Psychometric Properties of the Four-Item Morisky Green Levine Medication Adherence Scale among Atherosclerosis Risk in Communities (ARIC) Study Participants

Pharmacist intervention to improve adherence to medication among heart failure patients at North East Ethiopia hospital

Heart failure (HF) is a major and growing medical problem and its management is still challenging due to the coexistence of complications, co-morbidity, and medication non-adherence. HF patients who are adherent to their medication have fewer HF exacerbations, improved survival, and lower healthcare expenditure. Adherence to HF medication plays a pivotal role in attaining maximal therapeutic outcomes. The aim was to assess the medication adherence of heart failure patients at Debre Berhan Comprehensive Specialized Hospital (DBCSH). A pre-post interventional study was undertaken from July 1, 2022, to December 31, 2022, at the medical referral clinic of DBCSH. The educational interventions were provided for 6 months. Medication adherence was determined using the Morisky Green Levin Medication Adherence Scale (MGLS). The data was entered into Epidata version 4.2.0 and analyzed using SPSS version 25.0 statistical software. Descriptive statistics and binary logistic regression analysis were performed. The strength of the association between predictor variables and outcome variables was determined using a 95% confidence interval and adjusted odd ratio. In the pre-intervention phase, 54.6% of patients had medium medication adherence, while in the post-intervention phase, 36.4% of patients had high medication adherence and 61.9% of patients had medium medication adherence. Following the intervention, medication cost (120, 50%), inadequate availability of drugs (75, 31%), and forgetfulness (30, 13%) were the main reasons for medication non-adherence. The presence of co-morbidity and the number of co-morbidity (p < .05) were significantly associated with the occurrence of decreased medication adherence in the pre-intervention phase. Interventions by pharmacists to educate HF patients about the nature of their disease and providing brochures to increase awareness of their medications have been shown to improve medication adherence.

The Simplified Medication Adherence Questionnaire: validation of a Brazilian-Portuguese version in hypertensive adults

Background

Self-reported adherence scales are widely used in research and practice because they are low in cost and easy to apply. A free version in Brazilian-Portuguese of the Simplified Medication Adherence Questionnaire (SMAQ) can be a useful alternative for determining the adherent behavior of hypertensive patients.

Purpose

To translate and evaluate the psychometric properties of the Brazilian-Portuguese version of the SMAQ therapeutic adherence scale for patients with arterial hypertension.

Patients and methods

A multicenter, cross-sectional study was conducted in five outpatient units in Maceió-AL and Aracaju-SE between January and July 2019. A total of 117 patients aged over 18 years using antihypertensive drugs were recruited. The cross-cultural adaptation followed international methodological recommendations. Internal consistency (Cronbach's alpha) was tested as a reliability parameter. Criterion and construct validity were verified by concurrent validation, exploratory factor analysis (EFA), and validation by known groups.

Results

The participants had a mean age of 56.6 years (SD = 10.7 years); most were female (72.6%). The mean number of antihypertensives prescribed per patient was 1.87 (SD = 0.87). There were 79.5% (n = 86) of patients considered non-adherent. Internal consistency was satisfactory (Cronbach's alpha = 0.63). A satisfactory correlation coefficient was verified with the Morisky-Green-Levine test as an external criterion (r = 0.56, p < 0.001). The scale's sensitivity measured through known group validity was 75.3%, specificity 29.5%, positive predictive value 63.9%, and negative predictive value 41.9%. We identified two factors of the instrument's construct from EFA: specific medication-taking behaviors and barriers to adherence. The initial KMO measure of sampling adequacy was 0.691, and Bartlett's test of sphericity was significant (χ2 = 118.342, p < 0.001).

Conclusion

The Brazilian-Portuguese version of the SMAQ scale proved valid and reliable for determining adherence to the pharmacotherapy in hypertensive patients. It showed more ability to detect non-adherent patients but with low specificity, possibly influenced by high social desirability.

Quality of measurement properties of medication adherence instruments in cardiovascular diseases and type 2 diabetes mellitus: a systematic review and meta-analysis

BACKGROUND

Medication adherence has a major impact on reducing mortality and healthcare costs related to the treatment of cardiovascular diseases and diabetes mellitus. Selecting the best patient-reported outcome measure (PROM) among the many available for this kind of patient is extremely important. This study aims to critically assess, compare and synthesize the quality of the measurement properties of patient-reported outcome measures to assess medication adherence among patients with cardiovascular diseases and/or type 2 diabetes mellitus.

METHODS

This review followed the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines and was reported according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). The searches were performed in Web of Science, SCOPUS, PubMed, CINAHL, EMBASE, LILACS, PsycINFO, and ProQuest (gray literature).

RESULTS

A total of 110 records encompassing 27 different PROMs were included in the review. The included records were published between 1986 and 2023, most of which reported studies conducted in the United States and were published in English. None of the PROMs were classified in the category "a", thus being recommended for use due to the quality of its measurement properties. The PROMs that should not be recommended for use (category "c") are the MTA, GMAS, DMAS-7, MALMAS, ARMS-D, and 5-item questionnaire. The remaining PROMs, e.g., MMAS-8, SMAQ, MEDS, MNPS, ARMS-12, MGT, MTA-OA, MTA-Insulin, LMAS-14, MARS-5, A-14, ARMS-10, IADMAS, MAQ, MMAS-5, ProMAS, ARMS-7, 3-item questionnaire, AS, 12-item questionnaire, and Mascard were considered as having the potential to be recommended for use (category "b").

CONCLUSION

None of the included PROMs met the criteria for being classified as trusted and recommended for use for patients with cardiovascular diseases and/or type 2 diabetes mellitus. However, 21 PROMs have the potential to be recommended for use, but further studies are needed to ensure their quality based on the COSMIN guideline for systematic reviews of PROMs.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019129109.

Exploring Patient Beliefs and Medication Adherence in the Mediterranean Context: A Cross-Sectional Study in Patients with Cardiovascular Diseases and Cardiometabolic Disorders in Greece-The IACT-Study

BACKGROUND

Evidence has shown that poor adherence to vascular medications contributes to a considerable proportion of all cardiovascular disease (CVD) events and mortality. The aim of the present work was to examine patients' beliefs/views that affect their level of adherence to the assigned medical treatment in the context of a multi-center study in Greece.

METHODS

Between July 2022 and April 2023, 1988 patients (1180 females) with established cardiovascular disease or relevant cardiometabolic disorders were chosen from seven medical centers in Greece. The 4-item Morisky Medication Adherence Questionnaire gauged medication adherence and investigated patients' beliefs/views regarding treatment.

RESULTS

Among participants, 51.2% showed perfect medication adherence, contrasting with 48.8% displaying poor adherence. Patients with negative medication beliefs were around three times more likely to be non-adherent (OR = 2.73; 95% CI = 2.28-3.28). Non-adherers held concerns about drug efficacy (OR = 2.34; 95% CI = 1.10-4.97) and favored alternative therapies (OR = 2.25; 95% CI = 1.75-2.91).

CONCLUSION

The findings highlight the significance of addressing patient beliefs/views to improve medication adherence. The distinct Mediterranean context, influenced by cultural, socioeconomic, and clinical factors, emphasizes the need for tailored interventions. This underscores the call for contextually sensitive strategies to boost medication adherence and improve health outcomes in this unique region.

Team based collaborative care model, facilitated by mHealth enabled and trained nurses, for management of heart failure with reduced ejection fraction in India (TIME-HF): design and rationale of a parallel group, open label, multi-centric cluster randomised controlled trial

Background: Heart failure (HF) is a debilitating condition associated with enormous public health burden. Management of HF is complex as it requires care-coordination with different cadres of health care providers. We propose to develop a team based collaborative care model (CCM), facilitated by trained nurses, for management of HF with the support of mHealth and evaluate its acceptability and effectiveness in Indian setting. Methods: The proposed study will use mixed-methods research. Formative qualitative research will identify barriers and facilitators for implementing CCM for the management of HF. Subsequently, a cluster randomised controlled trial (RCT) involving 22 centres (tertiary-care hospitals) and more than 1500 HF patients will be conducted to assess the efficacy of the CCM in improving the overall survival as well as days alive and out of hospital (DAOH) at two-years (CTRI/2021/11/037797). The DAOH will be calculated by subtracting days in hospital and days from death until end of study follow-up from the total follow-up time. Poisson regression with a robust variance estimate and an offset term to account for clustering will be employed in the analyses of DAOH. A rate ratio and its 95% confidence interval (CI) will be estimated. The scalability of the proposed intervention model will be assessed through economic analyses (cost-effectiveness) and the acceptability of the intervention at both the provider and patient level will be understood through both qualitative and quantitative process evaluation methods. Potential Impact: The TIME-HF trial will provide evidence on whether a CCM with mHealth support is effective in improving the clinical outcomes of HF with reduced ejection fraction in India. The findings may change the practice of management of HF in low and middle-income countries.

Medication Adherence among Patients with Diabetes Mellitus and Its Related Factors-A Real-World Pilot Study in Bulgaria

Background and Objectives: The objective is to evaluate medication adherence level (MA) and the relevant determinants of MA among patients with type 2 diabetes mellitus (T2DM) monitored in ambulatory settings by general practitioners. Materials and Methods: A cross-sectional study was conducted among patients with T2DM monitored in a GP practice in Sofia, Bulgaria (September-December 2022). All patients were interviewed according to a predesigned questionnaire after granting informed consent. MA level was evaluated through the Morisky-Green four-item questionnaire, and health-related quality of life was evaluated by EQ-5D-5L and VAS (visual analogue scale). Data were aggregated and statistically evaluated. Results: The total number of observed patients was 93. Around 48.4% of patients were female, and 90.3% of patients were between 50 and 80 years of age. Multimorbidity was identified among 70% (n = 65) of the respondents. High and medium levels of MA were revealed in 64.51% and 33.3% of respondents, respectively. Patients treated with insulin secretagogues were most adherent to the therapy (n = 83.3%) in comparison with the other treatment groups. The onset of the disease, professional status, age, gender, number of therapies, and quality of life did not affect the level of MA (p > 0.05). VAS scores among nonsmokers (VAS = 63.16 ± 20.45 vs. 72.77 ± 14.3) and non-consumers of alcohol (VAS = 63.91 ± 19.34 vs. VAS = 72.54 ± 15.98) were statistically significant lower (p < 0.05). A significant related factor for MA was years lived with diabetes (OR = 3.039, 95% CI 1.1436-8.0759, p = 0.0258). The longer the disease duration, the more the odds for a high MA level increased. Conclusions: The number of nonadherent diabetic patients in Bulgaria is low, which might be evidence of patients' concern about their own health and understanding about the importance of prescribed therapy. Further comprehensive study with additional patients is required to confirm the results and investigate the predicting factors for a high level of MA.

Video-based teach-to-goal intervention on inhaler technique on adults with asthma and COPD: A randomized controlled trial

BACKGROUND

Incorrect use of inhalers is a problem associated with poor patient outcomes. Despite improvement in the technique after verbal educations, this deteriorates over-time requiring re-enforcement through different educative strategies. This study aimed to assess the impact of a novel video-based teach-to-goal (TTG) educational intervention on: mastery of inhaler technique, disease control, medication adherence and disease-related quality of life (QoL) over-time among asthma and COPD patients.

METHODS

This prospective, open-label, randomized controlled trial was registered in ClinicalTrials.gov: Identifier NCT05664347. After baseline assessment participants received either a verbal (control group) or a video-based (intervention group) TTG strategy. After 3-month the intervention was assessed for impact on the intended outcomes. Inhaler technique was assessed using standardized checklists, disease control using the Asthma control test and COPD assessment test respectively for asthma and COPD patients while adherence using the Morisky Green Levine scale. For QoL, the mini asthma quality of life questionnaire and the St. George respiratory questionnaire were used for asthmatic and COPD patients, respectively. Differences in outcomes between intervention-control groups were analyzed using either Chi-Square (X2)/Fisher Exact or Mann Whitney test. The impact of intervention on outcomes over-time was examined using either McNemar or Wilcoxon test.

RESULTS

At baseline, intervention (n = 51) and control (n = 52) groups had comparable demographic/clinical characteristics. At follow-up, inhaler technique improved among intervention group compared to control group (93.4% vs 67%) and to baseline (93.4% to 49.5%), (P<0.05). Similarly, medication adherence ameliorated among the intervention group in comparison to control group (88.2% to 61.5%) and to baseline (88.2% to 66.7%), (P<0.05). In regards to disease control, results showed an amelioration among the intervention group compared to baseline (35.3% to 54.9%) (P<0.05). QoL scores improved significantly among asthma patients (intervention group) at follow-up vs baseline. Better scores were also observed for COPD patients compared to controls, (P<0.05).

CONCLUSION

Video-based (TTG) was effective in enhancing inhaler technique over time as well as improving disease control, medication adherence, and QoL.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05664347. https://clinicaltrials.gov/ct2/show/NCT05664347.

Association of positive psychological variables with disease activity, functional disability and erythrocyte sedimentation rate in patients with rheumatoid arthritis: a preliminary study

Rheumatoid arthritis (RA) is a chronic autoimmune disease which has shown positive correlations between negative psychological variables and disease activity in transversal studies and in the follow-up. However, the association of positive psychological variables with disease parameters including disease activity (DAS-28), functional disability (HAQ) and erythrocyte sedimentation rate (ESR) has not been investigated. Patients with RA attending the external consultation of a third level hospital were invited to participate and fill in a questionnaire with personal, disease and psychological variables; body mass index was also obtained as well as ESR. A total of 49 patients were included. The three dependent variables correlated among them, with the highest correlation for DAS-28 and HAQ (r=0.645, p<0.01), followed by somatization and HAQ (r=0.614, p<0.01) or DAS-28 (r=0.537, P<0.01). In addition, HAQ showed negative correlations with environmental mastery (r=- 0.366, p<0.01), personal growth (r=-0.292, p<0.05) and monthly extra money (r=-0.328, p<0.05), and borderline negative correlations with emotion perception (r=-0.279, p=0.053) and self-acceptance (r=-0.250, p=0.08). ESR showed a significant negative correlation with emotion perception (r=-0.475, p<0.01). In conclusion, we observed important correlations of positive psychological variables with disease activity, functional disability and ESR that could be addressed in order to prevent or treat these disease features.

Adherence to Acromegaly Treatment and Analysis of the Related Factors-A Real-World Study in Bulgaria

The purpose was to assess the level of medication adherence (MA) and related factors among individuals with acromegaly. The secondary goal was to assess the quality of life of patients and whether and how it correlates with the level of adherence. A prospective one-year study was conducted among patients with acromegaly diagnosed, treated, and monitored in the reference center for rare endocrine diseases in Bulgaria in 2021. Clinical data, patients reported outcomes, and health economics data were collected to define the predictors of non-adherence to medicines. Medication adherence level was assessed through a free Morisky-Green 4-item questionnaire. A total of 179 patients with acromegaly were observed. Approximately 62% were female, 50% were between 41 and 60 years, and the mean age at diagnosis was 40.4 years. The response rate to the questionnaires was 53% (n = 95; mean age 53.5 years, 73% female and 26% male). Patients with high levels of MA reported higher median values for the 36-Item Short Form Health Survey (SF-36) in comparison with those with low levels: 65.5 vs. 48.5 (p = 0.017). Similar results for EQ-5D-3L (3-level EuroQol 5D version) values and the level of MA were found: 0.656 vs. 0.796 (p = 0.0123). A low level of adherence was revealed in 34.7% of the patients, with no difference among different age groups. A significant positive determinant for adherence was years lived with acromegaly (OR = 5.625, 95% CI 1.7401-18.1832, p = 0.0039), as shorter duration was related to higher odds for high level of adherence. The current study demonstrates the importance of MA assessment for patients with acromegaly in Bulgaria. The medication adherence to the prescribed therapy among the observed group of patients with acromegaly varied as the percentage of adherent patients was around 65%. Still, there are low-adherent patients, and the responsible factors should be further investigated.

The Effect of Remote-Based Monitoring and Education Program on Cancer Pain Management in an Outpatient Pain Clinic

BACKGROUND

Pain is one of the most feared consequences of cancer for patients and their families. Many barriers may hinder optimal pain management.

AIM

Examine the effect of remote-based monitoring and education program on cancer pain management, patient-related barriers, and level of adherence to pain medication.

METHODS

A sample of 134 patients was assigned to two groups; 68 in the intervention group and 66 in the control. The intervention group received three educational sessions by telephone. Both groups completed questionnaires at baseline and one month after the initial visit.

RESULTS

Significant differences were found between the groups in the levels of pain right now (p = .030), pain at its least (p = .016), and in the percentage of achieved pain relief (p = .048). Moreover, the intervention group experienced lower levels of interference with their general activity (p = < .001), mood (p = .011), and normal work (p = .004) post-intervention. The Attitudinal Barriers differences were statistically significant in the total mean (p = < .001), and the subscales of physiological effects (p = < .001), fatalism (p = < .001), communication (p = < .001), harmful effects (p = < .001). Participants in the intervention group exhibited higher adherence levels (p = .001).

CONCLUSIONS

Patients suffering from cancer-related pain can benefit from remote-based monitoring and education programs to improve pain management outcomes, overcome barriers, and increase adherence. Further research is needed to investigate the different available educational methods and long-term effects.

Translation and validation of the Arabic version of the Morisky, Green and Levine (MGL) adherence scale

The Morisky Green Levine (MGL) adherence scale is a 4-item tool used for the detection of medication nonadherence among patients with chronic health conditions. Despite being widely used in Arabic-speaking research contexts, it has never been validated in Arabic language. The aim of this study was to translate and validate the MGL tool into Arabic. A standard forward-backward process was used to translate the questionnaire. Cronbach’s alpha coefficient was measured to assess internal consistency of the scale. The test-retest reliability measured the consistency of participants’ responses over time. Construct validity was evaluated by Explanatory factor analysis (EFA); Kaiser-Meyer-Olkin value and Bartlett’s test of sphericity were determined. Convergent validity was assessed using a preexisting medications Arabic Adherence Assessment Tool (AAAT). The model fit was evaluated using confirmatory factor analysis (CFA). Associations between the MGL scale scores and the patient demographic/clinical characteristics were tested by linear regressions. A total of 201 participants were included into the study. The MGL scale categorization revealed that 20.9%, 59.2% and 19.9% of the participants had high, moderate and low levels of adherence respectively. Adequate internal consistency (alpha = 0.593) was observed. A significant strong ICC and Pearson’s correlations were generated between responses at time 1 and time 2. EFA results elucidated the suitability of the data for factor analysis. Pearson’s coefficient (r) revealed a significant strong correlation between MGL scale and AAAT. CFA results confirmed a good fit for the suggested model. Linear regression revealed higher number of medications, more frequent outpatient clinic visits and not experiencing medication adverse effect factors significantly associated with better adherence. The Arabic version of MLG scale is a reliable valid tool to assess adherence among Arabic-speaking communities. Implementing interventions targeting patients not compliant to regular clinic visits and those at higher risk of experiencing medication side effects can greatly enhance medication adherence.

Non-adherence to medication and associated factors among type 2 diabetes patients at Clinique Medicale Fraternite, Rwanda: a cross-sectional study

BACKGROUND

Type 2 Diabetes Miletus (T2DM) is a public health burdens that alarmingly increases and leads to morbidity and mortality over the last decades globally. Its management is multifaceted and adherence to diabetic medications plays great roles in life of T2DM patients. But epidemiology on adherence and its associated factors remain unknown in Rwanda. Therefore, this study determined the extent of non-adherence and its predictors among T2DM patients seeking healthcare services at the Clinique Medicale la Fraternite.

METHODS

A cross-sectional study among 200 adults' patients with T2DM receiving care in the Medicale la Fraternite clinic was investigated. Bivariate and multivariate logistic regression models were performed based on odds ratio employed to examine associated predictors of non-adherence. The cut-off value for all statistical significances tests were considered at p < 0.05 with 95% for the confidence intervals.

RESULTS

Overall, more than a half of T2DM patients (53.5%) had poor medication adherence. Being females [OR = 2.1, 95%CI(1.13-3.71), p = 0.002], consuming anti-diabetic drugs for 4-10 years [OR = 2.18, 95%CI(1.09-4.34), p = 0.027], experiencing poor communication with healthcare providers [OR = 2.4; 95%CI (1.36-4.25), p = 0.003] and being perceived as burden of the family [OR = 5.8; 95%CI(1.3-25.7), p < 0.021] had higher odds of non-adherence to anti-diabetic medications. Those with poor HbA1C [OR = 4.26; 95%CI(1.7-10.67), p = 0.002] had 4.26 times higher odds to be non-adherent compared to those with good HbA1C. Respondents with primary [OR = 3.56; 95%CI (1.12-11.28), p = 0.031] and secondary education [OR = 2.96; 95%CI (1.11-7.87), p = 0.03] were more likely to be non-adherent than those with informal education respectively. Those with normal BMI [OR = 5.17; 95%CI(1.63-16.37), p = 0.005] and those with overweight or obese [OR = 3.6; 95%CI (1.04-9.1), p < 0.02] had higher odds of being non-adherent than those with underweight.

CONCLUSION

Sex, glycaemia, communication with healthcare providers, education and gycosylated hemoglobin were the major predictors of non-adherence. Interventions for tackling this problem through bringing together efforts to stem this epidemic and controlling predictors of non-adherence are urgently recommended.

A multicentric, 2 × 2 factorial, randomised, open-label trial to evaluate the clinical effectiveness of structured physical activity training and cognitive behavioural therapy versus usual care in heart failure patients: a protocol for the PACT-HF trial

Background: Heart failure (HF) is a multi-morbid chronic condition, which adversely affects the quality of life of the affected individual. Engaging the patient and their caregivers in self-care is known to reduce mortality, rehospitalisation and improve quality of life among HF patients. The PACT-HF trial will answer whether clinical benefits in terms of mortality and hospitalisation outcomes can be demonstrated by using a pragmatic design to explore the specific effects of physical activity, and cognitive behavioural therapy in HF patients in India. Methods: We will conduct a 2 × 2 factorial, randomized, open-label trial, which aims to see if rehabilitation strategies of structured physical activity training and cognitive behavioural therapy for depression and self-management reduce the risk of repeat hospitalisation and deaths in HF patients in India. Patients will be randomised to (1) physical activity + usual care (2) cognitive behaviour therapy + usual care, (3) physical activity + cognitive behaviour therapy + usual care, and (4) usual care at 1:1:1:1 ratio. Time to mortality will be the primary outcome. A composite of mortality and hospitalisation for HF will be the main secondary outcome. Additional secondary outcomes will include ‘days alive and out of hospital’, cumulative hospitalisation, quality of life, Minnesota Living with Heart Failure questionnaire score, depression score, six minutes walking distance, handgrip strength, and adherence to medicines and lifestyle.  The effects of intervention on the primary outcome will be estimated from Cox proportional hazard models. For the continuous secondary outcome variables, differences between randomised groups will be estimated from linear mixed models or generalised estimating equations (GEE) as appropriate. Discussion: PACT-HF is designed to provide reliable evidence about the balance of benefits and risks conferred by physical activity and cognitive behavioural therapy-based cardiac rehabilitation for those with HF, irrespective of their initial disease severity.

Patient-reported outcome measures after thrombectomy in patients with acute stroke: fine-tuning the modified Rankin Scale

BACKGROUND

In patients with stroke undergoing endovascular treatment (EVT), long-term outcome is usually only evaluated by the modified Rankin Scale (mRS). Patient-reported outcomes (PROMs) are standardized assessments that consider clinical outcomes from the perspective of the patient. We aimed to evaluate PROMs through a smartphone-based communication platform in patients with stroke who received EVT.

METHODS

Consecutive patients with stroke who underwent EVT were offered to participate in the PROMs-through-App program (NORA). A set of standardized PROMs were collected at 7, 30 and 90 days after discharge. Disability was determined by clinicians (mRS) at 90 days. To characterize the potential ceiling effect of mRS in the assessment of different domains, the rate of abnormal PROMs among patients with excellent outcome (mRS 0-1) was calculated.

RESULTS

From June 2020 to October 2021, 186 patients were included. The median PROMs collection rate per patient was 80% (50-100%). A correlation was consistently seen between disability measured by mRS and the different PROMs. The rate of abnormal PROMs ranged from 20.83% (HADS at 7 days) to 59.61% (Mental PROMIS at 7 days). At 90 days, among patients with an excellent outcome, the rate of abnormal PROMs ranged from 8.7% (HADS) to 47.83% (Physical PROMIS).

CONCLUSIONS

A specifically designed digital platform allows a high collection rate of PROMs among stroke patients who underwent EVT. The mRS score shows a ceiling effect and seems insufficient to fine-tune long-term clinical results. The use of PROMs may allow a better characterization of long-term outcome profiles after EVT.

Impact of medication therapy management interventions on drug therapy problems, medication adherence and treatment satisfaction among ambulatory heart failure patients at Tikur Anbessa Specialised Hospital, Addis Ababa, Ethiopia: a one-group pre-post quasi-experimental study

OBJECTIVE

To determine the impact of medication therapy management interventions on drug therapy problems (DTPs), medication adherence and treatment satisfaction among ambulatory heart failure (HF) patients.

STUDY DESIGN, SETTING AND PARTICIPANTS

A one-group pre-post quasi-experimental study was conducted on 423 ambulatory HF patients at Tikur Anbessa Specialised Hospital (TASH), Addis Ababa, Ethiopia. All ambulatory HF patients ≥18 years old attending the adult cardiac clinic of TASH and having a complete medical record and fully met the inclusion criteria were taken as study participants.

INTERVENTIONS

Educational interventions along with a brochure with information on the nature of HF disease and its treatment were provided to study participants. DTPs encountered were resolved by a team of pharmacists and physicians.

RESULTS

In the preintervention phase, 288 DTPs were identified with a mean (SD) of 1.3±1.1. A significant reduction of DTPs (0.67±1.1, p<0.001) was observed in the postintervention phase compared with the preintervention phase. At the postintervention phase, 36.4%, 61.9% and 1.7% of HF patients were highly, medium and low adherent to their treatment regimens, respectively. The total composite score for treatment satisfaction of the study participants was 80.35%.

CONCLUSIONS

The findings of this study demonstrated that by teaming up clinical pharmacists with cardiologists and cardiology fellows, it was possible to reduce the occurrence of DTPs, improve medication adherence and increase treatment satisfaction of HF patients attending at the outpatient cardiac clinic.

Socioeconomic impacts on medication adherence among patients with hypertension: A multicentre cross-sectional study in Lombok, Indonesia

Socioeconomic impacts on adherence are understudied, particularly in disadvantaged areas. This study aimed to evaluate socioeconomic factors on medication adherence among patients with hypertension in Lombok, Indonesia. A cross-sectional survey was conducted in all six public hospital outpatient clinics in Lombok in 2017. Data was obtained using a validated questionnaire to which the Morisky Green Levine Adherence Scale (MGLS) questionnaire was used to assess medication adherence. Binary logistic regression was performed to determine independent socioeconomic associations. A total of 693 patients with hypertension were included (response rate 84%). The majority had low adherence (76.2%). Significant independent associations were reported between setting and education with adherence (rural versus urban setting: odds ratio 3.54, p&lt;0.001; primary versus university level education: odds ratio 5.39, p&lt;0.001). Socioeconomic associations provide some basis for the development of patient and population-based interventions to improve adherence among patients with hypertension in Indonesia, particularly in disadvantaged areas.

Measurement Properties of Patient-Reported Outcome Measures for Medication Adherence in Cardiovascular Disease: A COSMIN Systematic Review

BACKGROUND AND OBJECTIVE

Several medication adherence patient-reported outcome measures (MA-PROMs) are available for use in patients with cardiovascular disease (CVD); however, little evidence is available on the most suitable MA-PROM to measure medication adherence in patients with CVD. The aim of this systematic review is to synthesise the measurement properties of MA-PROMs for patients with CVD and identify the most suitable MA-PROM for use in clinical practice or future research in patients with CVD.

METHODS

An electronic search of nine databases (PubMed, MEDLINE, CINAHL, ProQuest Health and Medicine, Cochrane Library, PsychInfo, Scopus, Embase, and Web of Science) was conducted to identify studies that have reported on at least one of the measurement properties of MA-PROMs in patients with CVD. The methodological quality of the studies included in the systematic review was evaluated using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist.

RESULTS

A total of 40 MA-PROMs were identified in the 84 included studies. This review found there is a lack of moderate-to-high quality evidence of sufficient content validity for all MA-PROMs for patients with CVDs. Only eight MA-PROMs were classified in COSMIN recommendation category A. They exhibited sufficient content validity with very low-quality evidence, and moderate-to-high quality evidence for sufficient internal consistency. The 28 MA-PROMs that meet the requirements for COSMIN recommendation category 'B' require further validation studies. Four MA-PROMs including Hill-Bone Compliance Medication Scale (HBMS), the five-item Medication Adherence Report Scale (MARS-5), Maastricht Utrecht Adherence in Hypertension (MUAH), and MUAH-16 have insufficient results with high quality evidence for at least one measurement property and consequently are not recommended for use in patients with CVD. Two MA-PROMs (Adherence to Refills and Medications Scale [ARMS] and ARMS-7) are comprehensive and have moderate to high quality evidence for four sufficient measurement properties.

CONCLUSION

From the eight MA-PROMs in COSMIN recommendation category A, ARMS and ARMS-7 were selected as the most suitable MA-PROMs for use in patients with CVD. They are the most comprehensive with be best quality evidence to support their use in clinical practice and research.

Rationale and Design of a Pharmacist-led Intervention for the Risk-Based Prevention of Heart Failure: The FIT-HF Pilot Study

Background: Given rising morbidity, mortality, and costs due to heart failure (HF), new approaches for prevention are needed. A quantitative risk-based strategy, in line with established guidelines for atherosclerotic cardiovascular disease prevention, may efficiently select patients most likely to benefit from intensification of preventive care, but a risk-based strategy has not yet been applied to HF prevention. Methods and Results: The Feasibility of the Implementation of Tools for Heart Failure Risk Prediction (FIT-HF) pilot study will enroll 100 participants free of cardiovascular disease who receive primary care at a single integrated health system and have a 10-year predicted risk of HF of ≥5% based on the previously validated Pooled Cohort equations to Prevent Heart Failure. All participants will complete a health and lifestyle questionnaire and undergo cardiac biomarker (B-type natriuretic peptide [BNP] and high-sensitivity cardiac troponin I [hs-cTn]) and echocardiography screening at baseline and 1-year follow-up. Participants will be randomized 1:1 to either a pharmacist-led intervention or usual care for 1 year. Participants in the intervention arm will undergo consultation with a pharmacist operating under a collaborative practice agreement with a supervising cardiologist. The pharmacist will perform lifestyle counseling and recommend initiation or intensification of therapies to optimize risk factor (hypertension, diabetes, and cholesterol) management according to the most recent clinical practice guidelines. The primary outcome is change in BNP at 1-year, and secondary and exploratory outcomes include changes in hs-cTn, risk factor levels, and cardiac mechanics at follow-up. Feasibility will be examined by monitoring retention rates. Conclusions: The FIT-HF pilot study will offer insight into the feasibility of a strategy of quantitative risk-based enrollment into a pharmacist-led prevention program to reduce heart failure risk. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT04684264.

Assessment of adherence to anti-tuberculosis treatment and predictors for non-adherence among the caregivers of children with tuberculosis

BACKGROUND

Information on the extent of patient medication adherence and the use of interventions to advance adherence are scarce in clinical practice. This study aimed to assess medication adherence and risk factors for non-adherence among the caregivers of children with tuberculosis (TB).

METHODS

This prospective study was conducted among the caregivers of 443 child TB patients registered during the study. Caregivers of children were queried using a structured questionnaire consisting of sociodemographic and socio-economic factors and the role of healthcare workers during the treatment course. Risk factors for non-adherence were estimated using a logistic regression model.

RESULTS

In multivariate analysis, the independent variables that had a statistically significant positive association with non-adherence were male sex (adjusted odds ratio [AOR] 5.870 [95% confidence interval {CI} 1.99 to 17.29]), age ≥45 y (AOR 5.627 [95% CI 1.88 to 16.82]), caregivers with no formal education (AOR 3.905 [95% CI 1.29 to 11.79]), financial barriers (AOR 30.297 [95% CI 6.13 to 149.54]), insufficient counselling by healthcare workers (AOR 5.319 [95% CI 1.62 to 17.42]), insufficient counselling by health professionals (AOR 4.117 [95% CI 1.05 to 16.05]) and unfriendly attitude and poor support from healthcare professionals (AOR 11.150 [95% CI 1.91 to 65.10]).

CONCLUSIONS

Treatment adherence in the present study was 86% using the Morisky Green Levine Medication Adherence Scale and 90.7% using the visual analogue scale tool. Predictors of non-adherence need to be a focus and caregivers should be given complete knowledge about the importance of adherence to TB treatment.

Impact of pharmacist-led interventions in improving adherence to glaucoma medications in the geriatric population

OBJECTIVES

Geriatric patients can be non-adherent to ophthalmic glaucoma medications because of complex eye drops instillation techniques and forgetfulness, so pharmacists can play their part in improving the clinical outcomes of patients by acting as care providers. The purpose of the current study was to implement various pharmacist-led interventions to improve adherence to glaucoma medications and to evaluate the outcomes of interventions in the geriatric population.

METHODS

The Morisky Green Levine (MGL) adherence scale was used for analysis because it measures the extent of non-adherence and analyses the reasons for it. The interview-based sessions were conducted with control and interventional groups followed by educational interventions, including techniques for eye drop instillation, graphical images, precautionary measures, and individual patient counselling for the interventional group. Patients were asked to complete the adherence scale after the conclusion of every follow-up session for a duration of 6 months.

RESULTS

After 6 months of pharmacist-led interventions, a significant shift was found in the interventional group from low to high adherence according to MGL scale evaluation. Moreover, the number of patients in the interventional group whose intraocular pressure was in the safe range significantly increased and follow-up sessions significantly improved the patient's knowledge about glaucoma.

CONCLUSION

The results of this pharmacist-led educational interventional study showed it was effective in improving adherence to glaucoma medications in the geriatric patients, who showed better adherence scores and improved intraocular pressure.

Association of health literacy and medication adherence with health-related quality of life (HRQoL) in patients with ischemic heart disease

BACKGROUND

Medication Adherence (MA) and Health Related Quality of Life (HRQoL) are two inter-connected concepts, co-influenced by Health Literacy (HL), with significant impact on patient management and care. Thus, we aimed to estimate the association of HL and MA with HRQoL in IHD patients.

METHODS

Cross-sectional study of 251 IHD patients recruited from Lahore over 6 months period. HL, MA and HRQoL was assessed using validated questionnaires; 16-items of HL, Morisky Green Levine Scale (MGLS) and SF-12, respectively. Chi-square for significance, logistic-regression for association and linear regression for predictions were used.

RESULTS

IHD patients; males (p = 0.0001), having secondary-higher education (p = 0.0001), middle/upper class (p = 0.0001) and employed (p = 0.005) had adequate HL, and were more likely to be adherent (OR; 4.3, p = 0.014). Both physical (PCS-12) and mental (MCS-12) component scores of HRQoL for age, gender, education, area of residence, employment and MA were significantly higher in patients with adequate HL. In multinomial regression, improved PCS-12 scores tend to be higher in subjects having secondary-higher education (OR; 3.5, p = 0.067), employed (OR; 6.1, p = 0.002) and adherent (OR; 2.95, p = 0.218), while MCS-12 scores tend to be higher in patients < 65 years (OR; 2.2, p = 0.032), employed (OR; 3, p = 0.002) and adherent (OR; 4, p = 0.004). In adjusted model, HL (β;0.383, p = 0.0001) and MA (β; - 0.133, p = 0.018) were significantly associated with PCS-12, and MCS-12 with MA (β; - 0.161, p = 0.009) only.

CONCLUSION

Data suggested that adequate HL was significantly associated with adherence and both physical and mental dimensions of HRQoL were higher in IHD patients with adequate HL. Besides, HL and MA are independent predictors of HRQoL in IHD patients.

[Management of patients with dyslipidaemia in Spain. The Cardio Right Care Control of cardiovascular risk project]

OBJECTIVE

To ascertain the opinion of physicians about diagnostic criteria, control targets, control rates, and therapeutic approach of patients with dyslipidaemia in Spain.

METHODS

A specific questionnaire was created about diagnostic criteria, control targets, control rates, lipid lowering therapies, and therapeutic inertia in patients with dyslipidaemia. Physicians completed the questionnaire online during a 4-month period.

RESULTS

A total of 959 questionnaires were collected from all over Spain. The most frequent scale to stratify cardiovascular risk is SCORE (54.9%), and guidelines from the European Society of Cardiology are the most common guidelines used (50.5%). The majority of patients are on primary prevention (57.7%), and 31.4% have a high-very high cardiovascular risk. More than 70% of investigators considered that the target among patients at very high risk and those in secondary prevention is an LDL cholesterol < 70 mg/dL. It is considered by 60.0% and 66.4% of investigators that their patients on primary and secondary prevention, respectively, achieve control targets. Statins are the most common lipid lowering drugs used, followed by ezetimibe. In the majority of cases, when a patient is not adequately controlled with statins, there is an increase in the dose or a change to another statin. Poor adherence to treatment and therapeutic inertia are the main reasons for poor LDL cholesterol control.

CONCLUSIONS

The Cardio Right Care CVR Control project allows those aspects to be identified, as well as areas of improvement in patients with dyslipidaemia in Spain.

The Impact of a Slow-Release Large Neutral Amino Acids Supplement on Treatment Adherence in Adult Patients with Phenylketonuria

The gold standard treatment for phenylketonuria (PKU) is a lifelong low-phenylalanine (Phe) diet supplemented with Phe-free protein substitutes. Adherence to therapy becomes difficult after childhood. Supplementing with large neutral amino acids (LNAAs) has been proposed as an alternative medication to Phe-free protein substitutes (i.e., amino acid mixtures). The aim of this study was to evaluate adherence to therapy and quality of life (QoL) in a cohort of sub-optimally controlled adult PKU patients treated with a new LNAA formulation. Twelve patients were enrolled in a 12-month-trial of slow-release LNAAs (1g/kg/day) plus a Phe-restricted diet. Medication adherence was measured with the Morisky Green Levine Medication Adherence Scale; the QoL was measured using the phenylketonuria-quality of life (PKU-QoL) questionnaire. Phe, tyrosine (Tyr) levels, and Phe/Tyr ratios were measured fortnightly. Before treatment, 3/12 patients self-reported a ‘medium’ adherence to medication and 9/12 reported a low adherence; 60% of patients reported a full adherence over the past four weeks. After 12 months of LNAA treatment, all patients self-reported a high adherence to medication, with 96% reporting a full adherence. Phe levels remained unchanged, while Tyr levels increased in most patients. The Phy/Tyr ratio decreased. All patients had a significant improvement in the QoL. LNAAs may give patients a further opportunity to improve medication adherence and, consequently, their QoL.

Self-reported adherence among people with epilepsy in Brazil

BACKGROUND

Nonadherence rates among people with epilepsy (PWE) are widely variable, ranging from 26% to 95.4%. We aimed to identify nonadherence in Brazil, its determinant factors, its impact on patients' management, and to compare it with other chronic nonparoxysmal diseases.

METHODS

A multicenter observational case-control study was conducted between March 2015 and October 2016, and 153 subjects were included. Subjects' clinical-epidemiological data were surveyed with the Morisky-Green test (MGT), Brief Medication Questionnaire (BMQ), and the Liverpool adverse events profile (LAEP).

RESULTS

One hundred three PWE and 50 controls with other, nonparoxysmal chronic conditions were interviewed; both groups were matched according to age and socioeducational level. People with epilepsy were aged 36.4 ± 13.9 (range 18-67), 55% were women, mean age at epilepsy onset was 18.1 ± 15.5 years, 51.5% had pharmacoresistant epilepsy, and 48.5% were on monotherapy. 74.8% of patients and 70.0% controls were nonadherent to treatment according to MGT (p = 0.58); and barrier of recall (BMQ) was associated with nonadherence in 78% of PWE and 76% of controls (p = 0.84). Binary logistic regression analysis revealed LAEP (OR 1.05; 95%CI = 1.01-1.09; p = 0.03) and self-reported frequency of forgetfulness on the last three months (OR 19.13; 95%CI = 2.40-152.28; p < 0.01) as the main factors associated with nonadherence. Nonadherent subjects did not have more seizures and did not need emergency treatment more often than adherent ones.

CONCLUSION

Three of four PWE were not fully adherent to their treatment. Adherence assessment should be routine in all outpatient visits as well as interventions aimed to improving it. Adverse events are important predictors of adherence, and they should be considered when choosing the initial treatment of epilepsy.

Adherence profiles in kidney transplant patients: Causes and consequences

OBJECTIVE

Adherence is a dynamic phenomenon and a critical determinant of transplant patients outcome. The objective of this longitudinal study was to explore adherence in kidney transplant patients followed-up for up to three years after transplantation.

METHODS

Adherence was repeatedly estimated using the Morisky-Green-Levine 4-Item Medication Adherence Scale, in two successive cohorts of 345 (EPIGREN) and 367 (EPHEGREN) kidney transplant recipients. Mixed effect modeling with latent processes and latent classes was used to describe adherence time-profiles.

RESULTS

Two latent classes were identified. The adherent class represented 85% of the patients. Patients of the poorer-adherence class displayed a lower adherence at one month (p<10^-3), which worsened over time. Good adherence was associated with age >50 years, fewer depression episodes (5% vs. 13%, p = 0.001) and a better mental health component of quality of life (MCS-SF36 47 ± 11 vs. 41 ± 13, p = 0.015). Survival without acute rejection episodes was longer in the adherent class (p = 0.004).

CONCLUSIONS

The risk of poor adherence in renal transplant patients can be detected as early as one month post-transplantation, using appropriate and easy tools adapted to routine monitoring.

PRACTICE IMPLICATIONS

An early focus on vulnerable patients should allow putting into place actions in order to reduce the risk of poor outcome related to poor adherence.

Health related quality of life and its correlates among people with depression attending outpatient department in Ethiopia: a cross sectional study

BACKGROUND

Depression is a common mental disorder negatively affects the cognitive, emotion, behavior, functionality and quality of life of people. Poor quality of life results in high rates of relapse, inability to perform occupational and social activities, impaired future outlook, and increases overall health care related costs. However, there is no available evidence regarding the health related quality of people with depression in Ethiopia. Therefore, evaluating the quality of life of people with depression is crucial.

OBJECTIVE

The aim of this study was to assess the health related quality of life and its correlates among people with depression at Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia.

METHODS

An institutional based cross-sectional study was conducted from May ^1st to ^30th, 2018. A randomly selected 394 clients with depression were participated in this study. Health related quality of life was measured using world health organization quality of life brief. The collected data were coded and entered to SPSS version 20 for analysis. Step wise multiple linear regression analysis was used to identify the correlates of quality of life and the strength of the correlation was measured by β coefficient with 95% confidence interval.

RESULTS

The mean (±SD) scores of quality of life of people with depression were 41.3 ± 7.5, 42.8 ± 8.2, 38.9 ± 8.9 and 41.8 ± 6.5 for physical, psychological, social and environmental domains, respectively. The Multiple regression analysis showed that age of respondents, age of onset of depression, perceived stigma, living arrangement, social support level and duration of illness were statistically significant predictors of health related quality of life of people with depression in all or at least one domain of quality of life.

CONCLUSIONS

This study revealed that nearly half of study participants scored below the mean score in each domain of health related quality of life. This demonstrates a need for improving the quality of life of people with depression through the integration of a positive mental health approach and bio-psychosocial view together with the pharmacological treatments of depression. Moreover, strengthening social support, early identification and treatment of depression and prevention of stigma are also highly recommended to improve the quality of life of people with depression.

Endocrine Therapy Nonadherence and Discontinuation in Black and White Women

BACKGROUND

Differential use of endocrine therapy (ET) by race may contribute to breast cancer outcome disparities, but racial differences in ET behaviors are poorly understood.

METHODS

Women aged 20-74 years with a first primary, stage I-III, hormone receptor-positive (HR+) breast cancer were included. At 2 years postdiagnosis, we assessed nonadherence, defined as not taking ET every day or missing more than two pills in the past 14 days, discontinuation, and a composite measure of underuse, defined as either missing pills or discontinuing completely. Using logistic regression, we evaluated the relationship between race and nonadherence, discontinuation, and overall underuse in unadjusted, clinically adjusted, and socioeconomically adjusted models.

RESULTS

A total of 1280 women were included; 43.2% self-identified as black. Compared to white women, black women more often reported nonadherence (13.7% vs 5.2%) but not discontinuation (10.0% vs 10.7%). Black women also more often reported the following: hot flashes, night sweats, breast sensitivity, and joint pain; believing that their recurrence risk would not change if they stopped ET; forgetting to take ET; and cost-related barriers. In multivariable analysis, black race remained statistically significantly associated with nonadherence after adjusting for clinical characteristics (adjusted odds ratio = 2.72, 95% confidence interval = 1.75 to 4.24) and after adding socioeconomic to clinical characteristics (adjusted odds ratio = 2.44, 95% confidence interval = 1.50 to 3.97) but was not independently associated with discontinuation after adjustment. Low recurrence risk perception and lack of a shared decision making were strongly predictive of ET underuse across races.

CONCLUSIONS

Our results highlight important racial differences in ET-adherence behaviors, perceptions of benefits/harms, and shared decision making that may be targeted with culturally tailored interventions.

Investigation of medication adherence and reasons for poor adherence in patients on long-term glaucoma treatment regimes

PURPOSE

Long-term treatment adherence for a chronic asymptomatic condition is a demanding task for many patients. Treating progressive glaucoma can also be confounding for physicians, particularly when management relies on assumption of adherence. This study investigated associations between self-reported adherence and frequency of medication changes due to glaucoma progression.

METHODS

A total of 128 participants with primary open angle glaucoma were recruited from glaucoma clinics in Flinders Eye Center, South Australia, and completed confidential questionnaires. Information was obtained regarding beliefs about glaucoma and their treatment. Adherence was assessed using the four-item Morisky, Green and Levine Medication Adherence Questionnaire (MGL). Medical records were analyzed for the number of medication changes, due to glaucoma progression.

RESULTS

Adherence to topical glaucoma medication was categorized as 'high' in 41.4% (Morisky, Green and Levine (MGL). Data were analyzed for behaviors affecting adherence, history of adherence, and reasons for changed adherence. Chi-squared test demonstrated that there was no significant association noted between adherence and changes in medication regime (χ² (2,128)=0.968, P=0.915); however, a significantly lower adherence was detected if participants had difficulties with their drop regime (χ² (2,128)=7.24, P=0.027) or had help with drop insertion (χ² (1,128)=9.77, P=0.008).

CONCLUSION

This study revealed a higher rate of non-adherence than has previously been demonstrated in other studies. This may be attributed to the unique design of the confidential questionnaire and the independent and sympathetic questioning techniques used. Further work to develop a specific glaucoma medication adherence questionnaire would be valuable to enhance glaucoma management.

Association Between Medication Adherence and Oxidative Stress in Patients With First-Episode Mania

Poor adherence is a major problem in patients with manic episodes that impairs functionality and has unknown effects on oxidative stress. The objective of this study was to analyze the relationship between adherence to medication, severity of symptoms and oxidative stress in a sample of patients with a first episode of mania. A longitudinal, 6-month study was performed in 60 patients, who were classified as adherent and non-adherent to medication (mainly antipsychotics). Blood levels of oxidative stress parameters and expression of the antioxidant nuclear transcription factor NRF2 in mononuclear cells of peripheral blood were assessed at baseline and at the end of follow-up. In addition, clinical symptoms and functioning were evaluated. Linear multivariate regression was used to determine the relationship between adherence, oxidative stress, and clinical symptoms. Finally, 44 patients completed follow-up. The results of this study showed that at 6-month follow-up, adherence was significantly associated with better functioning and reduced clinical symptoms. Additionally, more severe symptoms were associated with increased levels of oxidative stress and antioxidant parameters. At study completion, non-adherents exhibited greater levels of antioxidants than adherent patients. In conclusion, poor adherence to medication is associated with a poorer prognosis in the medium term and causes increased antioxidant response.