Does packaging with a calendar feature improve adherence to self-administered medication for long-term use? A systematic review

Estimating the economic impact of blister-packaging on medication adherence and health care costs for a Medicare Advantage health plan

BACKGROUND

Medication nonadherence is a persistent challenge in the United States, leading to increased health care resource utilization (HCRU) and health care costs and worsened health outcomes. Medicare Star Ratings is a program developed by the Centers for Medicare and Medicaid Services (CMS) to evaluate Medicare health plan quality and performance. Three of the Medicare Part D Star Ratings quality measures assess medication adherence, showing the importance CMS places on improving medication adherence in older adults. Although a variety of medication adherence-enhancing interventions are available to help promote adherence among patients, one intervention that has shown success historically is blister-packaging.

OBJECTIVE

To model the potential impact of blister-packaging chronic medications on HCRU and health care costs in the Medicare population.

METHODS

An economic model was developed to assess the potential impact of blister-packaging the 3 Medicare Star Ratings adherence measure medication classes: renin-angiotensin system antagonists (RASAs), statins, and noninsulin antidiabetics. The model perspective was that of a hypothetical Medicare Advantage health plan with a plan size of 100,000 members. A 12-month time horizon was used in the model. The dichotomous adherence threshold in the model was set at 80% or greater of the proportion of days covered (PDC). Literature-based references were used to inform both the impact of blister-packaging on the number of patients who become adherent as well as the impact of medication adherence on HCRU and health care costs for each of the medication classes. One-way sensitivity analyses and several scenario analyses were conducted to assess model uncertainty.

RESULTS

Owing to increased adherence from the blister-packaging intervention, the hypothetical health plan in the analysis saw 776 additional members adherent to RASAs, 1,651 additional members adherent to statins, and 414 additional members adherent to oral antidiabetics. Although medication expenditure increased for all 3 medication classes (RASAs: $274,963; statins: $730,083; oral antidiabetics: $100,529), medical costs decreased across all classes (RASAs: -$4,098,848; statins: -$5,549,699; oral antidiabetics: -$917,968). Total net health care costs decreased by $3,823,885 for RASAs (-$3.19 per member per month [PMPM]), $4,819,616 for statins (-$4.02 PMPM), and $817,438 for oral antidiabetics (-$0.68 PMPM). The entire Medicare Advantage population scenario analysis saw reductions in total health care costs of $1,081,394,737 for RASAs, $1,362,987,376 for statins, and $231,171,496 for oral antidiabetics.

CONCLUSIONS

Dispensing chronic medications with blister-packaging for Medicare Advantage health plan patients was modeled to reduce HCRU and health care costs. Future studies are needed to assess whether the impact of blister-packaging medications is tied to reductions in HCRU and health care costs in real-world settings.

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.

A systematic review investigating the role and impact of pharmacist interventions in cardiac rehabilitation

BACKGROUND

Cardiovascular disease (CVD) is a predominant cause of mortality. Pharmacists play an important role in secondary prevention of CVD, however, their role in cardiac rehabilitation is under-reported and services are under-utilised.

AIM

To explore the role of pharmacists in cardiac rehabilitation, the impact of their interventions on patient outcomes, and prospects of future role development.

METHOD

Databases searched were PubMed, Embase, Medline, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and PsycINFO from January 2006 to October 2021. Randomised and non-randomised controlled trials were selected if they assessed the role of pharmacists in cardiac rehabilitation. Cochrane risk of bias tool, Joanna Briggs Institute (JBI) Critical Appraisal Tool for Quasi-Experimental Studies and the National Heart, Lung and Blood Institute (NIH) quality assessment tool, were used to assess quality and a narrative synthesis was conducted.

RESULTS

The search yielded 786 studies, only five met the inclusion criteria. The pharmacist-led interventions included patient education, medication review and reconciliation, and medication adherence encouragement. Four out of the five studies showed that pharmacist-led interventions in cardiac rehabilitation significantly improved patient clinical and non-clinical outcomes. One study showed a statistically significant reduction in low density lipoprotein-cholesterol (LDL-C) levels to optimal target of < 70 mg/dL (80% vs 60%, p = 0.0084). Two studies reported better medication adherence, and two studies showed greater improvement in all domains of health-related quality of life observed in the intervention group.

CONCLUSION

Pharmacist-led interventions in cardiac rehabilitation could lower CVD risk factors and hence recurrence. Although these findings support pharmacists' involvement in cardiac rehabilitation, larger intervention studies are needed to evaluate the feasibility of pharmacist-led interventions and their impact on hospital admissions and mortality risk.

Application of a WeChat-based mini-app as a patient reminder in Helicobacter pylori eradication: a prospective multi-center randomized controlled study

BACKGROUND

To improve the eradication rate of H. pylori, researchers have investigated the role of WeChat-based mini-app as an electronic reminding system in H. pylori treatment.

METHODS

Subjects from three medical centers were divided into two groups. Patients in the daily mini-app-based notification system group received daily notifications via the WeChat mini-app. Patients in the control group received one-time verbal education on the first clinical visit. Both groups received a 14-day quadruple therapy to eradicate H. pylori infection. Eradication rate, compliance, adverse events and satisfaction were evaluated.

RESULTS

Both intention-to-treat (ITT) and per-protocol (PP) analyses were conducted. The eradication rate in the daily mini-app-based notification system group was slightly higher compared with the control group (ITT analysis: 76.70% vs. 70.73%, p = 0.312; PP analysis: 85.87% vs. 82.86%, p = 0.562). The compliance was significantly higher in the daily mini-app-based notification system group (ITT analysis: 85.52% vs. 70.48%, p = 0.028; PP analysis: 92.39% vs. 81.90%, p = 0.030). The adverse event rates were similar between the two groups (PP analysis: 36.96% vs. 40.95%, p = 0.566). No significant difference in eradication rate was seen in each subgroup analysis by age, place of residence, grade of education, or endoscopic findings.

CONCLUSION

The study showed that daily mini-app-based notification improved patient compliance but not H. pylori eradication rate. Trial registration The research was registered in the Chinese Clinical Trial Registry (ChiCTR2000031011, 21/03/2020).

A randomized controlled trial to assess the influence of a picture-based antiemetic medication calendar on medication-taking behavior in adults receiving chemotherapy

OBJECTIVE

A prospective open-label randomized controlled trial to assess the role of a picture-based medication calendar on adherence to antiemetic regimens for adult patients receiving chemotherapy and assess the effect on other medication taking behaviors as well as patient satisfaction with the tool.

METHODS

Participants were randomly assigned 1:1 to routine care with or without calendar.

RESULTS

Adherence, stratified by education (university or postgraduate, p = 0.09; grade school, high school or college p = 0.32), was non-significantly different between study arms. At least 70% of intervention arm participants moderately or completely agreed that the calendar helped with medication taking behaviors. There was no statistical difference between study arms for perceived regimen complexity (p = 0.16). Medication Use and Self Efficacy score (adjusted for age) used to assess perceived self-efficacy with medication taking behaviors were not statistically significant between study arms (p = 0.09).

CONCLUSION

The picture-based medication calendar did not statistically affect adherence to scheduled antiemetics among outpatients receiving chemotherapy for solid organ tumor origins. However, participants indicated that the calendar was effective for keeping track of medications, had an easy-to-understand layout, and provided help around when and how to take medications related to the oncology regimen.

Strategies and Tools for Supporting the Appropriateness of Drug Use in Older People

Through this structured review of the published literature, we aimed to provide an up-to-date description of strategies (human-related) and tools (mainly from the digital field) facilitating the appropriateness of drug use in older adults. The evidence of each strategy and tool's effectiveness and sustainability largely derives from local and heterogeneous experiences, with contrasting results. As a general framework, three main steps should be considered in implementing measures to improve appropriateness: prescription, acceptance by the patient, and continuous monitoring of adherence and risk-benefit profile. Each step needs efforts from specific actors (physicians, patients, caregivers, healthcare professionals) and dedicated supporting tools. Moreover, how to support the appropriateness also strictly depends on the particular setting of care (hospital, ambulatory or primary care, nursing home, long-term care) and available economic resources. Therefore, it is urgent assigning to each approach proposed in the literature the following characteristics: level of effectiveness, strength of evidence, setting of implementation, needed resources, and issues for its sustainability.

Development and Validation of a Digital Image Processing-Based Pill Detection Tool for an Oral Medication Self-Monitoring System

Long-term adherence to medication is of critical importance for the successful management of chronic diseases. Objective tools to track oral medication adherence are either lacking, expensive, difficult to access, or require additional equipment. To improve medication adherence, cheap and easily accessible objective tools able to track compliance levels are necessary. A tool to monitor pill intake that can be implemented in mobile health solutions without the need for additional devices was developed. We propose a pill intake detection tool that uses digital image processing to analyze images of a blister to detect the presence of pills. The tool uses the Circular Hough Transform as a feature extraction technique and is therefore primarily useful for the detection of pills with a round shape. This pill detection tool is composed of two steps. First, the registration of a full blister and storing of reference values in a local database. Second, the detection and classification of taken and remaining pills in similar blisters, to determine the actual number of untaken pills. In the registration of round pills in full blisters, 100% of pills in gray blisters or blisters with a transparent cover were successfully detected. In the counting of untaken pills in partially opened blisters, 95.2% of remaining and 95.1% of taken pills were detected in gray blisters, while 88.2% of remaining and 80.8% of taken pills were detected in blisters with a transparent cover. The proposed tool provides promising results for the detection of round pills. However, the classification of taken and remaining pills needs to be further improved, in particular for the detection of pills with non-oval shapes.

[Modern issues of improving the prognosis in patients with atrial fibrillation after ischemic stroke]

The anticoagulant therapy with a priority of direct oral anticoagulants is an approach to the prevention of recurrent stroke in patients with atrial fibrillation (AF) that has presently proved its efficacy and is stated in international clinical guidelines. An extensive evidence-based database demonstrates advantages of rivaroxaban over other drugs of this class in secondary prevention of stroke in AF. Furthermore, these advantages are combined with the optimal safety profile. The rivaroxaban treatment may provide the most favorable prognosis due to the prevention of recurrent stroke in AF, reducing the rate of kidney disease progression, and slowing vascular atherosclerosis. An important beneficial feature of rivaroxaban is once-a-day intake, which is important in the context of a high incidence of cognitive disorders in this patient category, and may improve their compliance and, thus, help achieving the expected profile of treatment efficacy. Thus, rivaroxaban can be regarded as a drug of choice for secondary prevention of stroke in AF.

Electronic Smart Blister Packages to Monitor and Support Medication Adherence: A Usability Study

PURPOSE

An electronic version of the Dosepak^® (EDP) which records date and time of dosing events has been developed to monitor adherence to medication packaged in blisters. This study aimed to evaluate its usability and acceptance and to monitor dose-taking adherence for optimal implementation in future clinical trials and practice.

METHODS

Healthy volunteers aged over 18 years were asked to dispense placebo tablets twice daily from EDPs equipped with a re-usable electronic module for a total duration of four weeks. Afterwards, subjects were asked to complete an online questionnaire and partake in a short one-on-one interview. The usability of the EDP was assessed using the System Usability Scale (SUS), while dose-taking adherence was monitored by EDP records, pill counting, and self-report. The short interview explored user experiences in more detail.

RESULTS

Twenty subjects with median [IQR] age 41.5 [32-49.8] years, 55% female, 45% healthcare professionals, and 20% chronic medication users completed the study and found the EDP easy to use, with a mean [SD] SUS score of 78.0 [11.2]. Median [IQR] dose-taking adherence was 89% [82-95%] based on EDP records, 96.5% [89-100%] based on pill counting, 92% [91-96%] based on self-report, and the levels differed significantly (p < 0.05). Four themes emerged from the interviews: user preference, experience, patient burden, and ideas for improvement. Most participants preferred smaller sized blisters. They found the EDP simple to use and did not see any patient burden for its use in trials or clinical practice. Some reported forgetfulness and suggested reminders built into the blister or sent to their mobile phones. Adequate information or instruction should also be provided for older people and polypharmacy patients.

CONCLUSION

EDP had good perceived usability, was well accepted, and differed significantly from other adherence measurement methods. This study provides input to further guide scale-up of the blister packages.

Community pharmacist interventions to improve adherence to lipid lowering medication and their influence on clinical outcomes: A systematic review and meta-analysis

INTRODUCTION

Non-adherence is a major problem among patients with chronic diseases. Community pharmacists are ideally positioned to detect non-adherence and to provide patient-centred interventions.

OBJECTIVE

To conduct a systematic review of the impact of community pharmacist interventions on patient adherence to lipid lowering medication (LLM) prescriptions and clinical outcomes.

SEARCH METHOD

Five databases (MEDLINE, Cochrane Library, Science Direct, Scopus, and Web of Knowledge) were searched systematically to identify relevant reports published by December 2019. Study quality was assessed with the Cochrane risk of bias (RoB 2.0) tool.

SELECTION CRITERIA

Controlled trials in which community pharmacists conducted an intervention to improve patient adherence to LLM and clinical outcomes were evaluated.

MAIN RESULTS

Five studies (2408 participants) were included in the qualitative analysis. Four studies (n = 2266) were pooled in the meta-analysis. Participants in the intervention group (IG) had better adherence than those in the control group (CG) [odds ratio (OR) = 1.67; 95% confidence interval (CI) 1.38-2.02; P < 0.001; I² = 54%]. Better adherence rates were obtained when adherence was measured with validated questionnaires than when medication-possession ratio (MPR) measurements were used. Total cholesterol (TC) levels were not included in the meta-analysis due to data variability among the studies.

CONCLUSIONS

Pharmacist-led intervention can improve LLM adherence, but its influence on clinical outcomes, including lipid level control, remains to be clarified.

[Efficiency of the Decision-Making Module in the Personalized Choice of an Anticoagulant]

Aim        To evaluate the effectiveness of the decision-making module in selecting an oral anticoagulant for patients with atrial fibrillation.Material and methods        638 patients with atrial fibrillation aged 68.2±4.5 years were evaluated. The CHA2DS2-VASc, HAS-BLED, and 2MАСЕ scales, the creatinine clearance calculator, and the Morisky-Green questionnaire were used.Results   311 (48.75 %) patients had paroxysmal atrial fibrillation, 138 (21.6%) had persistent atrial fibrillation, 44 (22.7%) had long-standing persistent atrial fibrillation, and 145 (22.7 %) had permanent atrial fibrillation. Mean CHADS2‑VASc scale score was 4.82; НAS-BLED scale score was 2.9; 2MACE score was 2.28; and compliance score was 3.52. 172 (26.9 %) patients were treated with rivaroxaban; 166 (26 %), with apixaban; 84 (13.2 %), with dabigatran; 210 (32.9 %), with warfarin; and 6 (1 %), with acetylsalicylic acid.Conclusion            The developed decision-making module is based on scientific justification of personalized selection of the oral anticoagulant and updates the knowledge on major issues of prescription.

Blister Packaging Medications for Adherence for American Indians/Alaska Natives in the Outpatient Setting

OBJECTIVE

To compare adherence one year before and after blister pack implementation in America Indian and Alaska Native (AI/AN) patients and to describe the patient population who used blister packs in the outpatient setting.

METHODS

A retrospective analysis of AI/AN patients receiving blister packs was performed to determine medication adherence as measured by a variable medication possession ratio (MPR). Patient characteristics and the reason for blister pack initiation were also assessed.

RESULTS

Of the 25 patients receiving blister packs, 76% were female, 56% were elderly and 60% had cognitive impairment. The three most common types of medications used were hypertension meds, vitamins and diabetes meds. The average MPR one year before blister pack implementation was 67.4% and significantly increased to 86.0% one year after.

CONCLUSION

Blister packs significantly increased the average MPR after one year of implementation in a small group of AI/AN patients. Blister packs were utilized most commonly in patients who were female, had cognitive impairment, and who were taking numerous medications with a high pill burden in the outpatient setting.

Pharmacoadherence: An Opportunity for Digital Health to Inform the Third Dimension of Pharmacotherapy for Diabetes

The basis of pharmacotherapy requires knowledge of two properties of a drug: pharmacokinetics (PK) and pharmacodynamics (PD). In the era of precision medicine, there is growing interest in determining between-individual variations in PK and PD. While these two dimensions of pharmacotherapy are key foci of investigation, a third property is also emerging as a critical factor in understanding how a drug affects an individual. This third property of a drug is known as phamacoadherence (PA). There can be wide variation in PA among people with diabetes, whether they are using oral or injectable medications. The use of new digital health interventions and telehealth communication tools, such as smart insulin pens, is now creating opportunities for health care professionals to have a more complete understanding of the PA of drugs, which allows for more personalized prescribing practices.

[Decreasing cardiovascular morbidity: how to improve adherence to the treatment in the translational era]

Cardiovascular diseases are the main drivers of the morbidity and mortality in Russian Federation. We briefly discussed the poor adherence of the patients and outlined the solutions of this problem.

A systematic overview of systematic reviews evaluating medication adherence interventions

PURPOSE

To systematically summarize evidence from multiple systematic reviews (SRs) examining interventions addressing medication nonadherence and to discern differences in effectiveness by intervention, patient, and study characteristics.

SUMMARY

MEDLINE, the Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effects were searched for papers published from January 2004 to February 2017. English-language SRs examining benefits of medication adherence interventions were eligible. Inclusion was limited to adult patients prescribed medication for 1 of the following disease conditions: diabetes and prediabetes, heart conditions, hypertension and prehypertension, stroke, and cognitive impairment. Non-disease-specific SRs that considered medication adherence interventions for older adults, adults with chronic illness, and adults with known medication adherence problems were also included. Two researchers independently screened titles, abstracts, and full-text articles. They then extracted key variables from eligible SRs, reconciling discrepancies via discussion. A MeaSurement Tool to Assess systematic Reviews (AMSTAR) was used to assess SRs; those with scores below 8 were excluded. Conclusions regarding intervention effectiveness were extracted. Grades of Recommendation, Assessment, Development and Evaluation (GRADE) methodology was applied to assess evidence quality.

RESULTS

Of 390 SRs, 25 met the inclusion criteria and assessed adherence as a primary outcome. Intervention types most consistently found to be effective were dose simplification, patient education, electronic reminders to patients, and reduced patient cost sharing or incentives. Of 50 conclusions drawn by the SRs, the underlying evidence was low or very low quality for 45 SRs.

CONCLUSION

Despite an abundance of primary studies and despite only examining high-quality SRs, the vast majority of primary studies supporting SR authors' conclusions were of low or very low quality. Nonetheless, health system leaders seeking to improve medication adherence should prioritize interventions that have been studied and found to be effective at improving patient adherence, including dose simplification, education, reminders, and financial incentives.

Users' Perceptions of an in-Home Electronic Medication Dispensing System: A Qualitative Study

Background

Managing and taking multiple medications as prescribed can be a difficult task for older adults. In-home medication dispensing technologies could help enhance care. The objective of the study was to determine users’ perspectives on a medication dispensing system (MDS) in supporting medication adherence of individuals living at home with chronic conditions.

Methods

This analysis is a part of a randomized controlled trial on an MDS in a Western Canadian province. We interviewed participants who were recruited into the intervention group and started using an MDS. A maximum variation purposive sampling was used to select interview participants based on age, number of medications, and health conditions.

Results

Thirteen participants were interviewed; most participants were females (n=11) and the average age was 63.7 (SD=8.2) years with an average of 8.9 (SD=3.6) prescribed medications. The most common health conditions were hypertension, diabetes, arthritis, and anxiety and depression. Four main themes emerged from thematic analysis: MDS acceptability, MDS patient support, need for the MDS, and areas of technology improvement. Most of the participants found the MDS to be acceptable and convenient, although privacy and security was an issue for some older adults. Audio and visual reminders and pre-organized medication supported participants’ medication adherence and independence in daily routines. The perceived necessity of the MDS was split among participants with cost being one of the main concerns. Areas of technology improvement included the hard-to-open plastic medication packets and the sometimes inexact recording of medication adherence by the MDS if medications were dispensed on behalf of the patients.

Conclusion

The MDS is an acceptable tool for improving medication management and adherence in older adults. Increased medication adherence may lead to patient and system-level benefits.

Patient Centric Pharmaceutical Drug Product Design-The Impact on Medication Adherence

Medication adherence is a growing concern for public health and poor adherence to therapy has been associated with poor health outcomes and higher costs for patients. Interventions for improving adherence need to consider the characteristics of the individual therapeutic regimens according to the needs of the patients. In particular, geriatric and paediatric populations as well as dermatological patients have special needs/preferences that should be considered when designing drug products. Patient Centric Drug Product Pharmaceutical Design (PCDPD) offers the opportunity to meet the needs and preferences of patients. Packaging, orodispersible formulations, fixed dose combinations products, multiparticulate formulations, topical formulations and 3D printing are of particular relevance in a PCDPD process. These will be addressed in this review as well as their impact on medication adherence.

Does Antiretroviral Therapy Packaging Matter? Perceptions and Preferences of Antiretroviral Therapy Packaging for People Living with HIV in Northern Tanzania

INTRODUCTION

Despite improvements in treatment (eg, reduction in pill intake), antiretroviral therapy (ART) is dispensed in socially inefficient and uneconomical packaging. To make pills less conspicuous and decrease the risk of being stigmatized, people living with HIV (PLWH) often engage in self-repackaging - the practice of transferring ART from original packaging to alternative containers. This behavior has been associated with ART nonadherence and failure to achieve viral load suppression. While much of the literature on ART packaging has centered around medication adherence, patients stated preferences for ART packaging and packaging attributes that influence the observed ART nonadherence are understudied.

METHODS

We conducted a qualitative study to elucidate perceptions of ART packaging among PLWH at two large referral hospitals in Northern Tanzania. Interviews were conducted until thematic saturation was reached. Interviews were audio-recorded, transcribed and coded.

RESULTS

Of the 16 participants whose data were used in the final analysis, a majority were between 36 and 55 years of age (Mean 45.5 years SD: 11.1), had primary-level education (n=11, 68.8%), were self-employed (n=9, 56.3%), reported that they had self-repacked ART (n=14, 88%), and were taking ART for more than 6 years (n=11, 68.8%). Participants identified three attributes of ART packaging that increased anticipated HIV stigma and prompted self-repackaging, including visual identification, bulkiness, and the rattling noise produced by ART pill bottles.

CONCLUSION

Given the drastic reduction in the number of pills required for HIV treatment, there is an opportunity to not only assess the cost-effectiveness of innovative ART packaging but also evaluate the acceptability of such packaging among PLWH in order to address stigma and improve ART adherence.

The association of angiotensin receptor blocker-based combination therapy with persistence and adherence in newly treated, uncomplicated hypertensive patients

PURPOSE

We compared treatment adherence and persistence during treatment with an angiotensin receptor blocker (ARB)-based single pill combination (SPC) and free equivalent combination (FEC) and between SPCs of an ARB with a thiazide diuretic (TD) and an ARB with a calcium channel blocker (CCB) as initial treatment in uncomplicated hypertensive patients who received pre-packaged medications from the pharmacy.

PATIENTS AND METHODS

Uncomplicated hypertensive patients who started combination treatment consisting of ARB and either TD or CCB were identified from a Korean national claims database. We used propensity score matching to construct two pairs of cohorts: SPC and FEC cohorts (20,175 patients per cohort) and SPC cohorts of ARB + TD and ARB + CCB (45,253 patients per cohort). We compared adherence measured via the medication possession ratio as well as overall 1-year and initial treatment persistence.

RESULTS

Compared with the FEC cohort, the SPC cohort had significantly higher medication adherence (OR 1.31, 95% CI 1.25-1.37), overall persistence (HR 1.33, 95% CI 1.28-1.38), and initial treatment persistence (HR 1.61, 95% CI 1.56-1.64). Neither the rate of medication adherence nor the rate of treatment persistence differed significantly between the ARB + TD and ARB + CCB cohorts. However, the ARB + CCB cohort had a significantly higher rate of initial treatment persistence than did the ARB + TD cohort (HR 1.12, 95% CI 1.10-1.14).

CONCLUSION

Our data suggest that, compared with FEC therapy, initiating an ARB-based SPC therapy may increase adherence and persistence in patients with uncomplicated hypertension who also receive pre-packaged medication from the pharmacy. Although using an ARB + CCB SPC may improve initial treatment persistence, it does not increase adherence or overall persistence when compared with an ARB + TD SPC.

Effectiveness of low-cost reminder package combined with case-based health education to improve hypertensive patients' medication adherence: a clustered randomized controlled trial

PURPOSE

Medication adherence (MA) is a key factor for hypertensive patients' blood pressure control and forgetfulness is one of the main reasons that cause medication non-adherence. If effective, low-cost reminder package (LCRP) has great potentials for large-scale promotion. Therefore, this study aims to evaluate the effectiveness of combining LCRP and health education to improve MA among hypertensive patients.

PATIENTS AND METHODS

A clustered randomized controlled trial was performed in Beijing. A total of 518 hypertensive patients recruited from 8 community health care centers were randomized to receive LCRP combined with case-based health education or usual care. Randomization was performed at community level. Multilevel modeling was used to evaluate the study effect.

RESULTS

MA scores did not differ significantly at baseline between the intervention group and the control group. The results of multilevel modeling indicated that MA scores increased more in the intervention group, and the intervention effect on MA was 0.287 (95% CI: [0.103, 0.471], P=0.002). Patients' systolic blood pressure (SBP) and diastolic blood pressure (DBP) were not improved (SBP: difference=0.536, 95% CI [-3.207, 4.278]; DBP: difference=-0.927, 95% CI [-3.283, 1.428]).

CONCLUSION

LCRP combined with case-based health education could significantly improve hypertensive patients' MA.

Impact of financial burden, resulting from prescription co-payments, on antihypertensive medication adherence in an older publically insured population

Introduction

Medication co-payments represent a financial barrier to antihypertensive medication adherence. The introduction of co-payments for Irish publically insured patients was associated with a 5% reduction in adherence. However there is socioeconomic variability within this population, and the impact may be greater for those on lower income. We evaluated medication-related financial burden of the co-payment in a cohort of Irish publically insured antihypertensive users and tested its association with adherence at 12 months.

Methods

This was a prospective cohort study of community dwelling older (> 65 yrs) adults (n = 1152) from 106 Irish community pharmacies. Participants completed a structured telephone interview at baseline, and a follow-up interview at 12-months, which we linked to pharmacy records. We assessed medication-related financial burden at baseline using a single questionnaire item, and adherence at 12 months via questionnaire and refill-adherence as Proportion of Days Covered (PDC).

Results

A third of participants (30.1%) reported financial burden due to medication costs. In adjusted linear regression models financially burdened participants had significantly lower self-reported adherence (β = − 0.29, 95% CI -0.48 to − 0.11), although this was not evident with PDC (β = − 2.76, 95% CI -5.65 to 0.14).

Conclusion

This co-payment represents a financial barrier to antihypertensive adherence for many older Irish publically insured patients. The negative impact to adherence will potentially increase the risk of adverse outcomes, such as stroke, and increase long-term healthcare costs.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6209-8) contains supplementary material, which is available to authorized users.

Antithrombotic therapies for elderly patients: handling problems originating from their comorbidities

Compared with younger people, elderly people have higher risks for both thrombosis and bleeding. Furthermore, comorbidities frequently found in elderly patients complicate the management of antithrombotic therapy. Thus, when treating these patients, physicians often find it difficult to incorporate the principles of evidence-based medicine and must determine the best treatment option for each patient. Recently, in the fields of cerebrovascular and cardiovascular diseases, researchers have been rapidly accumulating new data regarding antithrombotic therapy, particularly in the areas of direct oral anticoagulants (DOACs) and dual antiplatelet therapy (DAPT). However, information related to elderly patients receiving antithrombotic therapy is still relatively limited. There are also more and more publications describing how antithrombotic therapy affects the pathogenesis of non-thrombotic diseases. Similarly, the number of reports concerning adherence to this therapy has been increasing lately. However, no review articles detailing these findings have yet been published. In actual clinical practice, antithrombotic therapy in the elderly is not a treatment strategy targeted to only one organ or disease. Rather, it requires an interdisciplinary approach aimed at maintaining the overall health of the patient. Thus, to assist physicians’ decision-making processes for elderly patients, an overview of recent findings related to the evidence regarding concomitant medications, the secondary benefits of antithrombotic therapy for patients with comorbidities, and evidence regarding medication adherence is provided.

Barriers to Beta-Blocker Use and Up-Titration Among Patients with Heart Failure with Reduced Ejection Fraction

PURPOSE

For patients with heart failure with reduced ejection fraction (HFrEF), guidelines recommend use of beta-blockers with gradual up-titration. However, many patients with HFrEF do not use beta-blockers and up-titration is rare. Our purpose was to identify and rank barriers to beta-blocker use and up-titration from the perspective of primary care physicians.

METHODS

We conducted 4 moderated, structured group discussions among 19 primary care physicians using the nominal group technique; 16 participants also completed a survey. Participants generated lists of barriers to beta-blocker use and up-titration among patients with HFrEF. Each participant had six votes with three votes assigned to the item ranked most important, two to the second most important item, and one to the third most important item. Investigators characterized items into themes. The percentage of available votes was calculated for each theme.

RESULTS

Fifteen of 16 participating primary care physicians who completed the survey reported that management of beta-blockers was their responsibility. Treatment/side effects, particularly hypotension, were identified as the most important barrier for beta-blocker use (72% of available votes) followed by polypharmacy (11%), healthcare system barriers (10%), and comorbidities (6%). Barriers to up-titration included treatment/side effects (49% of available votes), patient communication/buy-in (21%), polypharmacy (13%), and healthcare system barriers (8%).

CONCLUSIONS

Many barriers to guideline concordant use of beta-blockers among patients with HFrEF identified by primary care providers are not readily modifiable. Addressing these barriers may require development, testing, and dissemination of protocols for beta-blocker initiation and up-titration that are safe and appropriate in primary care.

Community pharmacist-led interventions and their impact on patients' medication adherence and other health outcomes: a systematic review

INTRODUCTION

Medication adherence can be defined as the extent to which one's medication-taking behaviour follows that mutually agreed upon by the prescribing physician. Optimal medication adherence is often deemed crucial for the success of a patient's treatment, as suboptimal adherence may lead to treatment failure and unnecessary medical expenditure. Increasing evidence has highlighted the positive contribution community pharmacist-led interventions can have on improving patients' adherence and health outcomes.

OBJECTIVES

To provide an overview of the published literature on community pharmacist-led interventions and their effectiveness in improving patients' adherence and health outcomes.

METHODS

A search strategy was developed, aiming to retrieve published reports of community pharmacy interventions worldwide. Medline, EMBASE, International Pharmaceutical Abstracts, Google Scholar and ProQuest Dissertations and Theses databases were searched. Articles meeting the inclusion criteria were collated, relevant data extracted, and a risk of bias assessment undertaken.

KEY FINDINGS

Twenty-two studies were included in the analysis, and their outcomes were reported in 26 peer-reviewed journal articles. Community pharmacist-led interventions have been shown to improve patients' adherence and contribute to better blood pressure control, cholesterol management, chronic obstructive pulmonary disease and asthma control. Studies in this review, however, did not report statistically significant effects of interventions on diabetes or depression control.

CONCLUSION

Community pharmacist-led interventions have been shown to contribute to improved adherence and better disease control. Future research should attempt to better understand which particular intervention components make the greatest contribution towards improving adherence and health outcomes, for patients with different medical conditions.

Rationale, design, and methodology of a trial evaluating three models of care for HCV treatment among injection drug users on opioid agonist therapy

BACKGROUND

People who inject drugs (PWID) constitute 60% of the approximately 5 million people in the U.S. infected with hepatitis C virus (HCV). Treatment of PWID is complex due to addiction, mental illness, poverty, homelessness, lack of positive social support, poor adherence-related skills, low motivation and knowledge, and poor access to and trust in the health care system. New direct-acting antiviral medications are available for HCV with high cure rates and few side effects. The life expectancy and economic benefits of new HCV treatments will not be realized unless we determine optimal models of care for the majority of HCV-infected patients. The purpose of this study is to evaluate the effectiveness of directly observed therapy and group treatment compared with self-administered individual treatment in a large, urban opioid agonist therapy clinic setting in the Bronx, New York.

METHODS/DESIGN

In this randomized controlled trial 150 PWID with chronic HCV were recruited from opioid agonist treatment (OAT) clinics and randomized to one of three models of onsite HCV treatment in OAT: 1) modified directly observed therapy; 2) group treatment; or 3) control - self-administered individual treatment. Participants were age 18 or older, HCV genotype 1, English or Spanish speaking, treatment naïve (or treatment experienced after 12/3/14), willing to receive HCV treatment onsite, receiving methadone or buprenorphine at the medication window at least once per week, and able to provide informed consent. Outcomes of interest include adherence (as measured by self-report and electronic blister packs), HCV treatment completion, sustained virologic response, drug resistance, and cost-effectiveness.

DISCUSSION

This paper describes the design and rationale of a randomized controlled trial comparing three models of care for HCV therapy delivered in an opioid agonist treatment program. Our trial will be critical to rigorously identify models of care that result in high adherence and cure rates. Use of blister pack technology will help us determine the role of adherence in successful cure of HCV. Moreover, the trial methodology outlined here can serve as a template for the development of future programs and studies among HCV-infected drug users receiving opioid agonist therapy, as well as the cost-effectiveness of such programs.

TRIAL REGISTRATION

This trial was registered with ClinicalTrials.gov ( NCT01857245 ). Trial registration was obtained prospectively on May 20th, 2013.

Psychotropic implant can be a new hope in psychiatry

Non-adherence to oral psychotropic medications is common in patients with severe mental illness (SMI). This substantially limits the effectiveness of treatment and results in higher rates of relapse, rehospitalization, suicide, early mortality and disability in SMI. This is a major concern for professionals, caregivers and policy makers. The pharmacological, psychological, psychosocial models and interventions have been there since last few decades to address non-adherence. These have not made major changes in treatment adherence and outcome of SMI. Hence new powerful, long acting and novel psychotropic implant can be developed and could soon revolutionize the treatment in psychiatry.

Group-Based Trajectory Models: Assessing Adherence to Antihypertensive Medication in Older Adults in a Community Pharmacy Setting

Antihypertensive medication nonadherence is highly prevalent, leading to uncontrolled blood pressure. Methods that facilitate the targeting and tailoring of adherence interventions in clinical settings are required. Group‐Based Trajectory Modeling (GBTM) is a newer method to evaluate adherence using pharmacy dispensing (refill) data that has advantages over traditional refill adherence metrics (e.g. Proportion of Days Covered) by identifying groups of patients who may benefit from adherence interventions, and identifying patterns of adherence behavior over time that may facilitate tailoring of an adherence intervention. We evaluated adherence to antihypertensive medication in 905 patients over a 12‐month period in a community pharmacy setting using GBTM, identifying three subgroups of adherence patterns: 52.8%, 40.7%, and 6.5% had very high, high, and low adherence, respectively. However, GBTM failed to demonstrate predictive validity with blood pressure at 12 months. Further research on the validity of adherence measures that facilitate interventions in clinical settings is required.

Implementation strategies for health systems in low-income countries: an overview of systematic reviews

BACKGROUND

A key function of health systems is implementing interventions to improve health, but coverage of essential health interventions remains low in low-income countries. Implementing interventions can be challenging, particularly if it entails complex changes in clinical routines; in collaborative patterns among different healthcare providers and disciplines; in the behaviour of providers, patients or other stakeholders; or in the organisation of care. Decision-makers may use a range of strategies to implement health interventions, and these choices should be based on evidence of the strategies' effectiveness.

OBJECTIVES

To provide an overview of the available evidence from up-to-date systematic reviews about the effects of implementation strategies for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on alternative implementation strategies and informing refinements of the framework for implementation strategies presented in the overview.

METHODS

We searched Health Systems Evidence in November 2010 and PDQ-Evidence up to December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of implementation strategies on professional practice and patient outcomes and that were published after April 2005. We excluded reviews with limitations important enough to compromise the reliability of the review findings. Two overview authors independently screened reviews, extracted data and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence) and assessments of the relevance of findings to low-income countries.

MAIN RESULTS

We identified 7272 systematic reviews and included 39 of them in this overview. An additional four reviews provided supplementary information. Of the 39 reviews, 32 had only minor limitations and 7 had important methodological limitations. Most studies in the reviews were from high-income countries. There were no studies from low-income countries in eight reviews.Implementation strategies addressed in the reviews were grouped into four categories - strategies targeting:1. healthcare organisations (e.g. strategies to change organisational culture; 1 review);2. healthcare workers by type of intervention (e.g. printed educational materials; 14 reviews);3. healthcare workers to address a specific problem (e.g. unnecessary antibiotic prescription; 9 reviews);4. healthcare recipients (e.g. medication adherence; 15 reviews).Overall, we found the following interventions to have desirable effects on at least one outcome with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects.1.Strategies targeted at healthcare workers: educational meetings, nutrition training of health workers, educational outreach, practice facilitation, local opinion leaders, audit and feedback, and tailored interventions.2.Strategies targeted at healthcare workers for specific types of problems: training healthcare workers to be more patient-centred in clinical consultations, use of birth kits, strategies such as clinician education and patient education to reduce antibiotic prescribing in ambulatory care settings, and in-service neonatal emergency care training.3. Strategies targeted at healthcare recipients: mass media interventions to increase uptake of HIV testing; intensive self-management and adherence, intensive disease management programmes to improve health literacy; behavioural interventions and mobile phone text messages for adherence to antiretroviral therapy; a one time incentive to start or continue tuberculosis prophylaxis; default reminders for patients being treated for active tuberculosis; use of sectioned polythene bags for adherence to malaria medication; community-based health education, and reminders and recall strategies to increase vaccination uptake; interventions to increase uptake of cervical screening (invitations, education, counselling, access to health promotion nurse and intensive recruitment); health insurance information and application support.

AUTHORS' CONCLUSIONS

Reliable systematic reviews have evaluated a wide range of strategies for implementing evidence-based interventions in low-income countries. Most of the available evidence is focused on strategies targeted at healthcare workers and healthcare recipients and relates to process-based outcomes. Evidence of the effects of strategies targeting healthcare organisations is scarce.

The Impact of Text Messaging on Medication Adherence and Exercise Among Postmyocardial Infarction Patients: Randomized Controlled Pilot Trial

Background

Adherence to evidence-based therapies such as medications and exercise remains poor among patients after a myocardial infarction (MI). Text message reminders have been shown to improve rates of adherence to medication and exercise, but the existing studies have been of short duration.

Objective

Two single-center randomized controlled pilot trials were conducted to evaluate the impact of text message reminders over 12 months on adherence to cardiac medications and exercise among patients receiving cardiac rehabilitation after hospitalization for MI.

Methods

In the medication adherence trial, 34 patients were randomized to receive usual care alone or usual care plus daily text message reminders delivered at the time of day at which medications were to be taken. In the exercise adherence trial, 50 patients were randomized to receive usual care alone or usual care plus 4 daily text messages reminding them to exercise as directed.

Results

The text message reminders led to a mean 14.2 percentage point improvement in self-reported medication adherence over usual care (P<.001, 95% CI 7-21). In the exercise trial, text message reminders resulted in an additional 4.2 days (P=.001, 95% CI 1.9-6.4) and 4.0 hours (P<.001, 95% CI 2.4-5.6) of exercise per month over usual care and a nonsignificant increase of 1.2 metabolic equivalents (METS; P=.06) in exercise capacity as assessed by a BRUCE protocol at 12 months.

Conclusions

Text message reminders significantly increased adherence to medication and exercise among post-MI patients receiving care in a structured cardiac rehabilitation program. This technology represents a simple and scalable method to ensure consistent use of evidence-based cardiovascular therapies.

Trial Registration

Clinicaltrials.gov NCT02783287; https://clinicaltrials.gov/ct2/show/NCT02783287 (Archived by WebCite at http://www.webcitation.org/6sBnvNb05)

Assessment of medication adherence and the costs associated with a calendar blister pack intervention among hypertensive patients in Malaysia: A randomized controlled trial

Objectives:

To assess the efficacy and costs of a calendar blister packaging intervention used to improve medication adherence.

Method:

A parallel randomized controlled trial was conducted with 73 hypertensive patients (intervention group = 35, control group = 38) at Hospital Kulim, Malaysia, for 7 months.

Results:

The intervention group demonstrated a significant improvement in medication possession ratio (p < 0.05) and percentage of on-time refills (p < 0.01) compared to control group. In addition, there was significantly lower blood pressure (p < 0.05) in intervention group. From the provider perspective, the average annual treatment cost per patient in the intervention group was MYR 2178.66 (~USD 526.95) (95% confidence interval = 1786.39–2570.94) compared to MYR 2693.09 (~USD 651.37) (95% confidence interval = 1903.23–3482.95) in the control group.

Conclusion:

This study provides evidence that calendar blister packaging has a positive impact on medication adherence, blood pressure and also has the potential for considerable cost savings.

Non-health care facility anticonvulsant medication errors in the United States

INTRODUCTION

This study provides an epidemiological description of non-health care facility medication errors involving anticonvulsant drugs.

METHODS

A retrospective analysis of National Poison Data System data was conducted on non-health care facility medication errors involving anticonvulsant drugs reported to US Poison Control Centers from 2000 through 2012.

RESULTS

During the study period, 108,446 non-health care facility medication errors involving anticonvulsant pharmaceuticals were reported to US Poison Control Centers, averaging 8342 exposures annually. The annual frequency and rate of errors increased significantly over the study period, by 96.6 and 76.7%, respectively. The rate of exposures resulting in health care facility use increased by 83.3% and the rate of exposures resulting in serious medical outcomes increased by 62.3%. In 2012, newer anticonvulsants, including felbamate, gabapentin, lamotrigine, levetiracetam, other anticonvulsants (excluding barbiturates), other types of gamma aminobutyric acid, oxcarbazepine, topiramate, and zonisamide, accounted for 67.1% of all exposures.

CONCLUSIONS

The rate of non-health care facility anticonvulsant medication errors reported to Poison Control Centers increased during 2000-2012, resulting in more frequent health care facility use and serious medical outcomes. Newer anticonvulsants, although often considered safer and more easily tolerated, were responsible for much of this trend and should still be administered with caution.

Non–Health Care Facility Cardiovascular Medication Errors in the United States

Background: Prior studies have not examined national trends and characteristics of unintentional non–health care facility (HCF) medication errors associated with cardiovascular drugs. Objective: To investigate non-HCF medication errors associated with cardiovascular drugs reported to poison control centers in the United States. Methods: A retrospective analysis of non-HCF medication errors associated with cardiovascular drugs from 2000 to 2012 was conducted using the National Poison Data System database. Results: There were 278 444 medication errors associated with cardiovascular drugs reported to US poison control centers during the study period, averaging 21 419 exposures annually. The overall rate of cardiovascular medication errors per 100 000 population increased 104.6% from 2000 to 2012 ( P < 0.001) and the highest rates were among older adults. Most cases (83.6%) did not require treatment at a HCF. Serious medical outcomes were reported in 4.0% of exposures. The cardiovascular drugs most commonly implicated in medication errors were β-blockers (28.2%), calcium antagonists (17.7%), and angiotensin-converting enzyme inhibitors (15.9%). Most of the 114 deaths were associated with cardiac glycosides (47.4%) or calcium antagonists (29.8%). Most medication errors involved taking or being given a medication twice (52.6%). Conclusions: This study describes characteristics and trends of non-HCF cardiovascular medication errors over a 13-year period in the United States. The number and rate of cardiovascular medication errors increased steadily from 2000 to 2012, with the highest error rates among older adults. Further research is needed to identify prevention strategies for these errors, with a particular focus on the older adult population.

Impact of Bubble Packaging on Adherence to Long-Term Oral Medications Used to Prevent Cardiovascular Disease

Background: Adherence to long-term pharmacotherapy is problematic in the United States. Bubble packaging of medications has been touted to improve patients’ use of medications. Scant research has assessed bubble packaging’s impact on adherence to multiple medications. Objective: To compare medication adherence between patients receiving medications to address cardiovascular disease risk factors in bubble packages to those receiving medications in pill bottles. Methods: This retrospective cohort study utilized prescription dispensing records from an independent pharmacy. Patients receiving statins, β-blockers, angiotensin-converting enzyme inhibitors, or oral hypoglycemic agents were identified and grouped into those who received medications in bubble packages and those received medications in pill bottles. Adherence was assessed with medication possession ratios. Patients were classified as adherent if their medication possession ratio was 80% or more. Results: Receiving medications in bubble packaging was significantly associated with greater adherence compared to pill bottles (P < .001). In adjusted models, greater numbers of medications filled (P = .024) and increasing patient age (P = .018) were significantly associated with low adherence, while bubble packaging was not (P = .13). Stratified analyses revealed that bubble packaging was significantly associated with greater adherence when 4 or fewer medications are filled (P = .012) and for patients between 18 and 44 years of age (P = .023). Conclusion: Bubble packages can improve medication adherence. However, they may not resolve complex issues contributing to the problem of nonadherence, especially for older patients and those prescribed multiple medications.

Effect of Reminder Devices on Medication Adherence: The REMIND Randomized Clinical Trial

IMPORTANCE

Forgetfulness is a major contributor to nonadherence to chronic disease medications and could be addressed with medication reminder devices.

OBJECTIVE

To compare the effect of 3 low-cost reminder devices on medication adherence.

DESIGN, SETTING, AND PARTICIPANTS

This 4-arm, block-randomized clinical trial involved 53 480 enrollees of CVS Caremark, a pharmacy benefit manager, across the United States. Eligible participants were aged 18 to 64 years and taking 1 to 3 oral medications for long-term use. Participants had to be suboptimally adherent to all of their prescribed therapies (with a medication possession ratio of 30% to 80%) in the 12 months before randomization. Participants were stratified on the basis of the medications they were using at randomization: medications for cardiovascular or other nondepression chronic conditions (the chronic disease stratum) and antidepressants (the antidepressant stratum). In each stratum, randomization occurred within blocks defined by whether all of the patient's targeted medications were dosed once daily. Patients were randomized to receive in the mail a pill bottle strip with toggles, digital timer cap, or standard pillbox. The control group received neither notification nor a device. Data were collected from February 12, 2013, through March 21, 2015, and data analyses were on the intention-to-treat population.

MAIN OUTCOMES AND MEASURES

The primary outcome was optimal adherence (medication possession ratio ≥80%) to all eligible medications among patients in the chronic disease stratum during 12 months of follow-up, ascertained using pharmacy claims data. Secondary outcomes included optimal adherence to cardiovascular medications among patients in the chronic disease stratum as well as optimal adherence to antidepressants.

RESULTS

Of the 53 480 participants, mean (SD) age was 45 (12) years and 56% were female. In the primary analysis, 15.5% of patients in the chronic disease stratum assigned to the standard pillbox, 15.1% assigned to the digital timer cap, 16.3% assigned to the pill bottle strip with toggles, and 15.1% assigned to the control arm were optimally adherent to their prescribed treatments during follow-up. There was no statistically significant difference in the odds of optimal adherence between the control and any of the devices (standard pillbox: odds ratio [OR], 1.03 [95% CI, 0.95-1.13]; digital timer cap: OR, 1.00 [95% CI, 0.92-1.09]; and pill bottle strip with toggles: OR, 0.94 [95% CI, 0.85-1.04]). In direct comparisons, the odds of optimal adherence were higher with a standard pillbox than with the pill bottle strip (OR, 1.10 [95% CI, 1.00-1.21]). Secondary analyses yielded similar results.

CONCLUSIONS AND RELEVANCE

Low-cost reminder devices did not improve adherence among nonadherent patients who were taking up to 3 medications to treat common chronic conditions. The devices may have been more effective if coupled with interventions to ensure consistent use or if targeted to individuals with an even higher risk of nonadherence.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02015806.

Pillbox intervention fidelity in medication adherence research: A systematic review

BACKGROUND

Pillboxes are widely available, have evidence of effectiveness, but translating pillboxes in self-management interventions requires an understanding of intervention components.

PURPOSE

To review components of intervention design, interventionist training, delivery, receipt, enactment, and targeted behaviors in adherence studies.

METHODS

Five multidisciplinary databases were searched to find reports of controlled trials testing pillboxes and medication adherence interventions in adults managing medications. Details of treatment fidelity, that is, design, training, delivery, receipt, and enactment, were abstracted.

FINDINGS

A total of 38 articles reporting 40 studies were included. Treatment fidelity descriptions were often lacking, especially reporting receipt and enactment, important for both control and intervention groups. Clearly reported details are needed to avoid making assumptions when translating evidence.

CONCLUSION

These findings serve as a call to action to explicitly state intervention details. Lack of reported intervention detail is a barrier to translating which components of pillboxes work in influencing medication adherence behaviors and outcomes.

A Case Study Investigation into the Use of Multi-compartment Compliance Aids in Older People Resident in Very Sheltered Housing

BACKGROUND

Multi-compartment compliance aids (MCAs) are repackaging systems for solid dosage form medicines, heralded by some as a solution to non-adherence but with little evidence of benefit.

OBJECTIVE

The aim was to use a theoretical approach to describe the behavioural determinants impacting the use of MCAs in older people from the perspectives of the individual and health and social care providers.

DESIGN

A case study investigation was conducted.

SETTING

The study took place in three very sheltered housing sites in North East Scotland.

SUBJECTS

Twenty residents (≥65 years) using an MCA for at least 6 months and 34 members of their care team [17 formal carers, eight general practitioners (GPs), eight pharmacists, one family member].

METHODS

Semi-structured, face-to-face interviews with items based on the Theoretical Domains Framework were conducted. Interviews were audio-recorded, transcribed and analysed thematically.

RESULTS

Several behavioural determinants impacted the use of MCAs from the perspectives of the stakeholders involved. Goals of use related to promoting adherence and safety, with less emphasis on independence. Beliefs of consequences related to these goals and were considered of value, with additional consequences of concern around reduced awareness of medicines and complexities of changing medicines. There was a lack of clearly defined roles of professionals for all processes of MCA use, with evidence of blurring and gaps in roles. There were additional issues relating to capabilities of older people in using MCAs and capacity issues for pharmacy-supplied MCAs.

CONCLUSIONS

Several behavioural determinants impacted the use of MCAs, and while MCAs were valued, there is a need to more clearly define, develop, implement and evaluate a model of care encompassing resident and medicines assessment, supply and ongoing review of MCAs.

Assessment of medication adherence app features, functionality, and health literacy level and the creation of a searchable Web-based adherence app resource for health care professionals and patients

OBJECTIVES

To assess the features and level of health literacy (HL) of available medication adherence apps and to create a searchable website to assist health care providers (HCP) and patients identify quality adherence apps.

PRACTICE DESCRIPTION

Medication nonadherence continues to be a significant problem and leads to poor health outcomes and avoidable health care expense. The average adherence rate for chronic medications, regardless of disease state, is approximately 50% leaving significant room for improvement.

PRACTICE INNOVATION

Smartphone adherence apps are a novel resource to address medication nonadherence. With widespread smartphone use and the growing number of adherence apps, both HCP and patients should be able to identify quality adherence apps to maximize potential benefits.

INTERVENTIONS

Assess the features, functionality and level of HL of available adherence apps and create a searchable website to help both HCP and patients identify quality adherence apps.

EVALUATION

Online marketplaces (iTunes, Google Play, Blackberry) were searched in June of 2014 to identify available adherence apps. Online descriptions were recorded and scored based on 28 author-identified features across 4 domains. The 100 highest-scoring apps were user-tested with a standardized regimen to evaluate their functionality and level of HL.

RESULTS

461 adherence apps were identified. 367 unique apps were evaluated after removing "Lite/Trial" versions. The median initial score based on descriptions was 15 (max of 68; range: 3 to 47). Only 77 apps of the top 100 highest-scoring apps completed user-testing and HL evaluations. The median overall user-testing score was 30 (max of 73; range: 16 to 55).

CONCLUSION

App design, functionality, and level of HL varies widely among adherence apps. While no app is perfect, several apps scored highly across all domains. The website www.medappfinder.com is a searchable tool that helps HCP and patients identify quality apps in a crowded marketplace.

Acetylsalicylic Acid Daily vs Acetylsalicylic Acid Every 3 Days in Healthy Volunteers: Effect on Platelet Aggregation, Gastric Mucosa, and Prostaglandin E2 Synthesis

Substantial platelet inhibition was observed 3 days after a single administration of acetylsalicylic acid 81 mg to healthy volunteers. Here we investigate prostaglandin E2 (PGE2 ) antrum concentrations and gastrointestinal symptoms in two treatment groups: one receiving losartan and acetylsalicylic acid every day and the other receiving losartan every day and acetylsalicylic acid every 3 days. Twenty-eight healthy volunteers from both sexes received either 50 mg losartan and acetylsalicylic acid 81 mg daily or 50 mg losartan and acetylsalicylic acid 81 every 3 days with placebo on the other days. Therapy was delivered for 30 days for both groups. Gastric endoscopy was performed before and after treatment period. Biopsies were collected for PGE2 quantification. Platelet function tests were carried out before and during treatment and TXB2 release on platelet rich plasma was measured. The every 3 day low-dose acetylsalicylic acid regimen produced complete inhibition of platelet aggregation compared to the daily treatment. Thromboxane B2 release was substantially abolished for both groups during treatment. There was no significant difference on the endoscopic score of both treatment groups after the 30-day treatment (P = .215). There was over 50% suppression of antrum PGE2 content on volunteers receiving acetylsalicylic acid daily (P = .0016), while for the every 3 day dose regimen there was no significant difference between pre and post-treatment antrum PGE2 dosages (P = .4193). Since PGE2 is involved in gastric healing, we understand that this new approach could be safer and as efficient as the standard daily therapy on a long-term basis.

Patient-Reported Factors Associated With Poor Phosphorus Control in a Maintenance Hemodialysis Population

OBJECTIVE

The purpose of this study was to determine the influence of patient-reported medication adherence and phosphorus-related knowledge on phosphorus control and pharmacy-reported adherence to phosphorus binding medication among patients on maintenance hemodialysis.

DESIGN

Retrospective, cross-sectional cohort study.

SUBJECTS

Seventy-nine hemodialysis patients (mean age 64.2 years, SD = 14 years; 46.8% female) in a stand-alone hemodialysis unit within an integrated learning healthcare system. Ten percent (10%) of subjects were Caucasian, 42% Latino, 19% African American, and 29% Asian. Forty-eight percent had diabetes; 72% had BMI ≥ 30. Inclusion criteria included the provision of survey data and having medication refill data available in the pharmacy system. 77.2% had mean phosphorus levels ≤ 5.5 mg/dL; 22.8% had mean phosphorus levels > 5.5 mg/dL.

INTERVENTION

Subjects were administered the 8-item Morisky Medication Adherence Scale (MMAS-8) and also reported on their phosphorus-related knowledge.

MAIN OUTCOME MEASURE

Phosphorus levels within an adequate range.

RESULTS

The mean serum phosphorus level was 4.96 mg/dL (SD = 1.21). In the well-controlled group, mean phosphorus was 4.44 mg/dL (SD = 0.76). In the poorly controlled group, mean phosphorus was 6.69 mg/dL (SD = 0.74). A total of 61% of patients reported at least some unintentional medication nonadherence, and 48% reported intentional medication nonadherence. Phosphorus-specific knowledge was low, with just under half of patients reporting that they could not name two high-phosphorus foods or identify a phosphorus-related health risk. Phosphorus binder-related nonadherence was substantially higher in the uncontrolled than the controlled group. Adjusting for age, individuals with poorer self-reported binder adherence were less likely to have controlled phosphorus levels (odds ratio = 0.71, P = .06).

CONCLUSION

Phosphorus-related non-adherence, but not low phosphorus-specific knowledge, was associated with poorer phosphorus control. Such findings provide important information for the development of evidence-based strategies for improving phosphorus control among patients on dialysis.

Retention in care and medication adherence: current challenges to antiretroviral therapy success

Health behaviors such as retention in HIV medical care and adherence to antiretroviral therapy (ART) pose major challenges to reducing new HIV infections, addressing health disparities, and improving health outcomes. Andersen's Behavioral Model of Health Service Use provides a conceptual framework for understanding how patient and environmental factors affect health behaviors and outcomes, which can inform the design of intervention strategies. Factors affecting retention and adherence among persons with HIV include patient predisposing factors (e.g., mental illness, substance abuse), patient-enabling factors (e.g., social support, reminder strategies, medication characteristics, transportation, housing, insurance), and healthcare environment factors (e.g., pharmacy services, clinic experiences, provider characteristics). Evidence-based recommendations for improving retention and adherence include (1) systematic monitoring of clinic attendance and ART adherence; (2) use of peer or paraprofessional navigators to re-engage patients in care and help them remain in care; (3) optimization of ART regimens and pharmaceutical supply chain management systems; (4) provision of reminder devices and tools; (5) general education and counseling; (6) engagement of peer, family, and community support groups; (7) case management; and (8) targeting patients with substance abuse and mental illness. Further research is needed on effective monitoring strategies and interventions that focus on improving retention and adherence, with specific attention to the healthcare environment.

Repackaged sodium valproate tablets--Meeting quality and adherence to ensure seizure control

PURPOSE

Sodium valproate, which is commonly repacked to assist with adherence to ensure seizure control, is hygroscopic and therefore sensitive to moisture. The aim of this study was thus to determine the stability implications of removing the enteric coated tablets from their original packaging and repackaging into a Dose Administration Aid (DAA) with storage under various environmental conditions.

METHODS

Physicochemical stability of enteric coated sodium valproate tablets repackaged into a DAA and stored at controlled room temperature, accelerated and refrigerated conditions was evaluated for 28 days. A validated high performance liquid chromatography method was used for the quantitation of the drug content.

RESULTS

Although the chemical stability (sodium valproate between 95 and 105% of labelled content) was maintained for 28 days for all storage conditions, for those tablets stored under accelerated conditions the integrity of the enteric coat was compromised after only 8 days.

CONCLUSIONS

Repackaging of enteric coated sodium valproate should be undertaken with caution and be informed by storage climate. This is particularly relevant for those patients living in hot, humid environments where they should be advised to store their DAA in a refrigerator.

Formulation approaches to pediatric oral drug delivery: benefits and limitations of current platforms

Introduction: Most conventional drug delivery systems are not acceptable for pediatric patients as they differ in their developmental status and dosing requirements from other subsets of the population. Technology platforms are required to aid the development of age-appropriate medicines to maximize patient acceptability while maintaining safety, efficacy, accessibility and affordability.

Areas covered: The current approaches and novel developments in the field of age-appropriate drug delivery for pediatric patients are critically discussed including patient-centric formulations, administration devices and packaging systems.

Expert opinion: Despite the incentives provided by recent regulatory modifications and the efforts of formulation scientists, there is still a need for implementation of pharmaceutical technologies that enable the manufacture of licensed age-appropriate formulations. Harmonization of endeavors from regulators, industry and academia by sharing learning associated with data obtained from pediatric investigation plans, product development pathways and scientific projects would be the way forward to speed up bench-to-market age appropriate formulation development. A collaborative approach will benefit not only pediatrics, but other patient populations such as geriatrics would also benefit from an accelerated patient-centric approach to drug delivery.

Adherence to medication before and after the use of a Drug-Dispensing System with usage control

<p>The aim of the present work was to assess the adherence to medication from polymedicated patients before and after the use of a Drug-dispensing System with Usage Control (DDSUC) and compare the levels of the clinical parameters - blood pressure, postprandial glycemia, glycated hemoglobin, triglycerides and cholesterol. DDSUC consisted of a monthly drug-dispensing package, in the shape of a blister with a calendar. This quasi-experimental study was performed in a Basic Health Unit. Twenty four patients were selected to use DDSUC for 4 months. Medication adherence was assessed through Morisky-Green test. Among the participants of the study, 62.5% were women and the average age was 67 years old. Before the use of DDSUC, 83.3% of the patients were considered as "less adherent". After the use of the system, 100% were considered as "more adherent" (p < 0.01), the means of the systolic blood pressure decreased 23.7 mmHg (p=0.000), the diastolic blood pressure decreased 12.1 mmHg (p=0.004) and glycemia diminished 79.3 mg/dl (p=0.000). The use of DDSUC improved the adherence to medication and decreased the values of the clinical parameters, making patients safer when it comes to respecting the correct use of their medication.</p>

Packaging interventions to increase medication adherence: systematic review and meta-analysis

OBJECTIVE

Inadequate medication adherence is a widespread problem that contributes to increased chronic disease complications and health care expenditures. Packaging interventions using pill boxes and blister packs have been widely recommended to address the medication adherence issue. This meta-analysis review determined the overall effect of packaging interventions on medication adherence and health outcomes. In addition, we tested whether effects vary depending on intervention, sample, and design characteristics.

RESEARCH DESIGN AND METHODS

Extensive literature search strategies included examination of 13 computerized databases and 19 research registries, hand searches of 57 journals, and author and ancestry searches. Eligible studies included either pill boxes or blister packaging interventions to increase medication adherence. Primary study characteristics and outcomes were reliably coded. Random-effects analyses were used to calculate overall effect sizes and conduct moderator analyses.

RESULTS

Data were synthesized across 22,858 subjects from 52 reports. The overall mean weighted standardized difference effect size for two-group comparisons was 0.593 (favoring treatment over control), which is consistent with the mean of 71% adherence for treatment subjects compared to 63% among control subjects. We found using moderator analyses that interventions were most effective when they used blister packs and were delivered in pharmacies, while interventions were less effective when studies included older subjects and those with cognitive impairment. Methodological moderator analyses revealed significantly larger effect sizes in studies reporting continuous data outcomes instead of dichotomous results and in studies using pharmacy refill medication adherence measures compared with studies with self-report measures.

CONCLUSIONS

Overall, meta-analysis findings support the use of packaging interventions to effectively increase medication adherence. Limitations of the study include the exclusion of packaging interventions other than pill boxes and blister packs, evidence of publication bias, and primary study sparse reporting of health outcomes and potentially interesting moderating variables such as the number of prescribed medications.

Health literacy in patients dealing with gout: a qualitative study

The objective of this study was to explore the health literacy of patients dealing with gout and to understand perceptions that might account for non-adherence to urate-lowering therapy (ULT). Semi-structured interviews involving patients with gout were conducted. The transcripts of the interviews were scored by two readers and a coding system to categorize the data was developed. Fifteen patients (14 men, mean age 63 years, mean disease duration 11 years) were interviewed; ten patients were recruited from secondary care and five from primary care. Six patients had gout tophi and 12 patients used ULT. Less than half of the patients were sufficiently aware of the pathophysiological processes that cause gout. Twelve patients indicated that treatment of gout only encompasses treatment of the acute attack. Patients were unaware of long-term treatment goals. Six patients admitted medication non-adherence at some point in time. Several reasons for non-adherence, such as healthcare professionals providing conflicting messages about medication, can be considered preventable. Half of the patients expressed that they, especially at the time of diagnosis, wanted to know more about the cause of gout, treatment goals and long-term consequences. In conclusion, the health literacy of patients dealing with gout was low in our study, especially with regard to medication. Yet, patients often recognized these knowledge gaps. Our data suggest that improving knowledge and addressing common misperceptions in training programmes, may ultimately contribute to adherence to ULT and an optimized outcome in patients with gout. This hypothesis needs to be confirmed in future research.

Knowledge, attitudes and beliefs of patients and carers regarding medication adherence: a review of qualitative literature

PURPOSE

The aim of this review is to cohere evidence on the knowledge, attitudes and beliefs of patients and carers regarding medication adherence. Medication adherence refers to "the extent to which the patient's action matches the agreed recommendations". Medication adherence is vital in preventing, managing and curing illnesses and, hence, is linked with positive health outcomes.

METHODS

A search was conducted using the following databases: CINAHL, Embase, PubMed and Web of Knowledge from inception to November 2013. Titles and abstracts were screened for inclusion in the review according to pre-defined inclusion and exclusion criteria. Studies were assessed for quality, and data were extracted into a data extraction form. Results were analysed thematically.

RESULTS

The final results included 34 articles. Eight analytical themes were identified: (i) beliefs and experiences of medicines, (ii) family support and culture, (iii) role of and relationship with health-care practitioners, (iv) factors related to the disease, (v) self-regulation, (vi) communication, (vii) cost and (viii) access. The theme, "beliefs and experiences of medicines", was present in 33 studies, with many discussing the influence that side effects have on medication adherence.

CONCLUSIONS

There are a number of variables that impact upon the knowledge, attitudes and beliefs of patients and carers regarding medication adherence. This review presents an overview of the analytical themes which offers the opportunity to examine interventions and their relative efficacies to increase medication adherence.