivational interviewing intervention in older adults

OBJECTIVE

Despite a known benefit in the reduction of cardiovascular risk, adherence to statins remains suboptimal. A qualitative analysis was conducted within an intervention that identified trajectories of statin adherence in patients and used motivational interviewing (MoI) to improve adherence. The objective of this qualitative study was to evaluate transcripts of an MoI telephonic intervention to identify potential, past, and current barriers to statin adherence and barriers specific to distinct adherence trajectories.

METHODS

The MoI intervention was customized by past 1-year adherence trajectories (rapid discontinuation, gradual decline, and gaps in adherence). Two authors independently extracted and documented barriers from phone transcripts. Themes were derived from literature a priori and by cataloging recurring themes from the transcripts.

RESULTS

The transcripts of calls made to 157 patients were reviewed of which 25.2% did not communicate a specific adherence barrier despite falling into a low-adherence trajectory when examining refill data. The most commonly reported barriers to statin adherence included adverse effects (40.1%), forgetfulness (30.0%), and lack of skills or knowledge pertaining to statins (25%). More patients in the rapid discontinuation group perceived medication as unnecessary, whereas more patients in the gaps in adherence group reported a communication barrier with their health care provider. Several barriers among patients who fell into low-adherence trajectories were reported. Some patients did not report any barriers, which may have indicated denial. MoI phone calls were useful in providing knowledge, clarifying medication regimens, and reinforcing the need to take statins.

CONCLUSION

This study identified patient-reported barriers to statin adherence elicited during an MoI telephonic intervention conducted by student pharmacists. There were differences in barriers reported by patients from each trajectory, which emphasize the need for additional tailored interventions to improve patient adherence.

The Impact of Sickle Cell Anemia and Mental Health Diagnoses on Healthcare Use and Preventive Care among Children Enrolled in Medicaid, 2005-2012

OBJECTIVE

To examine mental health diagnoses, healthcare use, and receipt of age-appropriate preventive care, including antibiotic prophylaxis, hydroxyurea therapy, and transcranial Doppler screenings, among children with sickle cell anemia (SCA).

STUDY DESIGN

Children aged 1-17 years with SCA from 6 states having 3 or more Medicaid claims with a SCA diagnosis within a year (2005-2012) were included. Children with mental health diagnoses were identified with 1 or more mental health encounters. Poisson and logistic regression models with general estimating equations assessed the relationship between mental health diagnoses, healthcare use, and receipt of age-appropriate preventive care.

RESULTS

In total, 7963 children with SCA were identified (22 424 person-years); 1593 person-years (7.1%) included 1 or more mental health diagnoses. Children with a mental health diagnosis were more likely to have inpatient admissions (incidence rate ratio [IRR] 1.46, 95% CI 1.36-1.56) and outpatient (IRR 1.27, 95% CI 1.21-1.34), emergency department (IRR 1.39, 95% CI 1.30-1.48), and well-child visits (IRR 1.19, 95% CI 1.11-1.29). Those with a mental health diagnosis were more likely to receive hydroxyurea therapy (odds ration [OR] 1.17, 95% CI 1.03-1.33) and less likely to receive transcranial Doppler screenings (OR 0.79, 95% CI 0.68-0.93).

CONCLUSIONS

Children with SCA do not receive adequate age-appropriate preventive care. Further research is necessary to identify key points of coordination between mental health and SCA services throughout the life course. This approach may help to increase receipt of age-appropriate preventive care and decrease reliance on acute care.

Prevalence of potentially serious alcohol-medication interactions in older adults in a community pharmacy setting: a cross-sectional study

OBJECTIVE

Previous prevalence estimates of POtentially Serious Alcohol-Medication INteractions in Older adults (POSAMINO) are based on in-home inventories of medications; however, this method is associated with under-reporting of medications when compared with dispensing records. This study aims to estimate the prevalence of POSAMINO among community-dwelling older adults using drug dispensing data from the community pharmacy setting.

DESIGN

Cross-sectional study.

SETTING

Irish Community Pharmacy.

PARTICIPANTS

1599 consecutive older adults presenting with a prescription to 1 of 120 community pharmacies nationwide; community-dwelling, aged ≥65 years, able to speak and understand English, with no evidence of cognitive impairment. The mean age of sample was 75.5 years (SD 6.5); 55% (n=884) female.

MEASURES

38 POSAMINO criteria were identified using participants' pharmacy dispensing records linked to self-reported alcohol consumption (beverage-specific quantity and frequency measures) over the last 12 months.

RESULTS

The overall prevalence of POSAMINO in the study population was 28%, with 10% at risk of at least one POSAMINO criteria and 18% at risk of two or more. Exposure to POSAMINO most commonly involved cardiovascular agents (19%) and central nervous system agents (15%). Exposure to a higher number of POSAMINO criteria was associated with younger age (adjusted incident rate ratio (AIRR): 0.97; 95% CI: 0.95 to 0.98), male sex (AIRR: 0.55; 95% CI: 0.45 to 0.67) and a higher number of comorbidities (AIRR: 1.05; 95% CI: 1.01 to 1.13).

CONCLUSION

This study adds to the growing body of evidence, which suggests that older adults are vulnerable to potentially serious alcohol-medication interactions, particularly those involving cardiovascular and central nervous system agents, increasing their risk of orthostatic hypotension, gastrointestinal bleeds and increased sedation. Application of the POSAMINO criteria at the point of prescribing may facilitate the risk stratification of older adults and prioritise alcohol screening and brief alcohol interventions in those at greatest risk of harm.

Adherence to oral anticancer chemotherapies and estimation of the economic burden associated with unused medicines

Background The list of oral and expensive chemotherapy agents has lengthened over the last few years and has created unique medication adherence concerns. In a real-life setting, patients often do not take their medications as prescribed. This pattern is associated with poor outcomes and increased health care costs. Objectives To estimate the adherence to oral anticancer chemotherapies and to determine the economic burden of unused medicines due to patients' death. Setting Alsace (France). Method This retrospective study was carried out by using ERASME, an Insurance Healthcare database. Main outcome measures Adherence was calculated using medication possession ratio and economic impact using prescription refill data. Results 10,734 patients were treated with oral anticancer medicines (cytotoxic agents, hormonal and targeted therapies). Averaged adherence of 0.86 was observed although it varied significantly between subclasses (cytotoxic agents: 0.69 ± 0.14, hormonal therapy: 0.91 ± 0.17 and targeted therapy: 0.79 ± 0.17). 1631 patients died during the study period. The expenses related to unused chemotherapies amounted to €152,175. Conclusions Our data showed that overall adherence to oral anticancer medicines was above the acceptable limit of adherence of 80% with a marked graduation in values between cytotoxic agents, hormonal and targeted therapies. These statistical significant differences in medication possession ratio could be related to the intrinsic toxicity of the three subclasses of molecules, their tolerance and adverse effects. To limit the cost associated with unused medicines, interventions such as dispensing expensive oral anticancer chemotherapies per unit over shorter periods and not only on monthly intervals could be implement.

The Need to Develop Standard Measures of Patient Adherence for Big Data: Viewpoint

Despite half a century of dedicated studies, medication adherence remains far from perfect, with many patients not taking their medications as prescribed. The magnitude of this problem is rising, jeopardizing the effectiveness of evidence-based therapies. An important reason for this is the unprecedented demographic change at the beginning of the 21st century. Aging leads to multimorbidity and complex therapeutic regimens that create a fertile ground for nonadherence. As this scenario is a global problem, it needs a worldwide answer. Could this answer be provided, given the new opportunities created by the digitization of health care? Daily, health-related information is being collected in electronic health records, pharmacy dispensing databases, health insurance systems, and national health system records. These big data repositories offer a unique chance to study adherence both retrospectively and prospectively at the population level, as well as its related factors. In order to make full use of this opportunity, there is a need to develop standardized measures of adherence, which can be applied globally to big data and will inform scientific research, clinical practice, and public health. These standardized measures may also enable a better understanding of the relationship between adherence and clinical outcomes, and allow for fair benchmarking of the effectiveness and cost-effectiveness of adherence-targeting interventions. Unfortunately, despite this obvious need, such standards are still lacking. Therefore, the aim of this paper is to call for a consensus on global standards for measuring adherence with big data. More specifically, sound standards of formatting and analyzing big data are needed in order to assess, uniformly present, and compare patterns of medication adherence across studies. Wide use of these standards may improve adherence and make health care systems more effective and sustainable.

Real-life adherence in capecitabine therapy using two analysis methods and persistence after 6 months of treatment

Medication adherence in the field of Oncology is crucial in therapy management and can influence the probability of achieving and maintaining efficacy over time. We conducted a cross-sectional study to evaluate adherence and persistence to oral therapy with Capecitabine, using two different calculation methods: therapy diary and indirect prescription refilling patterns. The main objective of the study was to compare the two methods of analysis and to propose a reliable adherence datum, yielded by the application of two complementary methodologies. We consequently set out to verify if data collected from therapy diaries can be superimposed to those gathered from prescription refilling patterns. Furthermore, we included data on patient-perceived quality in relation to Capecitabine therapy, as well as adverse reactions and their duration. Of 594 patients who used the study drug as of January 1, 2012, 45 completed their therapy diary. Adherence to treatment was 0.93 ± 0.10 and 0.84 ± 0.15, calculated using therapy diaries and pharmacy refill data, respectively. In terms of persistence, 53% of patients continued with treatment after six months of therapy. On a 1 to 5 scale, perceived quality was 3.31. In conclusion, when it comes to calculating adherence, it is important to preserve the objectivity of the method, which must be unencumbered by any conditioning. Regardless of the method, also considering what has already been discussed in the available literature, adherence in patients under treatment with Capecitabine, unlike persistence, is good.

Bridging the gap between physical and mental illness in community pharmacy (PharMIbridge): protocol for an Australian cluster randomised controlled trial

INTRODUCTION

There is a significant life expectancy gap attributable to physical comorbidities for people living with severe and persistent mental illness (SPMI) compared with the general population. Medications are a major treatment for SPMI management and physical illnesses, hence pharmacists are well positioned to support mental healthcare and comorbidities. The randomised controlled trial (RCT) aim is to evaluate effectiveness of an individualised, pharmacist led, support service for people experiencing SPMI focusing on medication adherence and physical comorbidity management, compared with standard care (a medication-management service; MedsCheck). METHODS AND ANALYSIS: PharMIbridge is a cluster RCT, whereby community pharmacies in four Australian regions will be randomised (1:1 ratio), to either Intervention Group (IG) or Comparator Group (CG). All IG and CG pharmacy staff will receive Blended-Mental Health First Aid training. Additionally, IG pharmacists will receive further training on medication adherence, goal setting, motivational interviewing, managing physical health concerns and complex issues relating to psychotropic medication. CG pharmacists will not receive additional training, and will provide standard care (MedsCheck). The primary outcome will be change in participants medication adherence for psychotropic medication over 6-months. Using mixed-effects logistic regression model and a cluster size of 48 pharmacies, a total of 190 participants will need to be recruited to each arm to find a statistically significant difference in medication adherence. Secondary outcomes will be changes in factors associated with cardiometabolic risk and quality of life, emphasising physical and psychological well-being; medication-related problems; adherence to other prescribed medication; pharmacists knowledge, confidence and ability to support people experiencing SPMI; and effects on healthcare utilisation. A within RCT-based economic evaluation comparing the intervention with standard care will be undertaken.

ETHICS AND DISSEMINATION

The protocol and pharmacist training programme received Griffith University Human Research Ethics Committee approval (HREC/2019/473 and HREC/2019/493 respectively). Results will be published in peer-reviewed journals and available at the Sixth Community Pharmacy Agreement website (http://6cpa.com.au/about-6cpa/).

TRIAL REGISTRATION NUMBER

ANZCTR12620000577910.

Patterns of Psychotropic Medication Use among Individuals with Traumatic Brain Injury

The relationship between psychotropic medication use and traumatic brain injury (TBI) is not well understood. The objective of this study was to describe patterns of psychotropic medication use during the months before and after TBI and compare with a non-TBI cohort. We conducted a retrospective cohort study using administrative claims data for a commercially insured population from 2008 to 2014, and assessed monthly prevalence of psychotropic medication use by class before and after TBI (or matched index in the non-TBI controls). We tested time trends and quantified rates of increase using autoregressive models, and determined whether TBI impacted psychotropic medication use using difference-in-difference models. Compared with those without TBI (n = 414,708), individuals with TBI (n = 207,354) were more likely to receive any psychotropic medication both before (36.9% vs. 19.5%, p < 0.001) and after TBI (48.2% vs. 25.7%, p < 0.001). Prior to TBI, the rate of monthly increase in use of psychotropic medications in the TBI cohort was three to four times the rate observed in the non-TBI cohort, and was highest for antidepressants in both cohorts. After accounting for between-group and time trends, TBI was associated with increased use of several psychotropic medications including antipsychotics (rate ratio [RR] 1.08; 95% confidence interval [CI] 1.07, 1.09) and anxiolytics (RR 1.05; 95% CI 1.04, 1.06). Patterns of psychotropic medication use differed significantly between individuals with and without TBI. These results suggest that a better understanding of events leading up to and following TBI is needed to elucidate the role psychotropic medications play in the natural history of TBI.

Factors Associated with Antihypertensive Medication Non-Adherence: A Cross-Sectional Study Among Lebanese Hypertensive Adults

BACKGROUND

Poor adherence to antihypertensives is associated with negative outcome of the disease as well as loss of health-care resources. Addressing the epidemic of poor adherence requires identifying factors associated with this behaviour. The aim of this study is to describe adherence to antihypertensive medication among Lebanese hypertensive patients and to evaluate the association between socio-economic, patient- and conditions-related factors and non-adherence.

METHODS

A cross-sectional study was carried out on adherence to antihypertensive medications covering all governorates of Lebanon. This study was conducted between February 2018 and January 2019 on a random sample of 1497 hypertensive patients. A face-to-face questionnaire was used to assess adherence to antihypertensive medication and its determinants according to the five World Health Organization (WHO) main categories. Logistic regression analysis was performed to test the adjusted association between the multiple exposure factors, and drug adherence data were collected by trained interviewers.

RESULTS

Adherence to antihypertensive medications was reported by 1253 (83.7%) of the patients. After multivariate analysis, patients who tried to control their stress level (OR = 0.77, 95% CI [0.38-0.95]), those who had normal BP readings (OR =0.49, 95% CI [0.18-0.97]), and those who believed in the effectiveness of their treatment (OR = 0.31, 95% CI [0.14-0.76]) had a significantly lower chance to exhibit non-adherence to their treatment. However, older patients (OR= 1.87, 95% CI [1.23-2.21]), divorced/separated patients (OR= 2.14, 95% CI [1.31-5.48]), married (OR=1.96, 95% CI [1.27-3.90]), widowed (OR=2.11, 95% CI [1.62-6.50]), obese patients (OR = 1.76, 95% CI [1.21-1.94]), and patients who smoked hookah and cigarettes (OR = 2.62, 95% CI [1.17-6.76]) were more likely to exhibit non-adherence.

CONCLUSION

Our study highlights the influence of factors such as old age, marital status, BMI and high level of emotional stress on non-adherence to medication in hypertensive patients. These determinants should be incorporated into adherence improving strategies.

Adherence to prophylactic dual antiplatelet therapy in patients with acute coronary syndrome - A study conducted at a Saudi university hospital

Objectives

The aim of this study was to evaluate patients’ self-reported adherence to dual antiplatelet therapy (DAPT) and determine the factors associated with premature discontinuation of DAPT.

Methods

The cross-sectional interview-based study was conducted among adult outpatients who visited the outpatient department of King Khalid University Hospital, Cardiac Center in Riyadh, Saudi Arabia, over a period of 3 months from May to July of 2016. Medication adherence was assessed using the Self-efficacy for Appropriate Medication Use Scale (SEAMS), which is composed of 13 items with a 3-point Likert scale.

Results

A total of 192 patients participated in the study. The majority of the participants were male (82.1%), and the mean age was 55.66 ± 10.80 years. More than 84% (84.4%) of the patients reported that they were “confident” in taking several medications each day. The minimum and maximum SEAMS scores were 22 and 39, respectively, with the mean score being 30.8 ± 3.5. Almost all patients had moderate scores and adherence; only one patient got a score of 39. Among sociodemographic characteristics, only health insurance and income were significantly associated with the medication adherence score (p < 0.05).

Conclusions

Study results concluded that patients had a moderate level of adherence towards DAPT in Saudi Arabia, however Patient education on DAPT is essential to improve adherence to medication treatment. More effective intentions and education methods should be developed to improve long-term DAPT adherence.

Comparative Performance of Comorbidity Measures in Predicting Health Outcomes in Patients with Chronic Obstructive Pulmonary Disease

Purpose

Multiple studies have suggested that comorbidities pose negative impacts on the survival of patients with chronic obstructive pulmonary disease (COPD); few have applied comorbidity measures driven from health insurance claims databases to predict various health outcomes. We aimed to examine the performance of commonly used comorbidity measures based on diagnosis and pharmacy dispensing claims information in predicting future death and hospitalization in COPD patients.

Methods

We identified COPD patients in a population-based Taiwanese database. We built logistic regression models with age, sex, and baseline comorbidities measured by either diagnosis or pharmacy claims information as predictors of subsequent-year death or hospitalization in a random 50% sample and validated the discrimination in the other 50%. The diagnosis-based comorbidity measures included the Charlson Index and the Elixhauser comorbidity measure; the pharmacy-based comorbidity measures included the updated Chronic Disease Score (CDS) and the Pharmacy-Based Comorbidity Index (PBDI).

Results

We identified 428,251 eligible patients. For overall death, the Elixhauser comorbidity measure showed the best predictive performance (c-statistic=0.832), followed by the PBDI (c-statistic=0.822), the Charlson Index (c-statistic=0.815), and the updated CDS (c-statistic=0.808). For overall hospitalization, the PBDI (c-statistics=0.730) and the Elixhauser comorbidity measure (c-statistics=0.724) outperformed the updated CDS (c-statistics=0.714) and the Charlson Index (c-statistics=0.710). For hospitalization due to cardiovascular, cerebrovascular, or respiratory diseases, the comorbidity models showed similar predictive ranks and demonstrated c-statistics higher than 0.75. However, none of the models could adequately predict hospitalization due to other reasons (c-statistics < 0.60).

Conclusion

Our study comprehensively compared the predictive performance of comorbidity measures. The Elixhauser comorbidity measure and the PBDI are useful tools for describing comorbid conditions and predicting health outcomes in COPD patients.

Persistence on HIV preexposure prophylaxis medication over a 2-year period among a national sample of 7148 PrEP users, United States, 2015 to 2017

Introduction

Persistence on preexposure prophylaxis for HIV prevention (PrEP) medication has rarely been reported for periods greater than one year, or in real‐world settings. This study used pharmacy fill records for PrEP users from a national chain pharmacy to describe persistence on PrEP medication over a two‐year period, and to explore correlates with PrEP medication persistence in a real‐world setting.

Methods

We analysed de‐identified pharmacy fill records of 7148 eligible individuals who initiated PrEP in 2015 at a national chain pharmacy. A standard algorithm was employed to identify TDF‐FTC use for PrEP indication. We considered three time periods for persistence, defined as maintaining refills in PrEP care: year 1 (zero to twelve months), year 2 (thirteen to twenty‐four months) and initiation to year 2 (zero to twenty‐four months). Individuals with 16 or more days of TDF‐FTC PrEP dispensed in a 1‐month period for at least three‐quarters of a given time period (e.g. nine of twelve months or eighteen of twenty‐four months) were classified as persistent on PrEP medication for the period.

Results

Persistence was 56% in year 1, 63% in year 2 and 41% from initiation to year 2. Individuals aged 18 to 24 had the lowest persistence, with 29% from initiation to year 2. Men had higher persistence than women, with 42% compared to 20% persistent from initiation to year 2. Individuals with commercial insurance and individuals who utilized a community‐based specialty pharmacy from the national chain also had higher persistence. Male gender, age >18 to 24 years, average monthly copay of $20 or less, commercial insurance, and utilization of a community‐based specialty pharmacy were positively associated in adjusted models with persistence in year 1 and from initiation to year 2; the same correlates, with the exception of utilization of a community‐based specialty pharmacy, were associated with higher persistence in year 2.

Conclusions

We found substantial non‐persistence on PrEP medication in both year 1 and year 2. Across the entire 2‐year period, only two out of every five users persisted on PrEP. Demographic, financial and pharmacy factors were associated with persistence. Further research is needed to explore how social, structural or individual factors may undermine or enhance persistence on PrEP, and to develop interventions to assist persistence on PrEP.

A quantitative evaluation of adherence and inhalation technique among respiratory patients: An observational study using an electronic inhaler assessment device

BACKGROUND

Problems related to poor adherence and inhaler technique (IT) are historically reported in the literature. Most common methods used for adherence and IT assessment are reported to be either inaccurate or subjective. Few electronic monitoring devices (EMDs) that provide an objective measure of both adherence and IT while patients use inhalers at home now exist. Therefore, this study aimed to examine adherence level and IT among respiratory patients in community care using such an EMD for the first time in England.

METHODS

A prospective, multicentre, observational cohort study was conducted. Patients with chronic obstructive pulmonary disease (COPD) or asthma were recruited from independent community pharmacies within West and South London. Patients were provided with a dry-powder inhaler (DPI) mounted with an EMD to use for 1 month. Adherence was also assessed using pharmacy dispensing data, inhaler dose counter and self-reporting.

RESULTS

Data were available for 48 patients. Only eight patients used their inhaler in the correct manner at the correct interval as identified by the chosen EMD. The median actual adherence rate, as measured by the EMD, was 42.7%. This was significantly different from the median dose counter adherence (100%), medication refill adherence (MRA) (100%), proportions of days covered (PDC) (97.8%) and self-reported adherence (P < .001, each). Within a 1-month period, there were 2188 files showing attempted use of the DPI, of which 840 had IT errors. The median technique error rate (TER) was 30.1%. Most common errors recorded were as follows: multiple inhalations, drug priming without inhalation and failure to prime the device correctly.

CONCLUSION

The current study demonstrates that measures such as dose counter, prescription refill and self-reporting showed a high level of adherence among the observed patients. However, the objective data provided by the EMD showed a significantly lower actual adherence rate, reflecting how adherence remains variable and problematic among patients in the community.

Patient Possession of Excess Medication Supply in the VA: A Retrospective Database Study

BACKGROUND

Medication overlap leading to medication excess is a form of therapeutic duplication, itself a type of potentially inappropriate prescribing.

OBJECTIVE

To determine the prevalence of potential medication excess in the Veterans Health Administration (VHA) and identify associated medication-level, patient-level, and system-level factors.

RESEARCH DESIGN

A retrospective database study.

SUBJECTS

All veterans who received ≥1 prescription dispensed by a VHA pharmacy in fiscal year 2014.

MEASURES

The primary outcome of "medication excess" was defined for each patient as the number of excess days' worth of medications for all overlap episodes (concurrently dispensed medications with the same name for >10 d). Predictors included medication-level, patient-level, and system-level factors. Multivariable negative binomial regression analyses estimated the rate ratio of each predictor with medication excess.

RESULTS

Among 4,687,453 veterans, 64% had ≥1 medication overlap episodes. Patients were prescribed a median of 7 [interquartile range (IQR), 3-12] unique medications, had a median of 2 (IQR, 0-5) overlap episodes, and a median of 27 (IQR, 0-96) days of medication excess. In adjusted regression models, factors associated with greater risk of medication excess included having more comorbidities, multiple prescribers, a combination of filling locations (consolidated mail-order pharmacy vs. local pharmacy), and multiple prescription durations (≥90 d vs. less).

CONCLUSIONS

Medication excess was high among VHA users, with nearly two-thirds of patients experiencing at least 1 duplicative medication. As systems such as mail-order pharmacies and 90-day supply are increasingly implemented to reduce costs and improve medication adherence, it is important to recognize the potential for systems-level inefficiencies and potentially inappropriate prescribing.

Comparison of Pharmacy Database Methods for Determining Prevalent Chronic Medication Use

BACKGROUND

Pharmacy dispensing data are frequently used to identify prevalent medication use as a predictor or covariate in observational research studies. Although several methods have been proposed for using pharmacy dispensing data to identify prevalent medication use, little is known about their comparative performance.

OBJECTIVES

The authors sought to compare the performance of different methods for identifying prevalent outpatient medication use.

RESEARCH DESIGN

Outpatient pharmacy fill data were compared with medication reconciliation notes denoting prevalent outpatient medication use at the time of hospital admission for a random sample of 207 patients drawn from a national cohort of patients admitted to Veterans Affairs hospitals. Using reconciliation notes as the criterion standard, we determined the test characteristics of 12 pharmacy database algorithms for determining prevalent use of 11 classes of cardiovascular and diabetes medications.

RESULTS

The best-performing algorithms included a 180-day fixed look-back period approach (sensitivity, 93%; specificity, 97%; and positive predictive value, 89%) and a medication-on-hand approach with a grace period of 60 days (sensitivity, 91%; specificity, 97%; and positive predictive value, 91%). Algorithms that have been commonly used in previous studies, such as defining prevalent medications to include any medications filled in the prior year or only medications filled in the prior 30 days, performed less well. Algorithm performance was less accurate among patients recently receiving hospital or nursing facility care.

CONCLUSION

Pharmacy database algorithms that balance recentness of medication fills with grace periods performed better than more simplistic approaches and should be considered for future studies which examine prevalent chronic medication use.

French national health insurance database analysis and field study focusing on the impact of secure prescription pads on zolpidem consumption and sedative drug misuse: ZORRO study protocol

INTRODUCTION

In recent years, data collected by the French Addictovigilance Network have shown the potential for abuse and addiction associated with zolpidem (the most sold hypnotic drug in France). Since 10 April 2017, new regulations have come into force that require zolpidem to be prescribed on special secure prescription pads, in order to reduce the risk of abuse or misuse. This measure has far-reaching repercussions that are not only limited to the consumption of zolpidem but also extend to the usage of sedative medication on a whole. The objective of the ZOlpidem and the Reinforcement of the Regulation of prescription Orders (ZORRO) study is to evaluate the overall impact of the new regulatory framework requiring zolpidem to be prescribed on special secure prescription pads. Three axes will be evaluated: the number of consumers, the type of consumption (chronic use versus occasional use, problematic consumption versus non-problematic use) and the consumption of other sedative molecules.The study has been registered in the Protocol Registration and Results System under the number NCT03584542 at stage "Pre-results".

METHODS AND ANALYSIS

The ZORRO study is an epidemiological, observational, national multicentre, non-controlled, prospective research project supported by the French National Agency for Medicines and Health Products Safety. The evaluation of the impact of the regulatory framework change relative to zolpidem will be done according to two axes: via an epidemiological study of the French National Health Insurance database and by the implementation of field studies of prescribers and consumers of zolpidem.

ETHICS AND DISSEMINATION

The Nantes Research Ethics Committee (Groupe Nantais d'Ethique dans le Domaine de la Santé), the Committee for the Protection of the Population and the Committee of Expertise in Research, Studies and Evaluations in the Field of Health approved this study. Results will be presented in national and international conferences and submitted to peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03584542; Pre-results.

Pharmacy-based interdisciplinary intervention for patients with chronic heart failure: results of the PHARM-CHF randomized controlled trial

AIMS

Medication non-adherence is frequent and is associated with high morbidity and mortality in patients with chronic heart failure (CHF). We investigated whether an interdisciplinary intervention improves adherence in elderly CHF patients.

METHODS AND RESULTS

The study population (mean age 74 years, 62% male, mean left ventricular ejection fraction 47%, 52% in New York Heart Association class III) consisted of 110 patients randomized into the pharmacy care and 127 into the usual care group. The median follow-up was 2.0 years (interquartile range 1.2-2.7). The pharmacy care group received a medication review followed by regular dose dispensing and counselling. Control patients received usual care. The primary endpoint was medication adherence as proportion of days covered (PDC) within 365 days for three classes of heart failure medications (beta-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and mineralocorticoid receptor antagonists). The main secondary outcome was the proportion of adherent patients (PDC ≥ 80%). The primary safety endpoint was days lost due to unplanned cardiovascular hospitalizations (blindly adjudicated) or death. Pharmacy care compared with usual care resulted in an absolute increase in mean adherence to three heart failure medications for 365 days [adjusted difference 5.7%, 95% confidence interval (CI) 1.6-9.8, P = 0.007]. The proportion of patients classified as adherent increased (odds ratio 2.9, 95% CI 1.4-5.9, P = 0.005). Pharmacy care improved quality of life after 2 years (adjusted difference in Minnesota Living with Heart Failure Questionnaire scores -7.8 points (-14.5 to -1.1; P = 0.02), compared to usual care. Pharmacy care did not affect the safety endpoints of hospitalizations or deaths.

CONCLUSION

Pharmacy care safely improved adherence to heart failure medications and quality of life.

The association between pharmacy refill-adherence metrics and healthcare utilisation: a prospective cohort study of older hypertensive adults

AIMS

Methods that enable targeting and tailoring of adherence interventions may facilitate implementation in clinical settings. We aimed to determine whether community pharmacy refill-adherence metrics are useful to identify patients at higher risk of healthcare utilisation due to low antihypertensive adherence, who may benefit from an adherence intervention.

METHODS

We conducted a prospective cohort study, recruiting participants (n = 905) from 106 community pharmacies across the Republic of Ireland. Participants completed a structured interview at baseline and 12 months. Antihypertensive medication adherence was evaluated from linked pharmacy records using group-based trajectory modelling (GBTM) and proportion of days covered (PDC). Healthcare utilisation included self-reported number of hospital visits (emergency department visits and inpatient admissions) and general practitioner (GP) visits, over a 6-month period. Separate regression models were used to estimate the association between adherence and number of hospital/GP visits. The relative statistical fit of each model using different adherence metrics was determined using the Bayesian information criterion (BIC).

RESULTS

For the number of hospital visits, significant associations were observed only for PDC but not for GBTM. Each 10% increase in refill-adherence by PDC was significantly associated with a 16% lower rate of hospital visits (adjusted incidence rate ratio 0.84, 95% CI 0.72-0.98, P = 0.036). Poorer adherence using both measures was associated with higher GP visits. Improvements in BIC favoured models using PDC.

CONCLUSIONS

Medication refill-adherence, measured using PDC in community pharmacy settings, could be used to recognise poor antihypertensive adherence to enable effective targeting of clinical interventions to improve hypertension management and outcomes.