[Compliance with hormone replacement therapy in menopausal women: results of a two-year prospective French study comparing transdermal treatment with fixed oral combination therapy]

Interventions for enhancing medication adherence

BACKGROUND

People who are prescribed self administered medications typically take only about half their prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications.

OBJECTIVES

The primary objective of this review is to assess the effects of interventions intended to enhance patient adherence to prescribed medications for medical conditions, on both medication adherence and clinical outcomes.

SEARCH METHODS

We updated searches of The Cochrane Library, including CENTRAL (via http://onlinelibrary.wiley.com/cochranelibrary/search/), MEDLINE, EMBASE, PsycINFO (all via Ovid), CINAHL (via EBSCO), and Sociological Abstracts (via ProQuest) on 11 January 2013 with no language restriction. We also reviewed bibliographies in articles on patient adherence, and contacted authors of relevant original and review articles.

SELECTION CRITERIA

We included unconfounded RCTs of interventions to improve adherence with prescribed medications, measuring both medication adherence and clinical outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive findings at earlier time points.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted all data and a third author resolved disagreements. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Pooling results according to one of these characteristics still leaves highly heterogeneous groups, and we could not justify meta-analysis. Instead, we conducted a qualitative analysis with a focus on the RCTs with the lowest risk of bias for study design and the primary clinical outcome.

MAIN RESULTS

The present update included 109 new RCTs published since the previous update in January 2007, bringing the total number of RCTs to 182; we found five RCTs from the previous update to be ineligible and excluded them. Studies were heterogeneous for patients, medical problems, treatment regimens, adherence interventions, and adherence and clinical outcome measurements, and most had high risk of bias. The main changes in comparison with the previous update include that we now: 1) report a lack of convincing evidence also specifically among the studies with the lowest risk of bias; 2) do not try to classify studies according to intervention type any more, due to the large heterogeneity; 3) make our database available for collaboration on sub-analyses, in acknowledgement of the need to make collective advancement in this difficult field of research. Of all 182 RCTs, 17 had the lowest risk of bias for study design features and their primary clinical outcome, 11 from the present update and six from the previous update. The RCTs at lowest risk of bias generally involved complex interventions with multiple components, trying to overcome barriers to adherence by means of tailored ongoing support from allied health professionals such as pharmacists, who often delivered intense education, counseling (including motivational interviewing or cognitive behavioral therapy by professionals) or daily treatment support (or both), and sometimes additional support from family or peers. Only five of these RCTs reported improvements in both adherence and clinical outcomes, and no common intervention characteristics were apparent. Even the most effective interventions did not lead to large improvements in adherence or clinical outcomes.

AUTHORS' CONCLUSIONS

Across the body of evidence, effects were inconsistent from study to study, and only a minority of lowest risk of bias RCTs improved both adherence and clinical outcomes. Current methods of improving medication adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. The research in this field needs advances, including improved design of feasible long-term interventions, objective adherence measures, and sufficient study power to detect improvements in patient-important clinical outcomes. By making our comprehensive database available for sharing we hope to contribute to achieving these advances.

Validity of chronic drug exposure presumed from repeated patient interviews varied according to drug class

OBJECTIVE

To evaluate the validity of chronic drug exposure presumed from cross-sectional interviews taking reimbursement data as reference.

STUDY DESIGN AND SETTING

The study concerned 2,985 elderly persons of the French Three-City cohort (1) who were interviewed on current drug use 2 and 4 years after inclusion and (2) whose reimbursement data were obtained from the main health care insurance system. Validity (sensitivity, Se; specificity, Sp; positive predictive value, PPV; negative predictive value, NPV) of chronic exposure presumed from follow-up interviews was investigated taking two exposure definitions from reimbursements as reference for the period between interviews: at least 80% coverage with and without a maximal time between reimbursements of 60 days.

RESULTS

Using 80% coverage as reference, validity of interview data was substantial for cardiovascular and antithrombotic drugs (Se, 85.3-95.4%; Sp, 67.1-97.6%; PPV, 65.9-86.6%; NPV, 93.3-99.3%). For benzodiazepines, nonsteroidal anti-inflammatory drugs, or analgesics, validity was low especially owing to PPVs (15.8-51.4%).

CONCLUSION

Using reported use at cross-sectional interviews as a proxy for chronic exposure between interviews was valid for drugs used regularly but not so for drugs used more irregularly.

Interventions for enhancing medication adherence

BACKGROUND

People who are prescribed self-administered medications typically take less than half the prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications, but also might increase their adverse effects.

OBJECTIVES

To update a review summarizing the results of randomized controlled trials (RCTs) of interventions to help patients follow prescriptions for medications for medical problems, including mental disorders but not addictions.

SEARCH STRATEGY

We updated searches of The Cochrane Library, MEDLINE, CINAHL, EMBASE, International Pharmaceutical Abstracts (IPA), PsycINFO (all via OVID) and Sociological Abstracts (via CSA) in January 2007 with no language restriction. We also reviewed bibliographies in articles on patient adherence and articles in our personal collections, and contacted authors of relevant original and review articles.

SELECTION CRITERIA

Articles were selected if they reported an unconfounded RCT of an intervention to improve adherence with prescribed medications, measuring both medication adherence and treatment outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive initial findings.

DATA COLLECTION AND ANALYSIS

Study design features, interventions and controls, and results were extracted by one review author and confirmed by at least one other review author. We extracted adherence rates and their measures of variance for all methods of measuring adherence in each study, and all outcome rates and their measures of variance for each study group, as well as levels of statistical significance for differences between study groups, consulting authors and verifying or correcting analyses as needed. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Therefore, we did not feel that quantitative analysis was scientifically justified; rather, we conducted a qualitative analysis.

MAIN RESULTS

For short-term treatments, four of ten interventions reported in nine RCTs showed an effect on both adherence and at least one clinical outcome, while one intervention reported in one RCT significantly improved patient adherence, but did not enhance the clinical outcome. For long-term treatments, 36 of 81 interventions reported in 69 RCTs were associated with improvements in adherence, but only 25 interventions led to improvement in at least one treatment outcome. Almost all of the interventions that were effective for long-term care were complex, including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counseling, family therapy, psychological therapy, crisis intervention, manual telephone follow-up, and supportive care. Even the most effective interventions did not lead to large improvements in adherence and treatment outcomes.

AUTHORS' CONCLUSIONS

For short-term treatments several quite simple interventions increased adherence and improved patient outcomes, but the effects were inconsistent from study to study with less than half of studies showing benefits. Current methods of improving adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. High priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term medical disorders.

Clinical guidelines for improving compliance with hormone therapy in Latin American women during the menopausal transition and thereafter

OBJECTIVE

To provide uniform, objective guidance for physicians and other health care workers in Latin America to enhance compliance with hormone therapy (HT), and to provide a tool for continued medical education and a source for answering clinical questions.

METHOD

Literature search using MEDLINE; identification of key relevant publications by a five-member expert committee; creation and validation of a 60-item questionnaire used to survey the opinion of 72 physicians participating in a Latin American symposium, "The Faces of Menopause".

RESULTS

On the basis of the validated responses, major points were identified to enhance compliance with HT with specific reference to Latin America, and two algorithms were created to provide practical guidance.

CONCLUSION

The present guidelines will facilitate optimal compliance with therapy in Latin American postmenopausal women who opt for HT and for whom HT is indicated.

Hormone therapy use among postmenopausal French women before the publication of the Women's Health Initiative study: duration of use and factors associated with discontinuation

OBJECTIVE

Compliance with recent recommendations concerning hormone therapy (HT) requires that we understand the reasons why women receiving HT continue or stop their treatment. Our aim was to estimate the duration of HT use and analyze factors associated with its discontinuation during the period before the publication of articles challenging the safety of HT.

DESIGN

With data from 3 mail questionnaires--at inclusion (in 1990), 3 years, and 6 years--we estimated the cumulative treatment continuation rate by the actuarial method and used the Cox model to analyze the factors associated with discontinuation.

SETTING

French women participating in the GAZEL cohort of employees of the French national power and electricity company (Electricité de France-Gaz de France).

PATIENT(S)

One thousand eighty-three postmenopausal women who were ever-HT users.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Discontinuation of HT.

RESULT(S)

A total of 91.6% of women consulted gynecologists, and 88% continued treatment 5 years after they had begun it. Those reporting hot flashes as a reason for taking HT and those younger than 45 years old at menopause were less likely to stop HT, as were women reporting alcohol use.

CONCLUSION(S)

Our results demonstrate the importance of providing information to physicians, primarily gynecologists, to ensure appropriate treatment of symptoms for menopausal women, especially those younger than 45 years old, while bearing their long-term health in mind.

Interventions to enhance medication adherence

BACKGROUND

People who are prescribed self-administered medications typically take less than half the prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications, but also might increase their adverse effects.

OBJECTIVES

To update a review summarizing the results of randomized controlled trials (RCTs) of interventions to help patients follow prescriptions for medications for medical problems, including mental disorders but not addictions.

SEARCH STRATEGY

Computerized searches were updated to September 2004 without language restriction in MEDLINE, EMBASE, CINAHL, The Cochrane Library, International Pharmaceutical Abstracts (IPA), PsycINFO and SOCIOFILE. We also reviewed bibliographies in articles on patient adherence and articles in our personal collections, and contacted authors of original and review articles on the topic.

SELECTION CRITERIA

Articles were selected if they reported an unconfounded RCT of an intervention to improve adherence with prescribed medications, measuring both medication adherence and treatment outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive initial findings.

DATA COLLECTION AND ANALYSIS

Study design features, interventions and controls, and results were extracted by one reviewer and confirmed by at least one other reviewer. We extracted adherence rates and their measures of variance for all methods of measuring adherence in each study, and all outcome rates and their measures of variance for each study group, as well as levels of statistical significance for differences between study groups, consulting authors and verifying or correcting analyses as needed.

MAIN RESULTS

For short-term treatments, four of nine interventions reported in eight RCTs showed an effect on both adherence and at least one clinical outcome, while one intervention reported in one RCT significantly improved patient compliance, but did not enhance the clinical outcome. For long-term treatments, 26 of 58 interventions reported in 49 RCTs were associated with improvements in adherence, but only 18 interventions led to improvement in at least one treatment outcome. Almost all of the interventions that were effective for long-term care were complex, including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counseling, family therapy, psychological therapy, crisis intervention, manual telephone follow-up, and supportive care. Even the most effective interventions did not lead to large improvements in adherence and treatment outcomes. Six studies showed that telling patients about adverse effects of treatment did not affect their adherence.

AUTHORS' CONCLUSIONS

Improving short-term adherence is relatively successful with a variety of simple interventions. Current methods of improving adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. High priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term medical disorders.

Hormone therapy prescription among physicians in France and Quebec

OBJECTIVE

Our objective was to compare physician characteristics associated with high-frequency hormone therapy (HT) prescription between gynecologists and general practitioners (GPs) within and between France and Quebec, Canada.

DESIGN

A self-administered mail survey was sent to a representative sample of 2,000 physicians in France and 1,000 physicians in Quebec. High-frequency prescribers were those who reported prescribing HT to more than 70% of their postmenopausal patients. The following characteristics were included in the analysis: country, specialty, age, gender, characteristics of the practice (solo or group, private or public, rural or urban, number of patients seen daily, duration of practice, percentage of women 45 years or older), teaching or research activities, participation in education course on HT, and practice patterns relating to menopausal women (having patient education materials available, providing materials to patients, and discussing the possibility of HT).

RESULTS

The analysis covered 974 physicians in France (389 GPs and 585 gynecologists) and 452 physicians in Quebec, Canada (318 GPs and 134 gynecologists). Despite differences in health care, in both countries gynecologists were more likely to be high-frequency prescribers than were GPs, although this difference was smaller in Quebec. Canadian physicians were more likely to prescribe HT. The difference between countries was greatest among GPs. Except for nationality and practice patterns designed to provide women with information, none of the physician characteristics was associated with high-frequency prescription among GPs. Among gynecologists, only the number of patients per day and the provision of information were associated with high-frequency prescription.

CONCLUSIONS

Notwithstanding a common language, differences in the prescription pattern of HT between countries were greatest at the level of primary care than secondary care. In both countries, specialists were more likely to prescribe HT than were GPs. Implementation of clinical practice guidelines to set baseline standards in the field of menopausal health remains a challenge but will need to take into account cultural characteristics as well as level of medical care.