Measures of adherence based on self-report exhibited poor agreement with those based on pharmacy records

Asthma medication adherence and exacerbations and lung function in children managed in Leicester primary care

Poor adherence to asthma preventer medication is associated with life-threatening asthma attacks. The quality and outcomes framework mandated primary care annual asthma review does not include adherence monitoring and the effect of poor adherence on lung function in paediatric primary care patients is unknown. The aim was to investigate the link between inhaled corticosteroid (ICS) adherence and spirometry, fraction of exhaled nitric oxide (FeNO) and asthma control in asthmatic school-age children in this cross-sectional observational study involving three Leicestershire general practices. Children 5-16 years on the practice's asthma registers, were invited for a routine annual asthma review between August 2018 and August 2019. Prescription and clinical data were extracted from practice databases. Spirometry, bronchodilator reversibility (BDR) and FeNO testing were performed as part of the review. 130 of 205 eligible children (63.4%) attended their review. Mean adherence to ICS was 36.2% (SEM 2.1%) and only 14.6% of children had good adherence (≥75% prescriptions issued). We found no differences in asthma exacerbations in the preceding 12 months between the adherence quartiles. 28.6% of children in the lowest and 5.6% in the highest adherence quartile had BDR ≥ 12% but this was not statistically significant (p = 0.55). A single high FeNO value did not predict adherence to ICS. Adherence to ICS in children with asthma in primary care is poor. The link between adherence to ICS and asthma exacerbations, spirometry and FeNO is complex but knowledge of adherence to ICS is critical in the management of children with asthma.

Agreement in the CARTaGENE cohort between self-reported medication use and claim data

OBJECTIVES

To describe the agreement of self-reported medication use with claim prescription records and to ascertain factors associated with agreement between the two data sources.

METHODS

Baseline data on self-reported medication use was extracted from CARTaGENE, a cohort study in Quebec, Canada, and from the provincial health insurance records (dispensation database) of the same individuals. Kappa statistics were used to estimate concordance beyond chance between the two data sources. Logistic regression models were adjusted to estimate the association between agreement and selected individual's characteristics (sex, age, education, region, income, utilization of health care system, and comorbidities).

RESULTS

Agreement between self-reported medication use and administrative data varied considerably across medication classes (kappa 0.54 for respiratory system and 0.91 for systemic hormonal preparations). Overall, agreement improved when a fixed time window of 90 days was used for exposure measurement. Sex, education level, frequency of health care use and the number of reported medications were associated with agreement.

DISCUSSION

Overall, there was a reasonable agreement between the two data sources, but important variations were found for the different drug classes. These results could be used by researchers to more accurately assess drug exposures using real-world data, which are increasingly important to regulators.

Association Between Medication Adherence and Risk of COPD in Adult Asthma Patients: A Retrospective Cohort Study in Canada

Background

Poor adherence to prescribed asthma medications and risk of severe asthma exacerbations have been well established. However, the effects of changes in asthma medication compliance levels and subsequent risk of COPD is unknown and yet to be investigated. This study investigated the independent effect of medication adherence (MA) and asthma severity levels on the risk of COPD.

Methods

We used four linked administrative health databases from the Population data BC to identify asthma patients aged 18 years and older between January 1, 1998 and December 31, 1999 without diagnosis of COPD. The primary event was time-to-COPD diagnosis during the follow-up period (January 1, 2000 to December 31, 2018). The proportion of days covered (PDC) – was used as a surrogate measure for medication adherence (MA) assessed at optimal-level (≥ 0.80), Intermediate-level (0.50–0.79), and low-level (< 0.5) of adherence. A propensity adjusted analysis with Marginal Structural Cox (MSC) model was employed to estimate the adjusted hazard ratios (aHR) and 95% confidence intervals (95% CI) for the effect of medication adherence and asthma severity over time.

Results

At cohort entry, the sample included 68,211 asthma patients with an overall mean age of 48.2 years. The 18-year incidence of COPD in asthma patients was 9.8 per 1000-persons year. In an inverse weighted propensity adjusted analysis of the MSC model, higher MA levels were significantly associated with decreased risk of COPD as follows: optimal-level (aHR: 0.19, 95% CI: 0.17–0.24); Intermediate-level (aHR: 0.20, 95% CI: 0.18, 0.23) compared to the low-level adherence group. A significant increase in COPD risk was observed in severe asthma patients with low medication adherence (aHR: 1.72, 95% CI: 1.52–1.93), independent of other patient factors.

Conclusion

Optimal (≥ 0.80) and intermediate adherence (0.5 to 0.79) levels were associated with reduced risk of COPD incidence over time. Interventions aimed at improving adherence to prescribed medications in adult asthma patients should be intensified to reduce their risk of COPD.

Assessing adherence to medications: Is there a difference between a subjective method and an objective method, or between using them concurrently?

Background

Patients' adherence to medication can be assessed by several subjective or objective methods. The Global Initiative for Asthma (GINA) has recommended the use of both measures simultaneously.

Objective

To assess patients' adherence to medication using a subjective or an objective method separately, and via using a combination of both methods. As well as identifying the degree of agreement between the two methods.

Methods

Participants who met the study inclusion criteria completed the Adherence to Asthma Medication Questionnaire (AAMQ). A retrospective audit was conducted in order to extract pharmacy refill records for the previous twelve months. The patients' pharmacy refill records were expressed using the Medication Possession Ratio (MPR). Data were analyzed using the Statistical Package for Social Science. The degree of agreement was determined by Cohen's kappa coefficient (κ).

Results

In terms of the difference in the ability of each method to identify non-adherent patients, a higher percentage of non-adherent patients were identified using the self-reported AAMQ (61.4%) compared to the pharmacy refill records (34.3%). When both methods, in combination, were used to assess adherence, the percentage of non-adherent patients was 80.0%, which is higher than each method when used separately. Twenty percent of the patients were considered adherent on both assessment methods, while 15.7% were considered non-adherent via both methods. Consequently, the AAMQ and pharmacy refill records agreed on 35.7% of the patients. The degree of agreement analysis showed a low correlation between the two methods.

Conclusion

The combination strategy resulted in a higher percentage of non-adherent patients, compared to using a subjective (the AAMQ) or an objective (the pharmacy refill records) method. The GINA guideline proposition may be supported by the present study's findings.

Measuring Medication Adherence in a Population-Based Asthma Administrative Pharmacy Database: A Systematic Review and Meta-Analysis

Background

Limited studies have systematically reviewed the literature to identify and compare the various database methods and optimal thresholds for measuring medication adherence specific to adolescents and adults with asthma. In the present study, we aim to identify the methods and optimal thresholds for measuring medication adherence in population-based pharmacy databases.

Methods

We searched PubMed, Embase, International Pharmaceutical Abstracts (IPA), Web of Science, Google Scholar, and grey literature from January 1, 1998, to March 16, 2021. Two independent reviewers screened the studies, extracted the data, and assessed the quality of the studies. A quantitative knowledge synthesis was employed.

Results

Thirty-eight (38) retrospective cohort studies were eligible. This review identified 20 methods for measuring medication adherence in adolescent and adult asthma administrative health records. Two measures namely the medication possession ratio (MPR) and proportion of days covered (PDC) were commonly reported in 87% of the literature included in this study. From the meta-analysis, asthma patients who achieved adherence threshold of "0.75-1.00" [OR: 0.56, 95% CI: 0.41 to 0.77] and ">0.5" [OR: 0.71, 95% CI: 0.54 to 0.94] were less likely to experience asthma exacerbation.

Conclusion

Despite their limitations, the PDC and the MPR still remain the most common measures for assessing adherence in asthma pharmacy claim databases. The evidence synthesis showed that an adherence threshold of at least 0.75 is optimal for classifying adherent and non-adherent asthma patients.

Measurement Properties of Existing Patient-Reported Outcome Measures on Medication Adherence: Systematic Review

BACKGROUND

Medication adherence is essential for improving the health outcomes of patients. Various patient-reported outcome measures (PROMs) have been developed to measure medication adherence in patients. However, no study has summarized the psychometric properties of these PROMs to guide selection for use in clinical practice or research.

OBJECTIVE

This study aims to evaluate the quality of the PROMs used to measure medication adherence.

METHODS

This study was guided by the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines. Relevant articles were retrieved from the EMBASE, PubMed, Cochrane Library, Web of Science, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases. The PROMs were then evaluated based on the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidelines.

RESULTS

A total of 121 unique medication adherence PROMs from 214 studies were identified. Hypotheses testing for construct validity and internal consistency were the most frequently assessed measurement properties. PROMs with at least a moderate level of evidence for ≥5 measurement properties include the Adherence Starts with Knowledge 20, Compliance Questionnaire-Rheumatology, General Medication Adherence Scale, Hill-Bone Scale, Immunosuppressant Therapy Barrier Scale, Medication Adherence Reasons Scale (MAR-Scale) revised, 5-item Medication Adherence Rating Scale (MARS-5), 9-item MARS (MARS-9), 4-item Morisky Medication Adherence Scale (MMAS-4), 8-item MMAS (MMAS-8), Self-efficacy for Appropriate Medication Adherence Scale, Satisfaction with Iron Chelation Therapy, Test of Adherence to Inhalers, and questionnaire by Voils. The MAR-Scale revised, MMAS-4, and MMAS-8 have been administered electronically.

CONCLUSIONS

This study identified 121 PROMs for medication adherence and provided synthesized evidence for the measurement properties of these PROMs. The findings from this study may assist clinicians and researchers in selecting suitable PROMs to assess medication adherence.

Development of an Item Bank to Measure Medication Adherence: Systematic Review

Background

Medication adherence is important in managing the progression of chronic diseases. A promising approach to reduce cognitive burden when measuring medication adherence lies in the use of computer‐adaptive tests (CATs) or in the development of shorter patient-reported outcome measures (PROMs). However, the lack of an item bank currently hampers this progress.

Objective

We aim to develop an item bank to measure general medication adherence.

Methods

Using the preferred reporting items for systematic review and meta-analysis (PRISMA), articles published before October 2019 were retrieved from PubMed, Embase, CINAHL, the Cochrane Library, and Web of Science. Items from existing PROMs were classified and selected (“binned” and “winnowed”) according to standards published by the Patient-Reported Outcomes Measurement Information System (PROMIS) Cooperative Group.

Results

A total of 126 unique PROMs were identified from 213 studies in 48 countries. Items from the literature review (47 PROMs with 579 items for which permission has been obtained) underwent binning and winnowing. This resulted in 421 candidate items (77 extent of adherence and 344 reasons for adherence).

Conclusions

We developed an item bank for measuring general medication adherence using items from validated PROMs. This will allow researchers to create new PROMs from selected items and provide the foundation to develop CATs.

Relationship of Inhaled Corticosteroid Adherence to Asthma Exacerbations in Patients with Moderate-to-Severe Asthma

BACKGROUND

Patients with asthma and elevated blood eosinophils are at increased risk of severe exacerbations. Management of these patients should consider nonadherence to inhaled corticosteroid (ICS) therapy as a factor for increased exacerbation risk.

OBJECTIVE

The objective of this study was to investigate whether poor adherence to ICS therapy explains the occurrence of asthma exacerbations in patients with elevated blood eosinophil levels.

METHODS

This historical cohort study identified patients within the Optimum Patient Care Research Database, aged 18 years or more, at Global Initiative for Asthma step 3 or 4, with 2 or more ICS prescriptions during the year before the clinical review. Patient characteristics and adherence (based on prescription refills and patient self-report) for ICS therapy were analyzed for those with elevated (>400 cells/μL) or normal (≤400 cells/μL) blood eosinophils.

RESULTS

We studied 7195 patients (66% female, mean age 60 years) with median eosinophil count of 200 cells/μL and found 81% to be not fully adherent to ICS therapy. A total of 1031 patients (14%) had elevated blood eosinophil counts (58% female, mean age 60 years), 83% of whom were not fully adherent to ICS. An increased proportion of adherent patients in the elevated blood eosinophil group had 2 or more exacerbations (14.0% vs 7.2%; P = .003) and uncontrolled asthma (73% vs 60.8%; P = .004) as compared with non-fully adherent patients.

CONCLUSIONS

Approximately 1 in 7 patients had elevated eosinophils. Adherence to ICS therapy was not associated with decreased exacerbations for these patients. Additional therapy should be considered for these patients, such as biologics, which have been previously shown to improve control in severe uncontrolled eosinophilic asthma.

Improvement of medication adherence in adolescents and young adults with SLE using web-based education with and without a social media intervention, a pilot study

BACKGROUND

Self-management skills, including medication management, are vital to the health of adolescents and young adults with systemic lupus erythematosus (SLE). The purpose of this study was to assess the feasibility and preliminary effects of an online educational program in a cohort of adolescent and young adults with SLE with and without a social media (SM) experience.

METHODS

Adolescents and young adults with SLE participated weekly for 8 sessions on a web-based educational program about SLE created specifically for this project. Subjects were randomized to respond to questions at the end of each weekly module in a journal or on a SM forum with other SLE subjects. Patients were surveyed prior to initiating the study, (T0) and 6 weeks after completion of the sessions (T1). Medication adherence for hydroxychloroquine, utilizing the medication possession ratio (MPR), was compared for the 3 months preceding T0 and for the 3 months following T1.

RESULTS

Twenty-seven of the 37 subjects (73%) enrolled completed the study, including the two required sets of surveys. Reasons for being lost to follow up included being too busy, forgetting, and/or not seeing email reminders. Medication adherence improved in all subjects (p < 0.001). The percentage of the SM intervention group that was adherent (MPR ≥ 80%) significantly improved from 50% to 92% (p = 0.03), while the control group did not. Secondary outcome measures that improved, only in the SM group, included self-efficacy, sense of agency (SOA), sense of community (SOC), and empowerment. There was a strong correlation between empowerment with SOA and SOC and in turn a strong correlation with SOA and SOC with MPR, providing a possible explanation for why social media participation helped to improve medication adherence. Subjective reporting of medication adherence was not reliably correlated to MPR.

CONCLUSIONS

This pilot study has demonstrated feasibility for the use of an online educational SLE website, recruitment, and measurement of chosen outcome measures. This study provides evidence for a larger multi-site trial which has the potential to address an important service gap by delivering self-management education and peer interactions in a format that is accessible, and engaging to young people with SLE.

TRIAL REGISTRATION

Trial registration: NCT03218033 . Retrospectively registered 14 July 2017.

Sensitivity of the Medication Possession Ratio to Modelling Decisions in Large Claims Databases

OBJECTIVES

When preparing administrative medical and pharmacy claims data for analysis, decisions about data clean up and analytical approach need to be made. However, information about the effects of various modelling decisions on adherence measures such as the medication possession ratio (MPR) is limited. We address this gap with this study.

METHODS

We utilized cross-sectional administrative claims data for commercially insured members filling at least two prescriptions for drugs within five classes of hypertension medication between 2008 and 2010. We divided nine modelling decisions into three categories: data scrubbing, study design, and MPR definition/calculations. We defined the base-case settings with commonly used values, varied each modelling decision singly and in combination, and measured the effects on the MPR.

RESULTS

Claims data for 358,418 individuals were available for analysis. Two modelling decisions were found to be highly influential, each yielding a difference of over 25 percentage points from the base case: the decision of whether to use interval- or prescription-based study periods, and the decision of how to handle overlapping prescription claims. The effect of other decisions was smaller, with a difference of 1-9 percentage points from the base case.

CONCLUSIONS

Some of the decisions considered had a large impact on the MPR. Therefore, it is important for researchers to standardize approaches for study period length and overlapping prescription claims. We also conclude that transparent reporting of modelling decisions will facilitate the interpretation of results and comparisons across studies.

The impact of incident depression on medication adherence in patients with type 2 diabetes

BACKGROUND

Depression has been correlated with suboptimal adherence to antidiabetic drugs (ADs). Most studies on this topic were cross-sectional; thus, the directionality of this relationship could not be established. The objective of this study was to measure the association between incident depression and AD nonadherence among newly treated patients with diabetes.

METHODS

We performed a population-based cohort study among new AD users using the Quebec public health insurance data. To avoid immortal time bias, we carried out depression diagnosis-time distribution matching by assigning a date of depression diagnosis to individuals without depression. Nonadherence (i.e.,<90% of days covered by≥1 AD) during the year following depression diagnosis (real or assigned date) was the outcome. Multivariate logistic regression analyses that adjusted for baseline adherence and other confounders were used to estimate the adjusted effect of depression on AD nonadherence.

RESULTS

Between 2000 and 2006, we identified 3,106 new AD users with a subsequent diagnosis of depression and 70,633 without depression, of which 52% and 49% became non-adherent to AD treatment, respectively. Among patients with depression, 52.0% were considered AD non-adherent in the year after depression diagnosis compared with 49.0% of matched patients without depression. Depression was associated with AD nonadherence after accounting for baseline adherence and other confounders with an adjusted odds ratio of 1.24 (95% confidence interval: 1.13-1.37).

CONCLUSIONS

The results suggest that depression is an independent risk factor for AD nonadherence. Patients with type 2 diabetes and depression might benefit from adherence-enhancing interventions.

Association between interpersonal continuity of care and medication adherence in type 2 diabetes: an observational cohort study

BACKGROUND

Prior studies have shown that, compared to patients with a low level of interpersonal continuity of care, patients with a high level of continuity of care have a lower likelihood of hospital admission and emergency department visits, and a higher likelihood of patient satisfaction. We sought to determine whether higher levels of continuity of care are associated with medication persistence and compliance among new users of oral antidiabetic treatment.

METHODS

We conducted a medicoadministrative cohort study of new users of oral antidiabetics aged 18 years or more among people covered by the Quebec public drug plan. We excluded people with fewer than 730 days of treatment and those who had been in hospital for 275 days or more in the first or second year after initiation of antidiabetic treatment. We categorized continuity of care observed in the first year after treatment initiation as low, intermediate or high. The association between continuity of care and medication persistence and compliance was assessed using generalized linear models.

RESULTS

In this cohort of 60 924 new users of oral antidiabetic treatment, compared to patients with a high level of continuity of care, those with an intermediate and a low level of continuity of care were less likely to be persistent (adjusted prevalence ratio 0.97 [95% confidence interval (CI) 0.96-0.98] and 0.96 [95% CI 0.95-0.97], respectively) and compliant (adjusted prevalence ratio 0.98 [95% CI 0.97-0.99] and 0.95 [0.94-0.97], respectively) with their antidiabetic treatment.

INTERPRETATION

A higher level of interpersonal continuity of care was associated with a higher likelihood of drug persistence and compliance. Since the strength of this association was weak, further research is required to determine whether continuity of care plays a role in medication adherence.

What do patients need to know? A study to assess patients' satisfaction with information about medicines

Objectives

This study aimed to determine the information needs and reported adherence of patients prescribed medicines for chronic conditions in those who have received a community pharmacy advanced service and those who have not.

Methods

A questionnaire was constructed using validated tools to measure medication information satisfaction and adherence together with questions eliciting information regarding the use of pharmacy services and demographic characteristics. This questionnaire was distributed from four community pharmacies to a convenience sample of 400 patients as they collected their medicines. Patients were eligible if prescribed more than one regular medicine and attending the pharmacy for longer than 3 months. The questionnaire was returned directly to the university.

Key Findings

Two hundred and thirty-two (58%) questionnaires were returned. All respondents desired further information about their prescribed medicines, particularly about potential medication problems. Dissatisfaction centred on side effects, interactions and certain medicine characteristics such as how long it will take to act. Satisfaction with information about medicines and adherence were significantly greater in a subgroup reporting that they had received an advanced pharmacy service, e.g. medicine use review (MUR).

Conclusion

Patients who had received an advanced service reported greater adherence and satisfaction with medicine-related information. This was a small, observational study, using a convenience sample of four pharmacies; in order to draw definitive conclusions, a larger study with participants randomised to receive an advanced service is required.

Medication Adherence Following Acute Coronary Syndrome: Does One Size Fit All?

Guideline-based management of acute coronary syndrome (ACS) is well established, yet some may challenge that strict implementation of guideline recommendations can limit the individualization of therapy. The use of all recommended medications following ACS places a high burden of responsibility and cost on patients, particularly when these medications have not been previously prescribed. Without close attention to avoiding non-adherence to these medications, the full benefits of the guideline recommendations will not be realized in many patients. Using a case example, we discuss how the recognition of adherence barriers can be an effective and efficient process for identifying patients at risk of non-adherence following ACS. For those identified as at risk, the World Health Organization's model of adherence barriers is explored as a potentially useful tool to assist with individualization of therapy and promotion of adherence.

Persistence and compliance with newly initiated antihypertensive drug treatment in patients with chronic kidney disease

BACKGROUND

Patients with chronic kidney disease initiating an antihypertensive drug (AH) treatment must persist and comply with it to slow disease progression and benefit from the reduction of cardiovascular morbidity and mortality.

OBJECTIVES

This study evaluates the persistence and compliance with AH treatment and identifies the associated factors among chronic kidney disease patients who initiated AH treatment.

METHODS

A population-based cohort study using Quebec administrative data was conducted. Patients who still take any AH 1 year after initiation were considered persistent. Of these patients, those who had ≥80% of days covered with an AH in the year after initiation were considered compliant. Factors associated with persistence and compliance were identified using a modified Poisson regression.

RESULTS

Of the 7,119 eligible patients, 78.8% were persistent, 87.7% of whom were compliant with their AH treatment. Compared with patients on diuretic monotherapy, those who initially used angiotensin-converting enzyme inhibitor monotherapy, angiotensin II receptor blocker monotherapy, calcium channel blocker monotherapy, β-blocker monotherapy, or multidrug therapy were more likely to be persistent. In contrast, individuals who visited their physicians ≥17 times were less likely to be persistent than those who visited between 0 and 8 times. The patients who were more likely to be compliant had initially used an angiotensin-converting enzyme inhibitor, β-blocker, calcium channel blocker, or multitherapy as opposed to a diuretic.

CONCLUSION

A year after initiating AH treatment, nearly a third of chronic kidney disease patients were either not taking an AH or had not been compliant. Factors associated with persistence and compliance could help identify patients who need help in managing their AH treatment.

Effectiveness of an asthma integrated care program on asthma control and adherence to inhaled corticosteroids

OBJECTIVE

To measure the effectiveness of an integrated care program for individuals with asthma aged 12-45 years, on asthma control and adherence to inhaled corticosteroids (ICS).

METHODS

Researchers used a theoretical model to develop the program and assessed effectiveness at 12 months, using a pragmatic controlled clinical trial design. Forty-two community pharmacists in Quebec, Canada recruited participants with either uncontrolled or mild-to-severe asthma. One group was exposed to the program; another received usual care. Asthma control was measured with the Asthma Control Questionnaire; ICS adherence was assessed with the Morisky medication adherence scale and the medication possession ratio. Program effectiveness was assessed with an intention-to-treat approach using multivariate generalized estimating equation models.

RESULTS

Among 108 exposed and 241 non-exposed, 52.2% had controlled asthma at baseline. At 12-months, asthma control had improved in both groups but the interaction between study groups and time was not significant (p = 0.09). The proportion of participants with good ICS adherence was low at baseline. Exposed participants showed improvement in adherence and the interaction between study groups and time was significant (p = 0.02).

CONCLUSION

An integrated intervention, with healthcare professionals collaborating to optimize asthma control, can improve ICS adherence.

Analysis of suicide attempts and completions at the South Texas Veterans Health Care System: a retrospective review

Background

Suicide continues to be a growing public health issue, and suicidal behaviors have been identified as a critical problem in the military population, with the number of soldiers dying by suicide exceeding those killed in action.

Objective

This study aimed to characterize the population with attempted or completed suicides at the South Texas Veterans Health Care System and to analyze differences between those 2 populations. Other outcomes included adherence to psychiatric medications 6 months before suicide attempt or completion and psychiatric hospitalizations, psychiatric emergency department visits, and “no-show” appointments to mental health providers.

Methods

Data were collected from the Suicide Prevention and Application Network for patients from South Texas Veterans Health Care System who had attempted or completed suicide between September 1, 2011, and September 30, 2013. Those data were supplemented with data from the computerized patient-record system. A retrospective chart review was conducted to collect further information.

Results

Of 120 events included in the analysis, there were 97 attempts (81%) and 23 completions (19%). Men were significantly more likely to complete a suicide than women were (P = .025). Those that attempted suicide were more likely to have previous attempts compared with those who completed suicide (mean of 1.01 versus 0.17 respectively, P = .0035). The most frequent method for attempt was toxic ingestion (accounting for 61.9% of attempts), while the most frequent method of completing suicide was by using a firearm (87.0%); there was a statistically significant difference found between methods used for suicide attempt versus completion (P &lt; .0001). Significantly more attempts than completions involved alcohol (21 versus 0 respectively; P = .013). Those on divalproex were less likely to complete suicide (16 attempts, 0 completions; P = .040). There were no differences between groups for the secondary outcomes studied.

Conclusions

Characteristics associated with completion of suicide in this analysis include male gender and using a firearm, while having previous attempts, being on divalproex, or using alcohol are associated with being more likely to attempt rather than complete suicide. More information is needed on how to appropriately identify high-risk veterans, and suicide safety plans should be developed for these patients to minimize their risk.

Concordance of Pharmacist Assessment of Medication Nonadherence With a Self-Report Medication Adherence Scale

OBJECTIVE

To evaluate the concordance of the Modified Morisky Scale (MMS) with a pharmacist assessment of medication adherence during a medication review.

METHODS

This retrospective study examined the electronic medical records (EMRs) of patients ≥18 years who received a medication review by a pharmacist from October 2008 to September 2009 at a homeless behavioral health clinic. In addition to the 6-item MMS, adherence was assessed using the first 4 items of the MMS, which comprise the original Morisky Scale. A final pharmacist assessment of adherence based upon the medication review was documented in the EMR. The McNemar test was used to assess the agreement between the MMS (6 and 4 items) and the pharmacist assessment of medication adherence.

RESULTS

A total of 288 patients were eligible for the study, which included 449 medication reviews. Nonadherence was identified in 61.7% and 49.7% of medication reviews using the 6 and 4 items of the MMS. The pharmacist assessment determined nonadherence in 23.8% of medication reviews. There were significant differences between the pharmacist adherence assessment and the 6 (P < .0001) and 4 (P < .0001) items of the MMS.

CONCLUSION

A combination of methods including self-report and pharmacist assessment may provide the greatest insight into adherence.

Accuracy of the Medication Adherence Report Scale (MARS-5) as a Quantitative Measure of Adherence to Inhalation Medication in Patients With COPD

Background: Self-report is considered most suitable to measure medication adherence in routine clinical practice. However, accuracy of self-report as a quantitative measure of adherence is not well documented. Objective: To assess the accuracy of a self-report measure of adherence (Medication Adherence Report Scale [MARS-5]) for identifying nonadherent users of inhalation medication among patients with chronic obstructive pulmonary disease (COPD), compared with medication refill adherence (MRA) as reference. Methods: We used baseline data from the Pharmaceutical Care for Patients with COPD (PHARMACOP)-trial (n = 734). Patients with incomplete MARS-5 and/or incomplete pharmacy refill records were excluded (n = 121). Internal consistency of MARS-5 (Crohnbach α) and Spearman rank correlation (ρ) with MRA were calculated. Different thresholds for nonadherence were used to calculate sensitivity, specificity, and positive predictive value (PPV), compared with dichotomized MRA (MRA ≥80% = adherent). A receiver operating characteristic (ROC) curve was plotted to determine the goodness of test. Results: 613 patients were included in the analysis. The mean adherence score by MARS-5 (range = 5-25) was 23.5 (SD = 2.6); mean adherence by MRA was 83.4% (SD = 23.8%). Internal consistency of MARS-5 was high (α = 0.77). Continuous MARS-5 scores correlated poorly with continuous MRA scores (ρ = 0.10; P = 0.011). When lowering the nonadherence threshold stepwise from 25 to 20, MARS-5 did not reach sufficient sensitivity (53% to 13%), specificity (57% to 94%), and PPV (42% to 57%) to detect nonadherers compared with dichotomized MRA. ROC curve plotting resulted in an area under the curve value of 0.56 (95% CI = 0.521-0.616; P = 0.005). Conclusion: Self-reported adherence measured by MARS-5 is inaccurate in identifying nonadherence to inhalation medication in patients with COPD.

Relationship between medication beliefs, self-reported and refill adherence, and symptoms in patients with asthma using inhaled corticosteroids

BACKGROUND

Beliefs play a crucial role in medication adherence. Interestingly, the relationship between beliefs and adherence varies when different adherence measures are used. How adherence, in turn, is related to asthma symptoms is still unclear. Our aim was to investigate the relationship between beliefs (ie, necessities and concerns) about inhaled corticosteroids (ICS) and subjectively as well as objectively measure adherence and the agreement between these measures. Further, the relationship between adherence and asthma symptoms was examined.

METHODS

A total of 280 patients aged 18-80 years who filled at least two ICS prescriptions in the preceding year were recruited to complete a questionnaire. The questionnaire included the Beliefs about Medicines Questionnaire to assess necessity beliefs and concerns about ICS, four questions about ICS use to measure self-reported adherence, and the Asthma Control Questionnaire to assess asthma symptoms. Proportion of days covered was used to determine pharmacy refill adherence.

RESULTS

Data from 93 patients with asthma were analyzed. Necessities were positively related to self-reported adherence (P = 0.01). No other associations were found between beliefs and subjective or objective adherence. There was no correlation between self-reported and refill adherence. Participants were significantly (P < 0.001) less adherent according to self-report data (24.4%) than according to pharmacy data (57.8%). No relationship was found between adherence and asthma symptoms.

CONCLUSION

Higher necessities are associated with higher self-reported adherence, suggesting that it could be more important to focus on necessities than on concerns in an attempt to improve adherence. Self-reported and refill adherence measurements cannot be used interchangeably. No relationship between adherence and asthma symptoms was found.

Perceived need to take medication is associated with medication non-adherence in patients with rheumatoid arthritis

BACKGROUND

This is the first cross-sectional study that aims to examine associations between beliefs about medication and non-adherence in patients with rheumatoid arthritis (RA) using disease-modifying antirheumatic drugs, taking potential psychological confounders into account.

METHODS

Eligible patients (diagnosed with RA for ≥1 year or ≥18 years, using greater than or equal to one disease-modifying antirheumatic drug) were included by their rheumatologist during regular outpatient visits between September 2009 and September 2010. Included patients received questionnaires. The Beliefs about Medicines Questionnaire was used to measure the perceived need to take medication (necessity beliefs), the concerns about taking medication (concern beliefs), general medication beliefs, and attitudes toward taking medication. Medication non-adherence (no/yes) was measured using the Compliance Questionnaire Rheumatology (CQR). Associations between beliefs and non-adherence, and the influence of demographical, clinical, and psychological factors (symptoms of anxiety/depression, illness cognitions, self-efficacy) were assessed using logistic regression.

RESULTS

A total of 580 of the 820 eligible patients willing to participate were included in the analyses (68% female, mean age 63 years, 30% non-adherent to their medication). Weaker necessity beliefs (OR [odds ratio]: 0.8, 95% CI [confidence interval]: 0.8-0.9) and an unfavorable balance between necessity and concern beliefs (OR: 0.9, 95% CI: 0.9-1.0) were associated with CQR non-adherence. Also, having an indifferent attitude toward medication (no/yes) was associated with CQR non-adherence (OR: 5.3, 95% CI: 1.1-25.8), but the prevalence of patients with an indifferent attitude toward medication was low. The associations were barely confounded by demographical, clinical, and psychological factors.

CONCLUSION

Increasing necessity beliefs about medication in clinical practice might be worthwhile in improving medication adherence in RA patients.

Adequate levels of adherence with controller medication is associated with increased use of rescue medication in asthmatic children

Background

The role of asthma controller medication adherence and the level of asthma control in children is poorly defined.

Aims

To assess the association between asthma controller medication adherence and asthma control in children using routinely acquired prescribing data.

Methods

A retrospective observational study of children aged 0–18 years prescribed inhaled corticosteroids only (ICS), leukotriene receptors antagonists (LTRA), or long-acting β2 agonists (LABA) and ICS prescribed as separate or combined inhalers, between 01/09/2001 and 31/08/2006, registered with primary care practices contributing to the Practice Team Information database. The medication possession ratio (MPR) was calculated and associations with asthma control explored. Poor asthma control was defined as the issue of prescriptions for ≥1 course of oral corticosteroids (OCS) and/or ≥6 short-acting β2 agonists (SABA) canisters annually.

Results

A total of 3172 children prescribed asthma controller medication were identified. Of these, 15–39% (depending on controller medication) demonstrated adequate MPR. Adequate MPR was associated with male gender, good socio-economic status, and oral LTRA therapy. Adequate MPR was more likely to be associated with increased use of rescue medication. However logistic regression only identified a significant relationship for ICS only (odds ratio [OR], 1.89; 95% confidence interval [CI], 1.35–2.48; p<0.001), LTRA (OR, 2.11; 95% CI, 1.27–3.48; p = 0.004) and LABA/ICS (OR, 2.85; 95% CI, 1.62–5.02; p<0.001).

Conclusion

Poor adherence was observed for all asthma controller medications, although was significantly better for oral LRTA. In this study adequate adherence was not associated with the use of less rescue medication, suggesting that adherence is a complex issue.

Home medicines reviews following acute coronary syndrome: study protocol for a randomized controlled trial

BACKGROUND

Despite continual improvements in the management of acute coronary syndromes, adherence to guideline-based medications remains suboptimal. We aim to improve adherence with guideline-based therapy following acute coronary syndrome using an existing service that is provided by specifically trained pharmacists, called a Home Medicines Review. We have made two minor adjustments to target the focus of the existing service including an acute coronary syndrome specific referral letter and a training package for the pharmacists providing the service.

METHODS/DESIGN

We will be conducting a randomized controlled trial to compare the directed home medicines review service to usual care following acute coronary syndromes. All patients aged 18 to 80 years and with a working diagnosis of acute coronary syndrome, who are admitted to two public, acute care hospitals, will be screened for enrolment into the trial. Exclusion criteria will include: not being discharged home, documented cognitive decline, non-Medicare eligibility, and presence of a terminal malignancy. Randomization concealment and sequence generation will occur through a centrally-monitored computer program. Patients randomized to the control group will receive usual post-discharge care. Patients randomized to receive the intervention will be offered usual post-discharge care and a directed home medicines review at two months post-discharge. The study endpoints will be six and twelve months post-discharge. The primary outcome will be the proportion of patients who are adherent to a complete, guideline-based medication regimen. Secondary outcomes will include hospital readmission rates, length of hospital stays, changes in quality of life, smoking cessation rates, cardiac rehabilitation completion rates, and mortality.

DISCUSSION

As the trial is closely based on an existing service, any improvements observed should be highly translatable into regular practice. Possible limitations to the success of the trial intervention include general practitioner approval of the intervention, general practitioner acceptance of pharmacists' recommendations, and pharmacists' ability to make appropriate recommendations. A detailed monitoring process will detect any barriers to the success of the trial. Given that poor medication persistence following acute coronary syndrome is a worldwide problem, the findings of our study may have international implications for the care of this patient group.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12611000452998.

Noncompliance in the use of cardiovascular medications in the Medicare Part D population

OBJECTIVES

(1) to assess non-compliance among Medicare Part D recipients for the cardiovascular medication classes; (2) to identify the probability of noncompliance for each medication class when controlling for the potential risk factors of age, gender, race/ethnic origin, census region, disease burden, dual eligibility enrollment status, Part D plan status, relative out-of-pocket (OOP) non-class costs, and relative OOP daily class costs.

DESIGN

Cross sectional retrospective review of 2007 Centers for Medicare & Medicaid Services (CMS) Part D data. All drugs within a drug class were used to conduct the assessment.

FINDINGS

Non-compliance was found to be lower than previously reported. Patients who are male, age 65 to 74, Black, or residing in the South are associated with higher noncompliance for cardiovascular medications among the therapeutic classes we studied. Dual eligibility enrollment is typically associated with improved compliance; enrollment in a Medicare Advantage Prescription Drug (MAPD) plan may or may not improve compliance dependent on the therapeutic class under study. Increased disease burden is associated with lower compliance. OOP non-class costs had an opposing effect on compliance as compared to OOP daily costs; higher OOP non-class costs were associated with better compliance.

CONCLUSION

Identifying patient characteristics that may contribute positively or negatively to medication compliance is an essential step to improved therapy. As a strategy to improve compliance, the proper selection of therapy that fits a particular patient is paramount.

Definition of patients treated with evidence based drugs in absence of prescribed daily doses: the example of acute myocardial infarction

PURPOSE

Define patients treated with evidence-based drugs in a cohort discharged after acute myocardial infarction (AMI) in absence of prescribed daily doses (PDD). To compare different drug use measures and analyze their impact on the effect estimate of risk factors related to drug use.

METHODS

AMI patients discharged in Rome during 2006-2007 were selected from the Hospital Information System. Drugs claimed during the 12 months after discharge were retrieved. Measures of drug use were defined as: 'continuity' (one prescription each follow-up quarter-year) and the 'proportion of days covered' calculated by defined daily doses (DDDs) or pill counts (PCs) (≥ 80% of individual follow-up). Poly-therapy was defined through the same drug use measure for all drug groups. Kappa index was calculated to analyze the concordance between measures. For each measure we estimated the effect of age, gender and Percutaneous Transluminal Coronary Angioplasty (PTCA) on poly-therapy.

RESULTS

Poly-therapy rates varied between 11.5 and 37.8% in the cohort and between 17.3 and 56.9% in patients with at least one prescription for all drugs. Concordance between all measures was high for antiplatelets (k=0.74) and very low for beta-blockers (k=0.22). According to measures used, gender and older age effects slightly varied, while PTCA remained a strong determinant of drug use.

CONCLUSIONS

Different measures of exposure to drug treatment may affect the estimate of the proportion of treated patients and the effect estimates of risk factors. Drug dispense registries are useful, but it is necessary to develop and validate methodologies in absence of PDD.

How well does patient self-report predict asthma medication possession? Implications for medication reconciliation and adherence assessment

BACKGROUND

Self-report is the most commonly used method for collecting information regarding asthma medication possession and adherence in clinical practice.

OBJECTIVE

To determine the agreement between self-report and pharmacy claims data for asthma medication possession.

METHODS

This is a retrospective study that examined pharmacy claims data 12 months before and after participants completed a structured asthma survey. This study was performed in a sample of health care workers and dependents >17 years old in a large, self-insured Midwestern United States health care center. The main outcome measure was agreement (kappa calculation) between self-report and pharmacy claims data of asthma medication possession.

RESULTS

Self-report of asthma medication use agreed moderately with pharmacy claims data for short-acting albuterol (κ=0.47 ± 0.03), salmeterol (κ=0.79 ± 0.04), and montelukast (κ=0.69 ± 0.03) but only slightly for inhaled corticosteroids (κ=0.18 ± 0.03) and prednisone (κ=0.10 ± 0.03) (n=1050 respondents). Both under self-reporting and over self-reporting were common with inhaled corticosteroids (14.4% and 23.1%, respectively) and varied significantly by specific drug type.

CONCLUSIONS

Self-report moderately agrees with asthma medication possession for most adult asthma patients, though the agreement differs considerably between and within asthma medication classes.

Agreement between self-reported and pharmacy data on medication use in the Northern Finland 1966 Birth Cohort

OBJECTIVE

To compare self-reported (SR) medication use and pharmacy data for major psychoactive medications and three classes of medications used for different indications, and to determine the socio-economic factors associated with the congruence.

METHODS

Postal questionnaire data collected in 1997 were compared with the register of the Social Insurance Institution of Finland on the reimbursed prescriptions purchased during 1997. Altogether 7625 subjects were included in this study. Drugs were categorized according to the Anatomical Therapeutic Chemical (ATC) system.

RESULTS

Kappa values were 0.77, 0.68, 0.84, 0.92 and 0.55 for antipsychotics, antidepressants, antiepileptics, antidiabetics and beta-blocking agents, respectively. Prevalence-adjusted and bias-adjusted kappa values were almost perfect (0.98-1.00). Reliability of antipsychotics use was better for married subjects than for those who were not married; and of antidepressants use for highly educated and married subjects than for those who were less educated and were not married. Altogether 414 (5.4%) responders and 285 (7.1%) non-responders had used at least one of the selected medications.

CONCLUSION

Agreement between the SR and pharmacy data was moderate for psychoactive medication use. Even though data collected by postal questionnaire may underestimate the prevalence of medication use due to non-participation it can be assumed accurate enough for study purposes.

Treatment adherence to disease-modifying antirheumatic drugs in patients with rheumatoid arthritis and systemic lupus erythematosus

Treatment adherence is critical in the management of rheumatic diseases. Recent advances in therapy for rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) are promising, although the impact on quality of life may be limited due to nonadherence. Databases including Ovid Medline, Scopus and the Epub-ahead-of-print subset of PubMed were searched for the period of the last 10 years using combined keywords patient compliance, medication adherence, disease modifying antirheumatic drug (DMARD), rheumatoid arthritis and systemic lupus erythematosus. Additional references from retrieved papers were considered. Inclusion criteria were the following: identification of a quantitative measure of adherence to medications including DMARDs and biologics; inclusion of well-defined measures of adherence; and patients with RA or SLE. Studies in RA and SLE patients demonstrated overall inadequate treatment adherence. Adherence was measured using multiple methods including pharmacy records, electronic monitoring, self-report and physician report. The evidence for interventions to improve treatment adherence was limited and demonstrated various results. Future research should further explore determinants of nonadherence and continue to examine the efficacy of implementing various strategies to improve medication management in this patient population.

Depression affects adherence measurement but not the effectiveness of an adherence intervention in heart failure patients

OBJECTIVES

To assess the influence of depressive symptoms on adherence with heart failure medications and to determine whether the effect of a pharmacy-based intervention to improve heart failure medication adherence is modified by depressive symptoms.

DESIGN

Secondary analysis of data from a randomized controlled trial.

SETTING

University-affiliated ambulatory care practice.

PATIENTS

Patients 50 years or older with congestive heart failure randomly assigned to usual care (n = 192) or intervention (n = 122).

INTERVENTION

Pharmacist-provided intervention to improve heart failure medication adherence.

MAIN OUTCOME MEASURES

Medication adherence was measured via patient self-report and using electronic prescription lids; depressive symptoms were measured using the Geriatric Depression Scale. General linear models examined the main effect of depressive symptoms on medication adherence and whether depressive symptoms modified the effectiveness of the intervention.

RESULTS

At baseline, 37% (n = 117) of participants screened positive for depression. In the usual care group, mean adjusted self-reported adherence was 75% for depressed participants and 81% for nondepressed participants (P = 0.04); mean adjusted adherence measured electronically was 71% for depressed participants and 69% for nondepressed participants (P = 0.65). INTERVENTION effectiveness did not differ for depressed compared with nondepressed participants.

CONCLUSION

The effectiveness of a pharmacy-based intervention to improve adherence does not appear to be influenced by depression. However, the method used to measure adherence (electronically measured versus self-reported) influences the interpretation of the relationship between depression and heart failure medication adherence.

Compliance with methotrexate treatment in patients with rheumatoid arthritis: influence of patients' beliefs about the medicine. A prospective cohort study

Objective of the study is to investigate how compliance during the first year of methotrexate (MTX) treatment in rheumatoid arthritis (RA) is influenced by the patients' perception of the necessity for and concern about MTX, the patients' functional disability, and the dose of MTX. A total of 126 RA patients completed a questionnaire at start of MTX treatment and after 9 months. The MTX compliance was measured by using the Compliance Questionnaire Rheumatology (CQR). The prevalence of having a CQR score in the bottom quartile was stratified according to age, gender, the duration of RA, MTX dose, years of school education, functional disability, use of folic acid, and co-morbidity. Crude and adjusted prevalence ratios (PR) with 95% confidence intervals (CI) were calculated by using log-binomial regression. The necessity and concern scales of the Beliefs about Medication Questionnaire were dichotomised into high perception of MTX necessity and low concern about MTX treatment, and the crude and adjusted PR of having a CQR score in the bottom quartile were estimated. The prevalence of having a CQR in the bottom quartile was 23%, both at baseline and after 9 months, and this finding was not associated with the MTX dose level or the patients' functional disability. Among patients with a CQR in the bottom quartile, the prevalence of having low perceptions of MTX necessity was 37.1 versus 14.0% for patients with high perceptions of necessity [adjusted PR: 0.3 (95% CI 0.2-0.8)]. The same tendency was seen after 9 months. The prevalence of having a CQR in the bottom quartile or not was almost equally distributed among patients who had high or low concerns about treatment at baseline. After 9 months, however, the prevalence of having a CQR in the bottom quartile was 18.9% for patients who had low concerns about the MTX treatment, versus 37.7% for patients who had higher concerns about the treatment [adjusted PR: 0.5 (95% CI 0.2-1.3)]. During the first year of treatment, compliance with MTX treatment among RA patients could be explained by strong perceptions of a personal need for the treatment. Compliance did not seem to be influenced by the patients' functional impairment or the MTX dose level.

Assessment of older adults' knowledge of and preferences for medication management tools and support systems

BACKGROUND

A variety of strategies are available to assist older adults who have difficulties managing medications. Little is known about older adults' knowledge of or willingness to use these strategies.

OBJECTIVE

To assess older adults' current use of, knowledge of, and preferences for medication management tools and supports.

METHODS

A cross-sectional study was conducted at a continuing care retirement community. All 152 independent-living residents were approached for participation. We developed a 6-page survey to gather information about knowledge of and preferences for medication management tools (eg, medi-sets, bubblepacks) and supports (eg, family, caregivers, regimen simplification). Information on demographic variables, medication management capacity, cognition, self-reported difficulty taking medications, and medication use were collected along with survey answers during an in-home interview. chi(2) and t-tests were used to compare knowledge and preferences by complexity and organizer use.

RESULTS

Our sample consisted of 109 participants ranging in age from 73 to 98 years (average 85.9). Most of the subjects were well educated (average 15.5 y of education), 98% were white, and 80% were female. The majority (82%) were using a medication tool, mainly simple, self-filled medi-sets (62%) and easy-open vials (55%). Knowledge about, use of, and preferences for other devices, including pharmacist-filled tools and programmable devices, were low. Participants who used medication organizers rated self-filled medi-sets higher than did non-users (4.7 vs 1.6; p < 0.01). Only 18% of participants had asked a provider to simplify their medications, while 40% did not realize that they could do so. Of those who did ask a provider, 80% asked a physician.

CONCLUSIONS

Educational strategies are needed to increase awareness of the pharmacist's role in facilitating medication management and the option of simplifying complex regimens. It is within the scope of pharmacy to provide this type of medication education.

Adherence: Comparison of Methods to Assess Medication Adherence and Classify Nonadherence

Background:

Medication adherence is suboptimal, and clinicians and researchers struggle with identifying nonadherent patients. Various measures of medication adherence exist, but there is controversy regarding which measures provide acceptable data and how nonadherence should be defined.

Objective:

To assess agreement among patient self-report, pharmacy refill, and electronic adherence measures and compare the sensitivity and specificity of different cut-points for defining nonadherence.

Methods:

Data were analyzed from 2 similarly designed randomized controlled trials that assessed a pharmacist's intervention to improve medication adherence among patients with hypertension or heart failure. For each participant, adherence was measured by patient self-report, prescription refill records, and electronic lids on medication containers. Agreement among measures was assessed using Spearman's correlation coefficient rho. Correlation coefficients were compared by patient characteristics using Fisher's Z transformation, The sensitivity and specificity of different cut-points for defining nonadherence were calculated.

Results:

Median adherence was 84% for self-report, 86% for electronic, and 91% for prescription refill adherence measurement. Refill and electronic adherence demonstrated the best agreement among measures (rho = 0.48). Age, depression, and other comorbid conditions influenced agreement among measures. Measures were generally in agreement, regardless of how nonadherence was defined. A cut-point of 80% illustrated a fair balance between sensitivity and specificity for all measures.

Conclusions:

All measures provided similar estimates of overall adherence, although refill and electronic measures were in highest agreement. In selection of a measure, practitioners should consider population and disease characteristics, since measurement agreement could be influenced by these and other factors. The commonly used, clinically based cut-point of 80% had a reasonable balance between sensitivity and specificity in studies of adherence in patients with heart failure or hypertension.

Refill adherence by the elderly for asthma/chronic obstructive pulmonary disease drugs dispensed over a 10-year period

OBJECTIVE

The objective was to survey prescription refill adherence for preventive asthma/chronic obstructive pulmonary disease (COPD) medication dispensed to patients 60 years and older over a 10-year period.

METHODS

A retrospective analysis was conducted based on a Swedish pharmacy record database in the county of Jämtland for the years 1994-2003. Satisfactory refill adherence was set as dispensed refills covering 80-120% of the prescribed treatment time for inhaled corticosteroids, combination products of adrenergics and steroids and anticholinergics.

RESULTS AND DISCUSSION

Only 28% (n=160) of the repeat prescriptions for inhaled corticosteroids had been dispensed with a satisfactory refill adherence, 59% showed an undersupply and 12% showed an oversupply. There was no difference in refill adherence in relation to age and gender. However, during the 10-year study period repeat prescriptions being dispensed for 2-4 years showed higher satisfactory refill adherence than those being dispensed for <2 years.

CONCLUSIONS

Our study shows that over half of the repeat prescriptions for inhaled corticosteroids dispensed to patients over 60 years showed an undersupply. Therefore, it is likely that elderly patients on long-term therapy have a non-optimal drug use of their preventive asthma/COPD medication.

Beliefs about medicines predict refill adherence to inhaled corticosteroids

OBJECTIVE

Despite the importance of the chronic use of inhaled corticosteroids (ICS) in maintaining asthma control, reported adherence varies between 40% and 60%. The Beliefs about Medicines Questionnaire (BMQ) has been shown to correlate with self-reported adherence. The aim of this study is to investigate whether beliefs about ICS (necessity and concerns), as measured by the BMQ, relate to adherence objectively measured by prescription-refill records.

METHODS

In a cross-sectional study of patients aged 18-45 years who filled at least two ICS prescriptions in 11 community pharmacies in The Netherlands, perceptions of ICS were assessed using the BMQ. Additionally, self-reported adherence was assessed using the Medication Adherence Report Scale. ICS prescription-refill adherence rates for a 12-month period prior to the survey were obtained from automated pharmacy dispensing records. Four attitudinal groups were defined using the necessity and concerns constructs. Statistical tests were used to examine associations between ICS adherence (assessed by subjective self-report and objective pharmacy records), specific beliefs about and attitudes towards ICS, and more general beliefs about pharmaceuticals.

RESULTS

Questionnaires were returned by 238 patients (51.1%). Both self-reported adherence (r=.38) and adherence by pharmacy records (rho=0.32) correlated with ICS necessity beliefs and concerns. Patients defined as skeptical, indifferent, ambivalent, or accepting, on the basis of these constructs, differed with respect to both their attitudes towards medicines in general and their adherence to medication.

CONCLUSIONS

Patients' beliefs about ICS correlate not only with adherence by self-report but also with a more objective measure of medication adherence calculated by pharmacy dispensing records. The necessity-concerns constructs offer a potentially useful framework to help clinicians elicit key treatment beliefs influencing adherence to ICS.

Adherence to multiple drug therapies: refill adherence to concomitant use of diabetes and asthma/COPD medication

PURPOSE

To investigate whether patients with drugs for two chronic diseases, type 2 diabetes and asthma/chronic obstructive pulmonary diseases (COPD), showed the same refill adherence pattern in relation to their drug treatments during a 3-year period.

METHODS

Patients 50 years and older who had been dispensed diabetes and asthma/COPD drugs in the county of Jämtland during 2001-2003 were included. The refill adherence was calculated based either on prescribed dosage or defined daily dose (DDD). A patient profile graph for each patient was constructed including the date of each dispensation and the time period covered by the dispensed drugs. For each patient, the dispensation pattern and the treatment persistency over time were determined.

RESULTS

In total, 56 patients were included in the study. Satisfactory refill adherence was found for 68% of the repeat prescriptions for diabetes drugs and for 42% of the repeat prescriptions for asthma/COPD drugs. About half (52%; 29/56) of the patients showed the same dispensation patterns for both diabetes and asthma/COPD drugs, and 86% (25/29) of these patients had a satisfactory refill adherence. However, there was no correlation or agreement regarding the dispensation patterns for diabetes and asthma/COPD drugs.

CONCLUSIONS

Patients showed higher refill adherence for their diabetes drugs than their asthma/COPD drugs. Our hypothesis that patients with satisfactory refill adherence to antihyperglycaemic drugs would also have satisfactory refill adherence to asthma/COPD drugs, was not supported.

Measurement of adherence in pharmacy administrative databases: a proposal for standard definitions and preferred measures

BACKGROUND

A variety of measures have been developed to calculate refill adherence from administrative data such as pharmacy claims databases. These measures have focused on improving the accuracy of adherence measures or clarifying the evaluation time frame. As a result, there are many measures used to assess adherence that may or may not be comparable or accurate.

OBJECTIVE

To compare available refill adherence measures.

METHODS

A systematic literature review was conducted to identify current or recently used measures of calculating adherence from administrative data. A MEDLINE search (January 1990-March 2006) was undertaken using the search terms adherence or compliance in the title combined with administrative, pharmacy, or records in any field, including subheadings medical, nursing, and hospital records. Non-English articles were excluded. Seven hundred fifteen articles were available for review. Review articles and letters were excluded from measure selection, but were included in the search terms and used to identify additional research articles. Adherence measures were excluded if they were incompletely described, produced non-numeric values, or were duplicates. Eleven refill adherence measures were identified and compared using data from the LOSE Weight (Long-term Outcomes of Sibutramine Effectiveness on Weight) study. Measures compared include Continuous Measure of Medication Acquisition (CMA); Continuous Multiple Interval Measure of Oversupply (CMOS); Medication Possession Ratio (MPR); Medication Refill Adherence (MRA); Continuous Measure of Medication Gaps (CMG); Continuous, Single Interval Measure of Medication Aquisition (CSA); Proportion of Days Covered (PDC); Refill Compliance Rate (RCR); Medication Possession Ratio, modified (MPRm); Dates Between Fills Adherence Rate (DBR); and Compliance Rate (CR).

RESULTS

The results suggest that the CMA, CMOS, MPR, and MRA are identical in terms of measuring adherence to prescription refills throughout the study period, each with a value of 63.5%; CMG and PDC are slightly lower (63.0%) and are equivalent to MRA when oversupply is truncated. CR, MPRm, RCR, and CSA result in higher adherence values of 84.4%, 86.6%, 104.8%, and 109.7%, respectively.

CONCLUSIONS

Five measures produce equivalent results for measuring prescription refill adherence over the evaluation period. Of these, MRA has the fewest calculations, is easily truncated if one desires to exclude surplus medication issues, and requires the least amount of data. MRA is therefore recommended as the preferred measure of adherence using administrative data.

Predictors of self-reported noncompliance with antihypertensive drug treatment: a prospective cohort study

BACKGROUND

Persistence and compliance are different aspects of the broader concept of adherence to drug treatment. In a prior study, determinants of nonpersistence in a group of patients newly prescribed antihypertensive medications were examined.

OBJECTIVE

To determine noncompliance among those who were persistent with therapy.

METHODS

A prospective cohort study was conducted, in which individuals prescribed a new antihypertensive monotherapy were identified through a network of 173 pharmacies. Participants were interviewed by telephone twice during a three-month period. At the end of this period, individuals who reported still taking the medication initially prescribed were included in the analysis. Self-reported noncompliance was measured at three months. Data were analyzed using a multivariate logistic regression model.

RESULTS

Of 509 eligible participants, 118 (23.2%) reported noncompliance with their drug treatment. Noncompliance was significantly associated with the use of angiotensin-converting enzyme inhibitors (adjusted OR [AOR] 3.0; 95% CI 1.17 to 7.92) compared with the angiotensin II receptor blocker losartan, and with the belief that hypertension is not a risk factor for cardiovascular diseases (AOR 2.0; 95% CI 1.21 to 3.33). On the other hand, noncompliance was inversely associated with the use of more than four pills of medication per day (AOR 0.3; 95% CI 0.15 to 0.64).

CONCLUSIONS

Compliance with drug treatment could be improved by proper selection of medication, and by attempts to correct the false perceptions patients may have about hypertension. Further research is needed to better understand the clinical significance of a higher number of pills as a predictor of good compliance. Further research is also needed using different means of measuring noncompliance.