Objectively measured, but not self-reported, medication adherence independently predicts event-free survival in patients with heart failure

Poor Medication Access as a Driver of Excess Heart-Failure Readmissions Among Patients Living in Economically Deprived Neighborhoods

BACKGROUND

Patients residing in socioeconomically deprived neighborhoods experience higher hospital readmission rates after hospitalization for heart failure (HF). The role of medication access in the excessive readmissions in this group is poorly understood. This study explored patients' perspectives on medication access by individuals living in socioeconomically deprived neighborhoods who had experienced HF readmission.

METHODS

We conducted semistructured in-depth interviews with 25 patients (mean age 61 ± 9 years, 96% Black, 40% women) who were readmitted with acute HF at Emory Healthcare hospitals and were living in highly deprived neighborhoods (top decile of the Social Deprivation Index). Qualitative descriptive analyses of the interviews were performed by using a multilevel coding strategy.

RESULTS

Most patients (84%) highlighted medications as a driver of HF readmission. Patients' reported reasons for lack of medication access included medication costs (60%), having access to refills only through an emergency department or hospitalization (36%), limited access to transportation (12%), and limited understanding of medications' role in disease management (12%).

CONCLUSION

Lack of access to medications for patients with HF who live in socioeconomically distressed neighborhoods exacerbate excess hospitalizations in this vulnerable population. This study focuses on patients' perspectives and experiences and identifies some potentially high-value areas to focus on in trying to enhance access and adherence to evidence-based therapies.

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.

Improving medication adherence in cardiovascular disease

Non-adherence to medication is a global health problem with far-reaching individual-level and population-level consequences but remains unappreciated and under-addressed in the clinical setting. With increasing comorbidity and polypharmacy as well as an ageing population, cardiovascular disease and medication non-adherence are likely to become increasingly prevalent. Multiple methods for detecting non-adherence exist but are imperfect, and, despite emerging technology, a gold standard remains elusive. Non-adherence to medication is dynamic and often has multiple causes, particularly in the context of cardiovascular disease, which tends to require lifelong medication to control symptoms and risk factors in order to prevent disease progression. In this Review, we identify the causes of medication non-adherence and summarize interventions that have been proven in randomized clinical trials to be effective in improving adherence. Practical solutions and areas for future research are also proposed.

The use of technology to improve medication adherence in heart failure patients: a systematic review of randomised controlled trials

BACKGROUND

Heart failure is an ever-growing contributor to morbidity and mortality in the ageing population. Medication adherence rates among the HF population vary widely in the literature, with a reported range of 10-98%. Technologies have been developed to improve adherence to therapies and other clinical outcomes.

AIMS

This systematic review aims to investigate the effect of different technologies on medication adherence in patients with heart failure. It also aims to determine their impact on other clinical outcomes and examine the potential of these technologies in clinical practice.

METHODS

This systematic review was conducted using the following databases: PubMed Central UK, Embase, MEDLINE, CINAHL Plus, PsycINFO and Cochrane Library until October 2022. Studies were included if they were randomised controlled trials that used technology to improve medication adherence as an outcome in heart failure patients. The Cochrane Collaboration's Risk of Bias tool was used to assess individual studies. This review was registered with PROSPERO (ID: CRD42022371865).

RESULTS

A total of nine studies met the inclusion criteria. Two studies showed statistically significant improvement in medication adherence following their respective interventions. Eight studies had at least one statistically significant result in the other clinical outcomes it measured, including self-care, quality of life and hospitalisations. All studies that evaluated self-care management showed statistically significant improvement. Improvements in other outcomes, such as quality of life and hospitalisations, were inconsistent.

CONCLUSION

It is observable that there is limited evidence for using technology to improve medication adherence in heart failure patients. Further studies with larger study populations and validated self-reporting methods for medication adherence are required.

Association between hospital-physician vertical integration and medication adherence rates

OBJECTIVE

To test the association between vertical integration of primary care providers (PCPs) and adherence rates for anti-diabetics, renin angiotensin system antagonists (RASA), and statins.

DATA SOURCES

Medicare Part B outpatient fee-for-service claims and Medicare Part D event data from 2014 to 2017.

STUDY DESIGN

We estimated difference-in-differences regressions, comparing changes in adherence among patients with PCPs who converted from independent to integrated to changes among patients whose PCPs remained independent or integrated during the study period. To test for heterogenous impacts by patient demographics, we estimated triple difference regressions that included additional interaction terms by comorbidity rates, age group, and race/ethnicity.

EXTRACTION METHODS

We extracted Medicare claims for adults with continuous enrollment in Parts B and D during the study period.

PRINCIPAL FINDINGS

The proportion of patients who had a vertically integrated PCP increased by approximately 23% over the study period. Changes in adherence did not differ significantly between patients based on whether their PCP became integrated (Statins: 0.18, 95% CI -0.13, 0.49; RASA: -0.13, 95% CI -0.46, 0.19; Anti-Diabetics: -0.20, 95% CI -0.78, 0.38). Among patients with PCPs who became integrated, there were significant decreases in adherence for patients who were Black, Asian, Hispanic, or Native American, above 80 years old, and had greater comorbidities for all three classes.

CONCLUSIONS

While there were no average changes in adherence following vertical integration of PCPs, health equity worsened, with significant declines in adherence for Black, Asian, Hispanic, and Native American patients, patients over 80 years old, and patients with greater comorbidities. These findings suggest that integration may reduce clinicians' incentives to compete based on the quality of care delivered. Given the price increases associated with integration, integration may be a net welfare loss.

Failure of Guidelines and Consensus Statements to Recommend Follow-up for Chronic Cardiovascular Conditions

BACKGROUND

Many cardiac conditions require long-term clinical follow-up to monitor progression of disease and tolerance and adherence to therapies. Providers are often unsure as to the frequency of clinical follow-up and who should provide the follow-up. In the absence of formal guidance, patients may be seen more frequently than necessary - thereby limiting clinic space for other patients, or not frequently enough, potentially leading to undetected progression of disease.

OBJECTIVES

To determine the extent to which guidelines (GL)/consensus statements (CS) provide guidance about appropriate follow-up for common cardiovascular conditions.

METHODS

We identified 31 chronic cardiovascular disease conditions for which long-term (beyond 1 year) follow-up is indicated and used PubMed and professional society websites to identify all relevant GL/CS (n = 33) regarding these chronic cardiac conditions.

RESULTS

Of the 31 cardiac conditions reviewed, GL/CS contained no recommendation or vague recommendation for long-term follow-up for 7 of the conditions. Of the 24 conditions with recommendations for follow-up, 3 had recommendations for imaging follow-up only without mention of clinical follow-up. Of the 33 GL/CS reviewed, 17 made any recommendations about long-term follow-up. When recommendations were made regarding follow-up, they were often vague, using terminology such as "as needed".

CONCLUSIONS

Half of GL/CS fail to provide recommendations for clinical follow-up of common cardiovascular conditions. Writing groups for GL/CS should adopt a standard of routinely including recommendations for follow-up including specific advice about level of expertise needed (eg, primary care physician, cardiologist), need for imaging or testing, and frequency of follow-up.

Remote Monitoring and Behavioral Economics in Managing Heart Failure in Patients Discharged From the Hospital: A Randomized Clinical Trial

IMPORTANCE

Close remote monitoring of patients following discharge for heart failure (HF) may reduce readmissions or death.

OBJECTIVE

To determine whether remote monitoring of diuretic adherence and weight changes with financial incentives reduces hospital readmissions or death following discharge with HF.

DESIGN, SETTING, AND PARTICIPANTS

The Electronic Monitoring of Patients Offers Ways to Enhance Recovery (EMPOWER) study, a 3-hospital pragmatic trial, randomized 552 adults recently discharged with HF to usual care (n = 280) or a compound intervention (n = 272) designed to inform clinicians of diuretic adherence and changes in patient weight. Patients were recruited from May 25, 2016, to April 8, 2019, and followed up for 12 months. Investigators were blinded to assignment but patients were not. Analysis was by intent to treat.

INTERVENTIONS

Participants randomized to the intervention arm received digital scales, electronic pill bottles for diuretic medication, and regret lottery incentives conditional on the previous day's adherence to both medication and weight measurement, with $1.40 expected daily value. Participants' physicians were alerted if participants' weights increased 1.4 kg in 24 hours or 2.3 kg in 72 hours or if diuretic medications were missed for 5 days. Alerts and weights were integrated into the electronic health record. Participants randomized to the control arm received usual care and no further study contact.

MAIN OUTCOMES AND MEASURES

Time to death or readmission for any cause within 12 months.

RESULTS

Of the 552 participants, 290 were men (52.5%); 291 patients (52.7%) were Black, 231 were White (41.8%), and 16 were Hispanic (2.9%); mean (SD) age was 64.5 (11.8) years. The mean (SD) ejection fraction was 43% (18.1%). Each month, approximately 75% of participants were 80% adherent to both medication and weight measurement. There were 423 readmissions and 26 deaths in the control group and 377 readmissions and 23 deaths in the intervention group. There was no significant difference between the 2 groups for the combined outcome of all-cause inpatient readmission or death (unadjusted hazard ratio, 0.91; 95% CI, 0.74-1.13; P = .40) and no significant differences in all-cause inpatient readmission or observation stay or death, all-cause cardiovascular readmission or death, time to first event, and total all-cause deaths. Participants in the intervention group were slightly more likely to spend fewer days in the hospital.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, there was no reduction in the combined outcome of readmission or mortality in a year-long intensive remote monitoring program with incentives for patients previously hospitalized for HF.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02708654.

Risk factor control among heart failure patients in the United States: Results from the NHANES 1999-2018

Background

Compliance with recommended pharmacological and non-pharmacological treatments to modify risk factors is associated with improved outcomes for patients with heart failure (HF).

Methods

We conducted an analysis of the National Health and Nutrition Examination Survey (NHANES) years 1999-2018 to evaluate the adequacy of risk factor control and compliance with recommended lifestyle and medications according to the clinical guidelines for the management of HF. Demographic, clinical, and healthcare-access factors associated with having risk factors uncontrolled or not receiving recommended medications were determined using logistic regression analyses.

Results

We collected 1906 participants aged 18 years or older with a self-reported history of HF. The majority were at target goals for blood pressure (45.07%), low-density lipoprotein cholesterol (22.04%), and glycated hemoglobin (72.15%), whereas only 19.09% and 27.38% were at targets for body mass index and waist circumference respectively. Besides, 79.49% and 67.23% of respondents reported smoking cessation and recommended alcohol consumption, whereas only 11.54% reported adequate physical activity. Proportion of taking beta blockers, angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs) and diuretics was 54.77%, 52.62% and 49.37%, respectively. Finally, the logistic regression analysis showed that metabolic syndrome and diabetes mellitus were associated with a higher likelihood of having risk factor uncontrolled, while metabolic syndrome, diabetes mellitus, and chronic kidney disease were predictors for not receiving recommended medications.

Conclusions

Risk factor control and adherence to recommended lifestyle and medications are non-ideal among HF patients in the USA. A systematic approach for risk factor optimization in people with HF is urgently needed.

Relation of Household Income to Access and Adherence to Combination Sacubitril/Valsartan in Heart Failure: A Retrospective Analysis of Commercially Insured Patients

Background: Outcomes in heart failure with reduced ejection fraction (HFrEF), are influenced by access and adherence to guideline-directed medical therapy. Our objective was to study the association between annual household income and: (1) the odds of having a claim for sacubitril/valsartan among insured patients with HFrEF and (2) medication adherence (measured as the proportion of days covered [PDC]). We hypothesized that lower annual household income is associated with decreased odds of having a claim for and adhering to sacubitril/valsartan. Methods: Using the Optum de-identified Clinformatics® Data Mart, patients with HFrEF and ≥6 months of enrollment for follow up (2016-2020) were included. Covariates included age, sex, race, ethnicity, educational attainment, US region, number of prescribed medications, and Elixhauser Comorbidity Index. Prescription for sacubitril/valsartan was defined by the presence of a claim within 6 months of HFrEF diagnosis. Adherence was defined as PDC≥80%. We fit multivariable-adjusted logistic regression models and hierarchical logistic regression accounting for covariates. Results: Among 322,007 individuals with incident HFrEF, 135,282 had complete data for analysis. Of the patients eligible for sacubitril/valsartan, 4.7% (6,372) had a claim within 6 months of HFrEF diagnosis. Following multivariable adjustment, individuals in the lowest annual income category (<$40,000) were significantly less likely (OR=0.83, 95% CI [0.76, 0.90]) to have a sacubitril/valsartan claim within 6 months of HFrEF diagnosis than those in the highest annual income category (≥$100,000). Annual income <$40,000 was associated with lower odds of PDC≥80% compared with income ≥$100,000 (OR=0.70, 95% CI [0.59, 0.83]). Conclusions: Lower household income is associated with decreased likelihood of a sacubitril/valsartan claim and medication adherence within 6 months of HFrEF diagnosis, even after adjusting for sociodemographic and clinical factors. Future analyses are needed to identify additional social factors associated with delays in sacubitril/valsartan initiation and long-term adherence.

Health-Related Quality of Life Is a Mediator of the Relationship Between Medication Adherence and Cardiac Event-Free Survival in Patients with Heart Failure

BACKGROUND

Health-related quality of life (HRQOL) is an important patient-reported outcome that is related to medication adherence, hospitalization and death. The nature of the relationships among medication adherence, HRQOL, and hospitalization and death is unknown. We sought to determine the relationships among medication adherence, HRQOL, and cardiac event-free survival in patients with heart failure.

METHODS AND RESULTS

We enrolled 218 patients with heart failure. Patients' medication adherence was measured objectively using the Medication Event Monitoring System. HRQOL was assessed using the Minnesota Living with Heart Failure Questionnaire. Patients were followed for up to 3.5 years to collect hospitalization and mortality data. Mediation analysis was used to determine the nature of the relationships among the variables. Patients with better medication adherence had better HRQOL (P = .014). Medication adherence and HRQOL were associated with cardiac event-free survival (both P < .05). Patients with medication nonadherence were 1.86 times more likely to experience a cardiac event than those with better medication adherence (P = .038). Medication adherence was not associated with cardiac event-free survival after entering HRQOL in the model (P = .118), indicating mediation by HRQOL of the relationship between medication adherence and cardiac event-free survival.

CONCLUSIONS

HRQOL mediated the relationship between medication adherence and cardiac event-free survival. It is important to assess medication adherence and HRQOL regularly and develop interventions to improve medication adherence and HRQOL to decrease hospitalization and mortality in patients with heart failure.

The effectiveness of the information-motivation-behavioral skills model-based intervention on preventive behaviors against respiratory infection among community-dwelling older adults

OBJECTIVE

To evaluate the effectiveness of an information-motivation-behavioral skills (IMB) model-based multi-component intervention on engagement and the quality of preventive behaviors against respiratory infections among community-dwelling older adults.

METHODS

This study was a controlled pretest-posttest study in which 91 community-dwelling older adults aged above 65 years were included. The intervention group (n = 42) received the six-week intervention theoretically based on the IMB model that comprised weekly group education and 5-10 min of tele-counseling per week.

RESULTS

The results showed that, after the intervention, the improvement in the level of knowledge, self-efficacy, self-reported engagement, and the quality of respiratory infection preventive behaviors was significantly greater in the intervention group compared to the control group. There was no significant difference between the two groups for the perceived threat of respiratory infection.

CONCLUSION

The IMB model-based intervention improved the engagement and quality of preventive behaviors by increasing the level of knowledge and self-efficacy in community-dwelling older adults.

PRACTICE IMPLICATIONS

The IMB model-based multi-component intervention can be an effective approach to improve preventive behaviors and will contribute to the preparation of communities for outbreaks of respiratory infections.

A mixed method study design to explore the adherence of haematological cancer patients to oral anticancer medication in a multilingual and multicultural outpatient setting: The MADESIO protocol

Background

Patients with haematologic malignancies are increasingly treated by oral anticancer medications, heightening the challenge of ensuring optimal adherence to treatment. However, except for chronic myelogenous leukaemia or acute lymphoid leukaemia, the extent of non-adherence has rarely been investigated in outpatient settings, particularly for migrant population. With growing numbers of migrants in Belgium, identifying potential differences in drug use is essential. Also, previous research regarding social determinants of health highlight important disparities for migrant population. Difficulties in communication between health caregivers and patients from different cultural and ethnic backgrounds has been underlined.

Methods

Using a sequential mixed method design, the MADESIO protocol explores the adherence to oral anticancer medications in patients with haematological malignancies and among first and second generation migrants of varied origin. Conducted in the ambulatory setting, a first quantitative strand will measure adherence rates and associated risk factors in two sub-groups of patients with haematological malignancies (group A: first and second generation migrants and group B: non-migrants). The second qualitative strand of this study uses semi-structured interviews to address address the patients’ subjective meanings and understand the statistical associations observed in the quantitative study (strand one). MADESIO aims to provide a first assessment of whether and why migrants constitute a population at risk concerning adherence to oral anticancer medications.

Discussion

Our protocol is designed to provide a comprehensive understanding of adherence in a specific population. The methodological choices applied allow to explore adherence among patients from diverse linguistic and cultural backgrounds. A particular emphasis has been paid to minimize the biases and increase the reliability of the data collected. Easily reproductible, the MADESIO design may help healthcare services to screen adherence to Oral anticancer medications and to guide providers in choosing the best strategies to address medication adherence of migrants or minority diverse population.

Primary Care Records of Chronic-Disease Patient Adherence to Treatment

The goal of managing adherence (AD) is to achieve better medication use by patients in order to maximize benefits and reduce risks. With the aim of improving treatment adherence by patients, we carried out a descriptive study to obtain information related to adherence management in primary care. Inclusion criteria were as follows: patients that had at least one record of any treatment adherence assessment variable. For those that had more than one recorded variable, we analyzed consistency across test results. For the comparative analysis of adherence records, patients were categorized into three groups on the basis of the healthcare unit that recorded the data: case management (CM), home care (HC), and primary care team (PCT). A total of 32,137 subjects met inclusion criteria; 79.56% of subjects were older than 65. As for the analysis of assessment records across care units, 69.73% of CM patients, 67.17% of HC patients, and 2.33% of PCT patients had adherence assessment records. CM units made a significantly greater number of records than HC units. We observed low adherence at a rate of 49.3% in the CM group, 31.91% in the HC group, and 17.58% in the PCT group. When more than one adherence variable was recorded, analysis revealed inconsistent test results or recorded variables in 9.06% of PCT cases, 14.83% of HC cases, and 20.47% of CM cases. The inconsistencies observed in records of adherence assessment and management across different care units reveal the huge variability that exists in managing and selecting a tool to assess adherence.

Contemporary Reevaluation of Race and Ethnicity With Outcomes in Heart Failure

Background

Variation in outcomes by race/ethnicity in adults with heart failure (HF) has been previously observed. Identifying factors contributing to these variations could help target interventions. We evaluated the association of race/ethnicity with HF outcomes and potentially contributing factors within a contemporary HF cohort.

Methods and Results

We identified members of Kaiser Permanente Northern California, a large integrated healthcare delivery system, who were diagnosed with HF between 2012 and 2016 and had at least 1 year of prior continuous membership and left ventricular ejection fraction data. We used Cox regression with time‐dependent covariates to evaluate the association of self‐identified race/ethnicity with HF or all‐cause hospitalization and all‐cause death, with backward selection for potential explanatory variables. Among 34 621 patients with HF, compared with White patients, Black patients had a higher rate of HF hospitalization (adjusted hazard ratio [HR], 1.28; 95% CI, 1.18–1.38) but a lower rate of death (adjusted HR, 0.78; 95% CI, 0.72–0.85). In contrast, Asian/Pacific Islander patients had similar rates of HF hospitalization, but lower rates of all‐cause hospitalization (adjusted HR, 0.89; 95% CI, 0.85–0.93) and death (adjusted HR, 0.75; 95% CI, 0.69–0.80). Hispanic patients also had a lower rate of death (adjusted HR, 0.85; 95% CI, 0.80–0.91). Sensitivity analyses showed that effect sizes for Black patients were larger among patients with reduced ejection fraction.

Conclusions

In a contemporary and diverse population with HF, Black patients experienced a higher rate of HF hospitalization and a lower rate of death compared with White patients. In contrast, selected outcomes for Asian/Pacific Islander and Hispanic patients were more favorable compared with White patients. The observed differences were not explained by measured potentially modifiable factors, including pharmacological treatment. Future research is needed to identify explanatory mechanisms underlying ongoing racial/ethnic variation to target potential interventions.

Association of Adherence to Weight Telemonitoring With Health Care Use and Death: A Secondary Analysis of a Randomized Clinical Trial

IMPORTANCE

Adherence to telemonitoring may be associated with heart failure exacerbation but is not included in telemonitoring algorithms.

OBJECTIVE

To assess whether telemonitoring adherence is associated with a patient's risk of hospitalization, emergency department visit, or death.

DESIGN, SETTING, AND PARTICIPANTS

This post hoc secondary analysis of the Better Effectiveness After Transition-Heart Failure randomized clinical trial included patients from 6 academic medical centers in California who were eligible if they were hospitalized for decompensated heart failure and excluded if they were discharged to a skilled nursing facility, were expected to improve because of a medical procedure, or did not have the cognitive or physical ability to participate. The trial compared a telemonitoring intervention with usual care for patients with heart failure after hospital discharge from October 12, 2011, to September 30, 2013. Data analysis was performed from November 8, 2016, to May 10, 2019.

INTERVENTIONS

The intervention group (n = 722) received heart failure education, telephone check-ins, and a wireless telemonitoring system that allowed the patient to transmit weight, blood pressure, heart rate, and selected symptoms. The control group (n = 715) received usual care. Patients were followed up for 180 days after discharge.

MAIN OUTCOMES AND MEASURES

The main outcome was within-person risk of hospitalization, emergency department visit, or death by week during the study period. Poisson regression was used to determine the within-person association of adherence to daily weighing with the risk of experiencing these events in the following week.

RESULTS

Among the 538 participants (mean [SD] age, 70.9 [14.1] years; 287 [53.8%] male; 269 [50.7%] white) in the present analysis, adherence was lowest during the first week after enrollment but steadily increased, peaking between days 26 and 60 at 69%, or 371 transmissions. Adherence to weight telemonitoring was associated with events in the following week; an increase in adherence by 1 day was associated with a 19% decrease in the rate of death in the following week (incidence rate ratio, 0.81; 95% CI, 0.73-0.90) and an 11% decrease in the rate of hospitalization (incidence rate ratio, 0.89; 95% CI, 0.86-0.91). Adherence in the previous week was not associated with reduced rates of emergency department visits (incidence rate ratio, 0.95; 95% CI, 0.90-1.02).

CONCLUSIONS AND RELEVANCE

In this study, lower adherence to weight telemonitoring in a given week was associated with an increased risk of subsequent hospitalization or death in the following week. It is unlikely that this is a result of the telemonitoring intervention; rather, adherence may be an important factor associated with a patient's health status.

Adherence to prescribed medications in patients with heart failure: insights from liquid chromatography-tandem mass spectrometry-based urine analysis

AIMS

None of the existing studies on adherence have directly measured levels of all medications (or their metabolites) in patients with heart failure (HF).

METHODS AND RESULTS

We used liquid chromatography-tandem mass spectrometry to measure the presence of prescribed drugs (diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, and mineralocorticoid receptor antagonists) in the urine of patients reviewed 4-6 weeks after hospitalization with HF. Patients were unaware that adherence was being assessed. Of the 341 patients studied, 281 (82.4%) were adherent, i.e. had all prescribed drugs of interest detectable in their urine. Conversely, 60 patients (17.6%) were partially or completely non-adherent. Notably, 24 of the 60 were non-adherent to only diuretic therapy and only seven out of all 341 patients studied (2.1%) were completely non-adherent to all prescribed HF drugs. There were no major differences in baseline characteristics between adherent and non-adherent patients.

CONCLUSION

Non-adherence, assessed using a single spot urine measurement of drug levels, was confirmed in one of five patients evaluated 4-6 weeks after hospitalization with HF.

Rationale and Design of EMPOWER, a Pragmatic Randomized Trial of Automated Hovering in Patients With Congestive Heart Failure

BACKGROUND

Congestive heart failure is a major cause of morbidity, mortality, and cost. Disease management programs have shown promise but lack firm evidence of effectiveness and scalability. We describe the motivation, design, and planned analyses of EMPOWER (Electronic Monitoring of Patients Offers Ways to Enhance Recovery), a randomized clinical trial of an innovative intervention incorporating behavioral economic principles with remote monitoring technology embedded within a healthcare system.

METHODS AND RESULTS

EMPOWER is an ongoing, pragmatic, randomized clinical trial comparing usual care to an automated hovering intervention that includes patient-level incentives for daily weight monitoring and diuretic adherence combined with automated feedback into the clinical care pathway, enabling real-time response to concerning clinical symptoms. Identification of eligible patients began in May 2016, and implementation of the intervention is feasible. Trial processes are embedded into existing clinical pathways. The primary outcome is time to readmission for any cause. Cost-effectiveness analyses are planned to evaluate the healthcare costs and health outcomes of the approach.

CONCLUSIONS

The EMPOWER trial incorporates leading-edge approaches in human motivation, derived from behavioral economics, with contemporary technology to provide scale and exception handling at low cost. The trial is also implemented within the naturalized environment of a health system, as much as possible taking advantage of the existing journeys of patients and workflows of clinicians. A goal of this pragmatic design is to limit resource utilization and also to test an intervention that would need minimal modification to be translated from research into a new way of practice.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov . Unique identifier: NCT02708654.

Discontinuation of angiotensin-converting enzyme inhibitors or beta-blockers and the impact on heart failure hospitalization rates

BACKGROUND

Adherence to evidence-based therapy is essential for optimal management of heart failure. Yet, medication adherence is poor in heart failure patients. The Ascertaining Barriers to Compliance Project decomposed the medication adherence process into initiation, implementation, and discontinuation stages, but electronic monitoring-based adherence analyses usually do not consider this process.

AIMS

The aim of this study was to describe individual-patient patterns of medication adherence from electronic monitoring data among adults with chronic heart failure, adherence types, and risk factors for increased all-cause hospitalization including measures of poor adherence such as discontinuation.

METHODS

Data from two prospective studies of adherence measured with electronic monitoring for heart failure patients were combined and restricted to monitoring of angiotensin-converting enzyme inhibitors and beta-blockers over an initial three-month period. Hospitalizations were recorded for this period as well as for a three-month follow-up period. Analyses were conducted using adaptive modeling methods to identify individual-patient adherence patterns, adherence types, and risk factors for an increased hospitalization rate.

RESULTS

Using electronic monitoring data for 254 heart failure patients, four adherence types were identified: highly consistent, consistent but variable, moderately consistent, and poorly consistent. Sixteen individually significant risk factors for increased hospitalization rates were identified and used to generate a multiple risk factors model. Medication discontinuation was the most important individual risk factor and most important in the multiple risk factors model.

CONCLUSION

Discontinuation of angiotensin-converting enzyme inhibitors or beta-blockers increases hospitalization rates for heart failure patients. Interventions that effectively address this problem are urgently needed.

A hybrid 4-item Krousel-Wood Medication Adherence Scale predicts cardiovascular events in older hypertensive adults

BACKGROUND

There is a need for a brief, open access, self-report medication adherence scale that overcomes challenges of existing adherence tools, is associated with incident cardiovascular disease (CVD), and identifies low 'implementation' adherers to antihypertensive medications to facilitate blood pressure management.

METHODS AND RESULTS

Antihypertensive medication adherence was assessed in a cohort of 1532 older hypertensive adults without prior CVD using the self-report 4-item Krousel-Wood Medication Adherence Scale (K-Wood-MAS-4), a hybrid tool developed to predict pharmacy refill and which captures four domains of adherence behavior: self-efficacy, physical function, intentional medication-taking, and forgetfulness. The 4-item scale categorized participants as low and high adherers using scores at least 1 and less than 1, respectively. Participants were followed after K-Wood-MAS-4 assessment to identify incident CVD events (stroke, myocardial infarction, congestive heart failure, or CVD death). The prevalence of low adherence was 38.7%. During a median follow-up of 2.8 years (maximum 3.8 years), 136 (8.9%) participants had an incident CVD event; 12.8 and 6.4% in low and high adherers, respectively. The adjusted hazard ratio (aHR) for incident CVD associated with low versus high adherence was 2.29 [95% confidence interval (CI): 1.61, 3.26]. Results were similar when stratified by age [<75 years - aHR 3.53 (95% CI: 1.65, 7.56); ≥75 years - aHR 1.98 (95% CI: 1.32, 2.97)], sex [women - aHR 1.90 (95% CI: 1.16, 3.12); men - aHR 2.80 (95% CI: 1.68, 4.65)], and race [black - aHR 2.22 (95% CI: 0.93, 5.31); white - aHR 2.26 (95% CI: 1.54, 3.34)].

CONCLUSION

Low medication adherence using the 'hybrid' K-Wood-MAS-4 predicts incident CVD in a cohort of older adults with established hypertension.

Patient-reported barriers to medication adherence in heart failure in Scotland

OBJECTIVES

Medication adherence is the end result of a complex set of interwoven factors. Non-adherence with medication in heart failure patients is associated with excess mortality and morbidity. Studies describing interventions to improve adherence in heart failure are limited by a lack of robust methods and inconsistent outcomes. The aim of this evaluation was to explore the barriers to medication adherence in Scottish heart failure patients in order to inform the development of complex interventions.

METHODS

Qualitative patient interviews. Participants were aged ≥18 years with current or previous signs or symptoms of clinical heart failure, reduced left ventricular ejection fraction ≤45% and confirmed adherence of <80% in tablet counts of heart failure therapy. Thematic analysis was employed.

KEY FINDINGS

Eleven patients were recruited. The median age was 79 years old, and participants were typically from socially deprived communities. Participants were prescribed a mean 9.9 different medications per day. Seven distinct themes emerged around barriers to medication adherence: co-morbidity; treatment burden; health literacy; trust in NHS; socioeconomic factors; autonomy and health expectations.

CONCLUSIONS

The factors affecting medication adherence in heart failure are multi-factorial and are unlikely to be improved by one single-faceted intervention. Future interventions need to treat patients holistically, build their trust as partners, simplify complex treatment regimens where possible and involve educational and social elements. The skill set and opportunities afforded to pharmacists may be well placed to deliver many of these aspects but this would need tested in the context of the development of complex interventions.

Interventions to Improve Medication Adherence: A Review

IMPORTANCE

Among adults with chronic illness, 30% to 50% of medications are not taken as prescribed. In the United States, it is estimated that medication nonadherence is associated with 125 000 deaths, 10% of hospitalizations, and $100 billion in health care services annually.

OBSERVATIONS

PubMed was searched from January 1, 2000, to September 6, 2018, for English-language randomized clinical trials of interventions to improve medication adherence. Trials of patients younger than 18 years, trials that used self-report as the primary adherence outcome, and trials with follow-up periods less than 6 months were excluded; 49 trials were included. The most common methods of identifying patients at risk for nonadherence were patient self-report, electronic drug monitors (pill bottles), or pharmacy claims data to measure gaps in supply. Patient self-report is the most practical method of identifying nonadherent patients in the context of clinical care but may overestimate adherence compared with objective methods such as electronic drug monitors and pharmacy claims data. Six categories of interventions, and characteristics of successful interventions within each category, were identified: patient education (eg, recurrent and personalized telephone counseling sessions with health educators); medication regimen management (using combination pills to reduce the number of pills patients take daily); clinical pharmacist consultation for chronic disease co-management (including education, increased frequency of disease monitoring via telephone or in-person follow-up visits, and refill reminders); cognitive behavioral therapies (such as motivational interviewing by trained counselors); medication-taking reminders (such as refill reminder calls or use of electronic drug monitors for real-time monitoring and reminding); and incentives to promote adherence (such as reducing co-payments and paying patients and clinicians for achieving disease management goals). The choice of intervention to promote adherence will depend on feasibility and availability within a practice or health system. Successful interventions that are also clinically practical include using combination pills to reduce daily pill burden, clinical pharmacist consultation for disease co-management, and medication-taking reminders such as telephone calls to prompt refills (maximum observed absolute improvements in adherence of 10%, 15%, and 33%, respectively).

CONCLUSIONS AND RELEVANCE

Adherence can be assessed and improved within the context of usual clinical care, but more intensive and costly interventions that have demonstrated success will require additional investments by health systems.

Capability for self-care of patients with heart failure

Background

A thorough analysis of the capability for self-care in patients with heart failure (HF) reduces the frequency of hospitalizations that are caused by decompensation. The aim of the study was to assess the effect of the method of therapy for HF, the degree of the acceptance of illness, and the occurrence of frailty syndrome on adherence to the therapeutic recommendations and self-care in patients with HF.

Methods

The study included 180 patients who were hospitalized after being diagnosed with HF. In all, we used the Polish versions of three validated instruments: the nine-item European Heart Failure Self-care Behavior Scale, Illness Acceptance Scale, and The Tilburg Frailty Indicator.

Results

The capability for self-care of patients with HF was 27.8%. More than 65% of the patients followed the recommendations for taking medication and also followed a low-sodium diet, while only 5.5% of the patients followed the recommendations for physical exercise. Positive correlations were found between the capability for self-care and frailty syndrome and its components: general frailty components vs the capability for self-care: r=0.4449, P=0.0000; physical frailty components vs the capability for self-care: r=0.3974, P=0.0000; emotional frailty components vs the capability for self-care: r=0.2831, P=0.0001; social frailty components vs the capability for self-care: r=0.2180, P=0.0032, and a negative correlation between the capability for self-care and the degree of the acceptance of the illnesses (r=−0.4662, P=0.0000).

Conclusion

A relatively low capability for self-care was found in patients with HF. The presence of frailty syndrome and a low level of the acceptance of illness are connected with a low capability for self-care.

Enhancing self-care adherence in patients with heart failure: a study protocol for developing a theory-based behaviour change intervention using the COM-B behaviour model (ACHIEVE study)

INTRODUCTION

Although international guidelines recommend self-care as an integral part of routine heart failure management, and despite evidence supporting the positive outcomes related to self-care, patients are frequently unable to adhere. Self-care can be modified through behaviour change interventions (BCIs). However, previous self-care interventions have shown limited success in improving adherence to self-care, because they were neither theory-based nor well defined, which precludes the identification of underlying causal mechanisms as well as reproducibility of the intervention. Thus, our aim is to develop an intervention manual that contains theory-based BCIs that are well-defined using eight descriptors proposed to describe BCIs in a standardised way.

METHODS AND ANALYSIS

BCIs will be based on statements of findings derived through qualitative meta-summary techniques and a quantitative meta-analysis. These reviews will be used to extract factors (target behaviours) associated with self-care adherence/non-adherence. Extracted target behaviours will be mapped onto the 'Capability, Opportunity, Motivation and Behaviour' (COM-B) model to capture the underlying mechanisms involved. To develop approaches for change, the 'Taxonomy of Behaviour Change Techniques' will be used to allow effective mapping of the target behaviours onto established behaviour change techniques. Suggested BCIs will then be translated into locally relevant interventions using the Normalisation Process Theory to overcome the difficulties of implementing theoretically derived interventions into practice. Finally, a consensus development method will be employed to fine-tune the content and acceptability of the intervention manual to increase the likelihood of successfully piloting and implementing future BCIs into the German healthcare system.

ETHICS AND DISSEMINATION

This study has been reviewed and approved by the Ethics Committee of the Medical Faculty of the Heinrich Heine University Düsseldorf, Germany (Ref #: 2018-30). The results will be disseminated via peer-reviewed journal publications, conference presentations and stakeholder engagement activities.

TRIAL REGISTRATION NUMBER

DRKS00014855; Pre-results.

Micronutrient Deficiency Independently Predicts Time to Event in Patients With Heart Failure

Background Dietary micronutrient deficiencies have been shown to predict event-free survival in other countries but have not been examined in patients with heart failure living in the United States. The purpose of this study was to determine whether number of dietary micronutrient deficiencies in patients with heart failure was associated with shorter event-free survival, defined as a combined end point of all-cause hospitalization and death. Methods and Results Four-day food diaries were collected from 246 patients with heart failure (age: 61.5±12 years; 67% male; 73% white; 45% New York Heart Association [NYHA] class III / IV ) and analyzed using Nutrition Data Systems for Research. Micronutrient deficiencies were determined according to methods recommended by the Institute of Medicine. Patients were followed for 1 year to collect data on all-cause hospitalization or death. Patients were divided according to number of dietary micronutrient deficiencies at a cut point of ≥7 for the high deficiency category versus <7 for the no to moderate deficiency category. In the full sample, 29.8% of patients experienced hospitalization or death during the year, including 44.3% in the high-deficiency group and 25.1% in the no/moderate group. The difference in survival distribution was significant (log rank, P=0.0065). In a Cox regression, micronutrient deficiency category predicted time to event with depression, NYHA classification, comorbidity burden, body mass index, calorie and sodium intake, and prescribed angiotensin-converting enzyme inhibitors, diuretics, or β-blockers included as covariates. Conclusions This study provides additional convincing evidence that diet quality of patients with heart failure plays an important role in heart failure outcomes.

Medication Adherence Mediates the Relationship Between Heart Failure Symptoms and Cardiac Event-Free Survival in Patients With Heart Failure

BACKGROUND

Heart failure (HF) symptoms such as dyspnea are common and may precipitate hospitalization. Medication nonadherence is presumed to be associated with symptom exacerbations, yet how HF symptoms, medication adherence, and hospitalization/death are related remains unclear.

OBJECTIVE

The aim of this study was to explore the relationships among HF symptoms, medication adherence, and cardiac event-free survival in patients with HF.

METHODS

At baseline, patient demographics, clinical data, and HF symptoms were collected in 219 patients with HF. Medication adherence was monitored using the Medication Event Monitoring System. Patients were followed for up to 3.5 years to collect hospitalization and survival data. Logistic regression and survival analyses were used for the analyses.

RESULTS

Patients reporting dyspnea or ankle swelling were more likely to have poor medication adherence (P = .05). Poor medication adherence was associated with worse cardiac event-free survival (P = .006). In Cox regression, patients with HF symptoms had 2 times greater risk for a cardiac event than patients without HF symptoms (P = .042). Heart failure symptoms were not a significant predictor of cardiac event-free survival after entering medication adherence in the model (P = .091), indicating mediation.

CONCLUSIONS

Medication adherence was associated with fewer HF symptoms and lower rates of hospitalization and death. It is important to develop interventions to improve medication adherence that may reduce HF symptoms and high hospitalization and mortality in patients with HF.

Stress, cognitive appraisal, coping, and event free survival in patients with heart failure

OBJECTIVES

To describe self-reported stress level, cognitive appraisal and coping among patients with heart failure (HF), and to examine the association of cognitive appraisal and coping strategies with event-free survival.

METHODS

This was a prospective, longitudinal, descriptive study of patients with chronic HF. Assessment of stress, cognitive appraisal, and coping was performed using Perceived Stress Scale, Cognitive Appraisal Health Scale, and Brief COPE scale, respectively. The event-free survival was defined as cardiac rehospitalization and all-cause death.

RESULTS

A total of 88 HF patients (mean age 58 ± 13 years and 53.4% male) participated. Linear and cox regression showed that harm/loss cognitive appraisal was associated with avoidant emotional coping (β = -0.28; 95% CI: -0.21 - 0.02; p = 0.02) and event free survival (HR = 0.53; 95% CI: 0.28 - 1.02; p = 0.05).

CONCLUSIONS

The cognitive appraisal of the stressors related to HF may lead to negative coping strategies that are associated with worse event-free survival.

Can Mindfulness Training Improve Medication Adherence? Integrative Review of the Current Evidence and Proposed Conceptual Model

Medication adherence is a complex, multi-determined behavior that is often influenced by system- (e.g., cost), drug- (e.g., regimen complexity), and patient-related (e.g., depression) factors. System-level approaches (e.g., making medications more affordable) are critically important but do not address patient-level factors that can undermine adherence. In this paper, we identify patient-level determinants of non-adherence and discuss whether mindfulness-training approaches that target these determinants can help to improve adherence to medical treatment. We highlight two chronic medical conditions (viz., heart failure and HIV) where poor adherence is a significant concern, and examine the evidence regarding the use of mindfulness interventions to improve medication adherence in these two conditions. We also discuss the theoretical underpinnings of mindfulness training with respect to medication adherence, and conclude by suggesting directions for future research.

Satisfaction with medication in coronary disease treatment: psychometrics of the Treatment Satisfaction Questionnaire for Medication

Objective:

to psychometrically test the Brazilian version of the Treatment Satisfaction Questionnaire for Medication - TSQM (version 1.4), regarding ceiling and floor effect, practicability, acceptability, reliability and validity.

Methods:

participants with coronary heart disease (n=190) were recruited from an outpatient cardiology clinic at a university hospital in Southeastern Brazil and interviewed to evaluate their satisfaction with medication using the TSQM (version 1.4) and adherence using the Morisky Self-Reported Measure of Medication Adherence Scale and proportion of adherence. The Ceiling and Floor effect were analyzed considering the 15% worst and best possible TSQM scores; Practicability was assessed by time spent during TSQM interviews; Acceptability by proportion of unanswered items and participants who answered all items; Reliability through the Cronbach's alpha coefficient and Validity through the convergent construct validity between the TSQM and the adherence measures.

Results:

TSQM was easily applied. Ceiling effect was found in the side effects domain and floor effect in the side effects and global satisfaction domains. Evidence of reliability was close to satisfied in all domains. The convergent construct validity was partially supported.

Conclusions:

the Brazilian TSQM presents evidence of acceptability and practicability, although its validity was weakly supported and adequate internal consistency was observed for one domain.

The impact of medication nonadherence on the relationship between mortality risk and depression in heart failure

OBJECTIVE

Heart failure affects more than 5 million U.S. adults, and approximately 20% of individuals with heart failure experience depressive symptoms. Depression is detrimental to prognosis in heart failure, conferring approximately a 2-fold increase in mortality risk. Medication nonadherence may help explain this relationship because depressed patients are less likely to adhere to the medication regimen.

METHOD

Depression, electronically monitored medication adherence, and mortality were measured in a sample of 308 patients with heart failure participating in a study of self-management behavior. Cardiovascular and all-cause mortality data were obtained from the Centers for Disease Control and Prevention's National Death Index (median 2.9-year follow-up). Cox proportional hazards regression was used to assess the relationship between depression and mortality, with and without adjustment for age, gender, disease severity, and medication nonadherence.

RESULTS

In adjusted analyses, depression was associated with an increased all-cause mortality risk (hazard ratio 1.87; 95% confidence interval 1.04-3.37). Depression was not related to cardiovascular mortality, potentially because of a low number of cardiac-related deaths. When medication nonadherence was added to the model, nonadherence (hazard ratio 1.01; 95% confidence interval 1.004-1.02), but not depression, predicted all-cause mortality risk.

CONCLUSIONS

Depressive symptoms confer increased all-cause mortality risk in heart failure, and medication nonadherence contributes to this relationship. Depression and nonadherence represent potentially modifiable risk factors for poor prognosis. Future research is needed to understand whether interventions that concomitantly target these factors can improve outcomes. (PsycINFO Database Record

Rationales and choices for the treatment of patients with NYHA class II heart failure

Heart failure (HF) in the United States represents a significant burden for patients and a tremendous strain on the healthcare system. Patients receiving a diagnosis of HF can be placed into 1 of 4 New York Heart Association (NYHA) functional classifications; the greatest proportion of patients are in the NYHA class II category, which is defined as patients having a slight limitation of physical activity but who are comfortable at rest, and for whom ordinary physical activity results in symptoms of HF. Because the severity of NYHA class II HF may be perceived as mild or unalarming by this definition, the urgency to treat this type of HF may be overlooked. However, these patients are optimal candidates for active intervention because their HF is at a critical point on the disease progression continuum when untoward changes can be halted or reversed. This review discusses the physiological consequences of NYHA class II HF with reduced ejection fraction and describes recent clinical trials that have demonstrated a therapeutic benefit for patients in this population. In doing so, we hope to establish that patients with NYHA class II disease merit careful attention and to provide reassurance to the treating community that options are available for these patients.

Predictors of Medication Adherence in the Elderly: The Role of Mental Health

The aging population routinely has comorbid conditions requiring complicated medication regimens, yet nonadherence can preclude optimal outcomes. This study explored the association of adherence in the elderly with demographic, socioeconomic, and disease burden measures. Data were from the fifth visit (2011-2013) for 6,538 participants in the Atherosclerosis Risk in Communities Study, conducted in four communities. The Morisky-Green-Levine Scale measured self-reported adherence. Forty percent of respondents indicated some nonadherence, primarily due to poor memory. Logit regression showed, surprisingly, that persons with low reading ability were more likely to report being adherent. Better self-reported physical or mental health both predicted better adherence, but the magnitude of the association was greater for mental than for physical health. Compared with persons with normal or severely impaired cognition, mild cognitive impairment was associated with lower adherence. Attention to mental health measures in clinical settings could provide opportunities for improving medication adherence.

Comparison of self-report and electronic monitoring of 6MP intake in childhood ALL: a Children's Oncology Group study

Adequate exposure to oral 6-mercaptopurine (6MP) during maintenance therapy for childhood acute lymphoblastic leukemia (ALL) is critical for sustaining durable remissions; accuracy of self-reported 6MP intake is unknown. We aimed to directly compare self-report to electronic monitoring (Medication Event Monitoring System [MEMS]) and identify predictors of overreporting in a cohort of 416 children with ALL in first remission over 4 study months (1344 patient-months for the cohort) during maintenance therapy. Patients were classified as "perfect reporters" (self-report agreed with MEMS), "overreporters" (self-report was higher than MEMS by ≥5 days/month for ≥50% of study months), and "others" (not meeting criteria for perfect reporter or overreporter). Multivariable logistic regression examined sociodemographic and clinical characteristics, 6MP dose intensity, TPMT genotype, thioguanine nucleotide levels, and 6MP nonadherence (MEMS-based adherence <95%) associated with the overreporter phenotype; generalized estimating equations compared 6MP intake by self-report and MEMS. Self-reported 6MP intake exceeded MEMS at least some of the time in 84% of patients. Fifty patients (12%) were classified as perfect reporters, 98 (23.6%) as overreporters, 2 (0.5%) as underreporters, and 266 (63.9%) as others. In multivariable analysis, the following variables were associated with the overreporter phenotype: non-white race: Hispanic, odds ratio (OR), 2.4, P = .02; Asian, OR, 3.1, P = .02; African American, P < .001; paternal education less than college (OR, 1.4, P = .05); and 6MP nonadherence (OR, 9.4, P < .001). Self-report of 6MP intake in childhood ALL overestimates true intake, particularly in nonadherent patients, and should be used with caution.

Relationship of Health Literacy of Heart Failure Patients and Their Family Members on Heart Failure Knowledge and Self-Care

We explored the relationships among patients' and family members' (FMs) health literacy, heart failure (HF) knowledge, and self-care behaviors using baseline data from HF patients and their FMs ( N = 113 pairs) in a trial of a self-care intervention. Measures included Rapid Estimate of Adult Literacy in Medicine, Atlanta HF Knowledge Test, a heart failure Medication Adherence Scale, and sodium intake (24-hr urine and 3-day food record). Patients with low health literacy (LHL) were more likely to have lower HF knowledge ( p < .001) and trended to poorer medication adherence ( p = .077) and higher sodium intake ( p = .072). When FMs had LHL, FMs were more likely to have lower HF knowledge ( p = .001) and patients trended toward higher sodium intake ( p = .067). When both patients and FMs had LHL, lowest HF knowledge and poorest medication adherence were observed ( p < .027). The health literacy of both patient and FM needs to be considered when designing interventions to foster self-care.

The Situation-Specific Theory of Heart Failure Self-Care: Revised and Updated

BACKGROUND

Since the situation-specific theory of heart failure (HF) self-care was published in 2008, we have learned much about how and why patients with HF take care of themselves. This knowledge was used to revise and update the theory.

OBJECTIVE

The purpose of this article was to describe the revised, updated situation-specific theory of HF self-care.

RESULT

Three major revisions were made to the existing theory: (1) a new theoretical concept reflecting the process of symptom perception was added; (2) each self-care process now involves both autonomous and consultative elements; and (3) a closer link between the self-care processes and the naturalistic decision-making process is described. In the revised theory, HF self-care is defined as a naturalistic decision-making process with person, problem, and environmental factors that influence the everyday decisions made by patients and the self-care actions taken. The first self-care process, maintenance, captures those behaviors typically referred to as treatment adherence. The second self-care process, symptom perception, involves body listening, monitoring signs, as well as recognition, interpretation, and labeling of symptoms. The third self-care process, management, is the response to symptoms when they occur. A total of 5 assumptions and 8 testable propositions are specified in this revised theory.

CONCLUSION

Prior research illustrates that all 3 self-care processes (ie, maintenance, symptom perception, and management) are integral to self-care. Further research is greatly needed to identify how best to help patients become experts in HF self-care.

Relationship between depression and medication adherence in cardiovascular disease: the perfect challenge for the integrated care team

Many individuals with cardiovascular disease (CVD) experience depression that is associated with poor health outcomes, which may be because of medication nonadherence. Several factors influence medication adherence and likely influence the relationship between depression and medication adherence in CVD patients. This comprehensive study reviews the existing literature on depression and medication adherence in CVD patients, addresses the methods of and problems with measuring medication adherence, and explains why the integrated care team is uniquely situated to improve the outcomes in depressed CVD patients. This paper also explores how the team can collaboratively target depressive symptoms and medication-taking behavior in routine clinical care. Finally, it suggests the limitations to the integrated care approach, identifies targets for future research, and discusses the implications for CVD patients and their families.

Psychometric Testing of the Self-Care of Coronary Heart Disease Inventory (SC-CHDI)

Although coronary heart disease (CHD) requires a significant amount of self-care, there are no instruments available to measure self-care in this population. The purpose of this study was to test the psychometric properties of the Self-Care of Coronary Heart Disease Inventory (SC-CHDI). Using the Self-Care of Chronic Illness theory, we developed a 22-item measure of maintenance, management, and confidence appropriate for persons with stable CHD and tested it in a convenience sample of 392 adults (62% male, mean age 61.4 ± 9.6 years). Factorial validity was tested with confirmatory factor analysis. Convergent validity was tested with the Medical Outcomes Study MOS-SAS Specific Adherence Scale and the Decision Making Competency Inventory (DMCI). Cronbach alpha and factor determinacy scores (FDS) were calculated to assess reliability. Two multidimensional self-care scales were confirmed: self-care maintenance included "consultative behaviors" (e.g., taking medicines as prescribed) and "autonomous behaviors" (e.g., exercising 30 minute/day; FDS = .87). The multidimensional self-care management scale included "early recognition and response" (e.g., recognizing symptoms) and "delayed response" (e.g., taking an aspirin; FDS = .76). A unidimensional confidence factor captured confidence in each self-care process (α = .84). All the self-care dimensions were associated with treatment adherence as measured by the MOS-SAS. Only self-care maintenance and confidence were associated with decision-making (DCMI). These findings support the conceptual basis of self-care in patients with CHD as a process of maintenance that includes both consultative and autonomous behaviors, and management with symptom awareness and response. The SC-CHDI confidence scale is promising as a measure of self-efficacy, an important factor influencing self-care. © 2016 Wiley Periodicals, Inc.

Predictors of medication adherence: fact or artifact

Numerous studies have examined socio-demographic, psychosocial, and other factors as potential contributors to poor adherence. Variability exists in the strength and consistency of findings. We speculated that the method of measuring adherence might be a factor in the variability in identification of predictor variables. We examined the identification of predictors of adherence by method of measurement in two randomized, controlled trials of adherence interventions. Both studies used the Aardex Medication Event Monitor and the Morisky Self-Report Scale. Twenty-one days of baseline data from 698 subjects were examined in relation to measures of depression, functional status, perceived therapeutic efficacy, number of co-morbidities, and socio-demographic indices. Analysis included Spearman rho, Pearson r, and multiple logistic regression. Differences in the identification of predictors between adherence measurement methods were identified. These data support the hypothesis that different measurement methods yield different predictors of adherence.

Toward appropriate criteria in medication adherence assessment in older persons: Position Paper

Nonadherence to medication regimens is a worldwide challenge; adherence rates range from 38 to 57 % in older populations with an average rate of less than 45 % and nonadherence contributes to adverse drug events, increased emergency visits and hospitalisations. Accurate measurement of medication adherence is important in terms of both research and clinical practice. However, the identification of an objective approach to measure nonadherence is still an ongoing challenge. The aim of this Position Paper is to describe the advantages and disadvantages of the known medication adherence tools (self-report, pill count, medication event monitoring system (MEMS) and electronic monitoring devices, therapeutic drug monitoring, pharmacy records based on pharmacy refill and pharmacy claims databases) to provide the appropriate criteria to assess medication adherence in older persons. To the best of our knowledge, no gold standard has been identified in adherence measurement and no single method is sufficiently reliable and accurate. A combination of methods appears to be the most suitable. Secondly, adherence assessment should always consider tools enabling polypharmacy adherence assessment. Moreover, it is increasingly evident that adherence, as a process, has to be assessed over time and not just at one evaluation time point (drug discontinuation). When cognitive deficits or functional impairments may impair reliability of adherence assessment, a comprehensive geriatric assessment should be performed and the caregiver involved. Finally, studies considering the possible implementation in clinical practice of adherence assessment tools validated in research are needed.

A Remote Medication Monitoring System for Chronic Heart Failure Patients to Reduce Readmissions: A Two-Arm Randomized Pilot Study

Background

Heart failure (HF) is a chronic condition affecting nearly 5.7 million Americans and is a leading cause of morbidity and mortality. With an aging population, the cost associated with managing HF is expected to more than double from US $31 billion in 2012 to US $70 billion by 2030. Readmission rates for HF patients are high—25% are readmitted at 30 days and nearly 50% at 6 months. Low medication adherence contributes to poor HF management and higher readmission rates. Remote telehealth monitoring programs aimed at improved medication management and adherence may improve HF management and reduce readmissions.

Objective

The primary goal of this randomized controlled pilot study is to compare the MedSentry remote medication monitoring system versus usual care in older HF adult patients who recently completed a HF telemonitoring program. We hypothesized that remote medication monitoring would be associated with fewer unplanned hospitalizations and emergency department (ED) visits, increased medication adherence, and improved health-related quality of life (HRQoL) compared to usual care.

Methods

Participants were randomized to usual care or use of the remote medication monitoring system for 90 days. Twenty-nine participants were enrolled and the final analytic sample consisted of 25 participants. Participants completed questionnaires at enrollment and closeout to gather data on medication adherence, health status, and HRQoL. Electronic medical records were reviewed for data on baseline classification of heart function and the number of unplanned hospitalizations and ED visits during the study period.

Results

Use of the medication monitoring system was associated with an 80% reduction in the risk of all-cause hospitalization and a significant decrease in the number of all-cause hospitalization length of stay in the intervention arm compared to usual care. Objective device data indicated high adherence rates (95%-99%) among intervention group participants despite finding no significant difference in self-reported adherence between study arms. The intervention group had poorer heart function and HRQoL at baseline, and HRQoL declined significantly in the intervention group compared to controls.

Conclusions

The MedSentry medication monitoring system is a promising technology that merits continued development and evaluation. The MedSentry medication monitoring system may be useful both as a standalone system for patients with complex medication regimens or used to complement existing HF telemonitoring interventions. We found significant reductions in risk of all-cause hospitalization and the number of all-cause length of stay in the intervention group compared to controls. Although HRQoL deteriorated significantly in the intervention group, this may have been due to the poorer HF-functioning at baseline in the intervention group compared to controls. Telehealth medication adherence technologies, such as the MedSentry medication monitoring system, are a promising method to improve patient self-management,the quality of patient care, and reduce health care utilization and expenditure for patients with HF and other chronic diseases that require complex medication regimens.

Trial Registration

ClinicalTrials.gov NCT01814696; https://clinicaltrials.gov/ct2/show/study/NCT01814696 (Archived by WebCite® at http://www.webcitation.org/6giqAVhno)

Differences in cardiovascular disease risk when antihypertensive medication adherence is assessed by pharmacy fill versus self-report: the Cohort Study of Medication Adherence among Older Adults (CoSMO)

BACKGROUND

Pharmacy refill adherence assesses the medication-filling behaviors, whereas self-report adherence assesses the medication-taking behaviors. We contrasted the association of pharmacy refill and self-reported antihypertensive medication adherence with blood pressure (BP) control and cardiovascular disease (CVD) incidence.

METHODS AND RESULTS

Adults (n = 2075) from the prospective Cohort Study of Medication Adherence among Older Adults recruited between August 2006 and September 2007 were included. Antihypertensive medication adherence was determined using a pharmacy refill measure, medication possession ratio (MPR; low, medium, and high MPR: <0.5, 0.5 to <0.8, and ≥0.8, respectively) and a self-reported measure, eight-item Morisky Medication Adherence Scale (MMAS-8; low, medium, and high MMAS-8: <6, 6 to <8, and 8, respectively). Incident CVD events (stroke, myocardial infarction, congestive heart failure, or CVD death) through February 2011 were identified and adjudicated. The prevalence of low, medium, and high adherence was 4.5, 23.7, and 71.8% for MPR and 14.0, 34.3, and 51.8% for MMAS-8, respectively. During a median of 3.8 years' follow-up, 240 (11.5%) people had a CVD event. Low MPR and low MMAS-8 were associated with uncontrolled BP at baseline and during follow up. After multivariable adjustment and compared to those with high MPR, the hazard ratios for CVD associated with medium and low MPR were 1.17 [95% confidence interval (CI) 0.87-1.56)] and 1.87 (95% CI: 1.06-3.30), respectively. Compared to those with high MMAS-8, the hazard ratios (95% CI) for MMAS-8 for medium and low MMAS-8 were 1.04 (0.79-1.38) and 0.89 (0.58-1.35), respectively.

CONCLUSION

While both adherence measures were associated with BP control, pharmacy refill but not self-report antihypertensive medication adherence was associated with incident CVD. The differences in these associations may be because of the distinctions in what each adherence measure assesses.

Comparison of methods to assess psychiatric medication adherence in methadone-maintained patients with co-occurring psychiatric disorder

BACKGROUND

Adherence with psychiatric medication is a critical issue that has serious individual and public health implications. This is a secondary analysis of a large-scale clinical treatment trial of co-occurring substance use and psychiatric disorder.

METHOD

Participants (n=153) who received a clinically-indicated psychiatric medication ≥30 days during the 12-month study and provided corresponding data from Medication Event Monitoring System (MEMS) and Morisky Medication Taking Adherence Scale (MMAS) self-report adherence ratings were included in the analyses. Accuracy in MEMS caps openings was customized to each participant's unique required dosing schedule.

RESULTS

Consistent with expectations, MEMS-based adherence declined slowly over time, though MMAS scores of forgetting medication remained high and did not change over the 12-month study. MEMS caps openings were not significantly impacted by any baseline or treatment level variables, whereas MMAS scores were significantly associated with younger age and presence of an Axis I disorder and antisocial personality disorder, or any cluster B diagnoses.

CONCLUSIONS

Results suggest that MEMS caps may be a more objective method for monitoring adherence in patients with co-occurring substance use and psychiatric disorder relative to the MMAS self-report. Participants in this study were able to successfully use the MEMS caps for a 12-month period with <1% lost or broken caps, suggesting this comorbid population is able to use the MEMS successfully. Ultimately, these data suggest that an objective method for monitoring adherence in this treatment population yield more accurate outcomes relative to self-report.

The agreement of patient-reported versus observed medication adherence in type 2 diabetes mellitus (T2DM)

OBJECTIVE

Medication adherence in type 2 diabetes mellitus (T2DM) improves glycemic control and is associated with reduced adverse clinical events, and accurately assessing adherence assessment is important. We aimed to determine agreement between two commonly used adherence measures-the self-reported Morisky Medication Adherence Scale (MMAS) and direct observation of medication use by nurse practitioners (NPs) during home visits-and determine the relationship between each measure and glycated hemoglobin (HbA1c).

RESEARCH DESIGN AND METHODS

We evaluated agreement between adherence measures in the Southeastern Diabetes Initiative (SEDI) prospective clinical intervention home visit cohort, which included high-risk patients (n=430) in 4 SEDI-participating counties. The mean age was 58.7 (SD 11.6) years. The majority were white (n=210, 48.8%), female (n=236, 54.9%), living with a partner (n=316, 74.5%), and insured by Medicare/Medicaid (n=361, 84.0%). Medication adherence was dichotomized to 'adherent' or 'not adherent' using established cut-points. Inter-rater agreement was evaluated using Cohen's κ coefficient. Relationships among adherence measures and HbA1c were evaluated using the Wilcoxon rank-sum test and c-statistics.

RESULTS

Fewer patients (n=261, 61%) were considered adherent by self-reported MMAS score versus the NP-observed score (n=338; 79%). Inter-rater agreement between the two adherence measures was fair (κ=0.24; 95% CI 0.15 to 0.33; p<0.0001). Higher adherence was significantly associated with lower HbA1c levels for both measures, yet discrimination was weak (c-statistic=0.6).

CONCLUSIONS

Agreement between self-reported versus directly observed medication adherence was lower than expected. Though scores for both adherence measures were significantly associated with HbA1c, neither discriminated well for discrete levels of HbA1c.

Accurate reporting of adherence to inhaled therapies in adults with cystic fibrosis: methods to calculate "normative adherence"

BACKGROUND

Preventative inhaled treatments in cystic fibrosis will only be effective in maintaining lung health if used appropriately. An accurate adherence index should therefore reflect treatment effectiveness, but the standard method of reporting adherence, that is, as a percentage of the agreed regimen between clinicians and people with cystic fibrosis, does not account for the appropriateness of the treatment regimen. We describe two different indices of inhaled therapy adherence for adults with cystic fibrosis which take into account effectiveness, that is, "simple" and "sophisticated" normative adherence.

METHODS TO CALCULATE NORMATIVE ADHERENCE

Denominator adjustment involves fixing a minimum appropriate value based on the recommended therapy given a person's characteristics. For simple normative adherence, the denominator is determined by the person's Pseudomonas status. For sophisticated normative adherence, the denominator is determined by the person's Pseudomonas status and history of pulmonary exacerbations over the previous year. Numerator adjustment involves capping the daily maximum inhaled therapy use at 100% so that medication overuse does not artificially inflate the adherence level.

THREE ILLUSTRATIVE CASES

Case A is an example of inhaled therapy under prescription based on Pseudomonas status resulting in lower simple normative adherence compared to unadjusted adherence. Case B is an example of inhaled therapy under-prescription based on previous exacerbation history resulting in lower sophisticated normative adherence compared to unadjusted adherence and simple normative adherence. Case C is an example of nebulizer overuse exaggerating the magnitude of unadjusted adherence.

CONCLUSION

Different methods of reporting adherence can result in different magnitudes of adherence. We have proposed two methods of standardizing the calculation of adherence which should better reflect treatment effectiveness. The value of these indices can be tested empirically in clinical trials in which there is careful definition of treatment regimens related to key patient characteristics, alongside accurate measurement of health outcomes.

Pilot Study to Test the Effectiveness of Different Financial Incentives to Improve Medication Adherence

BACKGROUND

Medication nonadherence affects health care costs, morbidity, and mortality. Concepts from behavioral economics can guide the development of interventions to improve medication adherence.

OBJECTIVE

To measure the relative effectiveness of 2 behavioral economic-based incentive structures to improve medication adherence.

METHODS

This randomized controlled trial compared adherence among participants taking antihypertensive or antihyperlipidemic medications randomized to usual care (UC), guaranteed pay-out (GPO) incentives, or lottery incentives. Daily adherence was measured over a 90-day period using electronic caps (Medication Event Monitoring System [MEMS]). The GPO group received $30 up-front in a virtual account, with $0.50 deducted for each missed dose. Lottery group participants were eligible for a weekly $50 drawing, but only if they had taken their medication as prescribed all week. An electronic survey assessed self-reported adherence. Statistical analysis included descriptive statistics, paired t tests, ANOVA, and Pearson's correlations.

RESULTS

In all, 36 participants were randomized (UC, n = 11; GPO, n = 14; lottery, n = 11). Mean percentage (±SD) of days adherent during the incentive period was highest in the lottery group (96% ± 5%), followed by the GPO group (94% ± 9%) and the UC group (94% ± 9%). There were no statistically significant differences among groups (P > 0.05). MEMS-measured adherence was not significantly correlated with a patient's self-reported adherence (P > 0.05) at baseline but was correlated at 90-day follow-up (P < 0.001).

CONCLUSIONS

Although no statistically significant differences in adherence were demonstrated in this small sample of highly adherent participants, larger studies in a more diverse population or with other medications might show otherwise.

Mechanism of engaging self-management behavior in rural heart failure patients

AIM

The purpose of this study was to examine the relationships among self-efficacy, patient activation and SM in rural heart failure patients discharged from critical access hospitals.

BACKGROUND

Heart failure is one of the most disabling and resource-consuming chronic conditions. Compared to their urban counterparts, rural heart failure patients had higher healthcare utilizations and worse health outcomes. Self-management (SM) plays a significant role in improving patients' outcomes and reducing healthcare use. Despite persistent recommendations of SM, engagement in SM still remains low in rural heart failure patients. SM is a complex behavior, which is influenced by various factors. Evidence on the efficacy of interventions to promote SM is limited and inconsistent. One reason is that the mechanism of engagement of SM in the rural heart failure population has not been fully understood.

METHODS

A correlational study was conducted using secondary data from a randomized control trial aimed to improve SM adherence. Path analysis was used to test the hypothesis of patient activation mediating the effect of self-efficacy on SM.

RESULTS

Data were collected from a sample of 101 heart failure patients (37% males) with an average age of 70 years. The final model provided a good fit to the data, supporting the hypothesis that self-efficacy contributes to SM through activation.

CONCLUSION

The results of this study showed that effective SM interventions should be designed to include strategies to promote both self-efficacy and activation.