Multifaceted interventions improve medication adherence and reduce acute hospitalization rates in medicaid patients prescribed asthma controllers

Cost-Effectiveness and Impact on Health Care Utilization of Interventions to Improve Medication Adherence and Outcomes in Asthma and Chronic Obstructive Pulmonary Disease: A Systematic Literature Review

BACKGROUND

Poor adherence to asthma and chronic obstructive pulmonary disease maintenance therapies impairs health outcomes. Proven and cost-effective programs to promote adherence and persistence are not yet in regular widespread use. Implementation costs are a potential barrier to uptake of such programs.

OBJECTIVE

We undertook a systematic literature review and narrative synthesis of studies investigating the cost-effectiveness of treatment adherence-promoting programs or that determined their impact on health care budget directly or via health care resource use (HCRU).

METHODS

We identified relevant publications using Medline and PreMEDLINE (PubMed), Embase (Embase.com, Elsevier), and EconLit for publications between January 2000 and July 2021. We also searched clinical trial databases and selected conference proceedings.

RESULTS

Of 1,910 potentially relevant articles, 26 met prespecified inclusion criteria and underwent data extraction. Eleven reported a direct assessment of adherence, 15 included economic evaluations, and 17 described HCRU. None included an analysis of biologic medication use. When they were studied, interventions were often found to be highly cost-effective, with dominant incremental cost-effectiveness ratios in some cases. Reductions in direct costs and HCRU (health care visits, hospital admissions, and/or the use of medications, including add-on/reliever treatment and antibiotics) were frequently reported. Reported use of maintenance treatments improved in some studies. Counseling and/or digitally informed programs were used in all cases in which favorable outcomes were observed.

CONCLUSIONS

Adherence-promoting interventions are mostly cost-effective and often result in reduced HCRU and associated costs. Multidisciplinary care involving one-to-one advice and digitally enhanced communications appear to offer the greatest benefit.

Medication economic burden of antidepressant non-adherence in Spain

Introduction: Non-adherence to antidepressants is associated with worse disease outcomes (morbidity and mortality) and correlates with higher healthcare resource utilization and costs. Methods: A population-based registry study was conducted to assess non-adherence and to analyze the economic burden of treatment and from non-adherence to antidepressants in 2021. Non-adherence was measured by the Medication Possession Ratio and those below 80% were classified as non-adherent. Results: In 2021, 246,718 patients (10.60% [95% CI: 10.48-10.72]) received antidepressants at a cost of €29 million. The median antidepressant cost per patient/year was €70.08€, ranging from €7.58 for amitriptyline to €396.66 for agomelatine. Out-of-pocket costs represented 6.09% of total expenditures, with a median copayment of €2.78 per patient. The 19.87% [95% CI 19.52-20.22)] of patients were non-adherent to antidepressants, costing €3.9 million (13.30% of total antidepressant costs). Non-adherence rates exceeded 20% for the tricyclic antidepressants, fluoxetine (23.53%), fluvoxamine (22.42%), and vortioxetine (20.58%). Venlafaxine (14.64%) and citalopram (14.88%) had the lowest non-adherence rates, of less than 15%. The median cost of non-adherent medications per patient/year was €18.96 and ranged from €2.50 (amitriptyline) to €133.42 (agomelatine). Conclusion: Reducing non-adherence to antidepressants is critical to improving clinical and economic outcomes. The implementation of interventions and standardized measures, including early detection indicators, is urgently needed. Antidepressants differ with regard to non-adherence and their cost, and this should be considered when prescribing this medication. The Medication Possession Ratio could be used by the healthcare provider and clinician to identify non-adherent patients for monitoring, and to take necessary corrective actions.

Determining the optimal threshold for medication adherence in adult asthma patients: an analysis of British Columbia administrative health database in Canada

OBJECTIVE

This study investigated the association between varying cutoffs for Medication Adherence (MA) among physician-diagnosed asthma patients and subsequent association with asthma exacerbation.

METHODS

We linked four administrative health databases obtained from the Population Data in British Columbia. Index cases were physician-diagnosed asthma patients between January 1, 1998, to December 31, 1999, aged 18 years and older. Patients were prospectively assessed in the follow-up period from January 1, 2000, to December 31, 2018, to identify asthma exacerbation. Two proxy measures were used to assess MA: the proportion of days covered (PDC) and the medication possession ratio (MPR). Using the generalized estimating equation (GEE) logistic regression adjusted for patient covariates, the outcome of "asthma exacerbation" was modeled against varying MA cutoffs; excellent '≥0.90'; very good '0.80-0.89'; good '0.70-0.799'; moderate '0.6-0.699'; mild '0.50-0.599' compared to poor '<0.50' for both PDC and MPR.

RESULTS

The sample included 68,211 physician-diagnosed asthma patients with a mean age of 48.2 years and 59.3% females. The adjusted odds ratios (OR) and 95% confidence interval (CI) at the various cutoff for PDC-levels predicting asthma exacerbation events were: Excellent MA [OR = 0.84, 95% (0.82-0.86), very good MA [OR: 0.86, (0.83, 0.89), good MA [0.91, (0.88-0.94)]; moderate MA [0.93, (0.90-0.96)]; mild MA [0.95, (0.92-0.98)]; compared to poor MA level. Threshold levels for both the PDC and MPR measure greater than 0.80 provided optimal threshold associated with over 15% reduced likelihood of experiencing asthma exacerbations.

CONCLUSION

Intervention aimed at improving asthma exacerbation events in adult asthma patients should encourage increased medication adherence threshold level greater than 0.80.

Supplemental data for this article is available online at at www.tandfonline.com/ijas .

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.

Refill Reminder Preference and Inhaled Corticosteroid Adherence Among Patients with Asthma

CONTEXT

Refill reminders can help patients improve adherence to inhaled corticosteroid (ICS) therapy. However, little is known about patient preferences for reminder type or whether patients who express a preference differ from patients who do not.

OBJECTIVES

To describe patient preferences for ICS prescription refill reminder type and to compare baseline ICS therapy adherence, measured as proportion of days covered (PDC) 1 year before initiating preference-based reminders, between patients who did and did not express a preference.

DESIGN

This substudy within a randomized multi-intervention study was conducted at Kaiser Permanente Colorado. Adults with asthma randomized to intervention were offered the opportunity to choose text, telephone, or email reminders. Patients who did and did not provide a preference were compared by baseline characteristics using log-binomial models.

MAIN OUTCOME MEASURE(S)

The primary outcomes were reminder preference and type.

RESULTS

A total of 1497 of 4545 patients (32.9%) expressed a preference; 789 (52.7%) chose text. The adjusted relative risk (aRR) of not providing a preference increased with decreasing PDC (PDC of 0.50 to < 0.80: aRR, 1.14; 95% confidence interval [CI], 1.04-1.25; PDC < 0.5: aRR, 1.76; 95% CI, 1.59-1.95) compared with patients with a PDC of 0.80 or greater.

CONCLUSION

Among patients who expressed a preference, text reminders were preferred. Patients who expressed a preference had higher baseline adherence. Further research is needed to determine whether expressing a preference for a refill reminder type is itself associated with adherence. Given that offering the opportunity to choose a reminder type only engaged a subset of patients, further work is needed to understand how best to leverage technology-enabled communication outreach to help patients optimize adherence.

Prevalence and impact of risk factors for poor asthma outcomes in a large, specialist-managed patient cohort: a real-life study

Background

Risk factors for poor asthma outcomes may have considerable influence on the control level and medical care of asthmatic patients. Our objective was to conduct a study that provides data on the level of symptom control and the frequency of specific risk factors for poor asthma outcomes on a large patient cohort.

Methods

A cross-sectional, non-interventional real-life study was conducted among asthmatic patients treated by respiratory specialists in Hungary. Asthma control and risk factor assessment were done according to Global Initiative for Asthma guideline (Box 2–2). In the data analysis, phase descriptive statistics, graphical outputs, and Fisher’s exact tests were used.

Results

Of 12743 patients enrolled by 187 specialists, asthma was well controlled in 36.0%, partially controlled in 29.29%, and uncontrolled in 34.71% of the cases. The most common comorbidities were rhinitis/sinusitis (66.84%), cardiovascular diseases (43.81%), and gastroesophageal reflux disease (20.11%). The following risk factors had the strongest relationship with uncontrolled disease: incorrect inhaler technique causing side effects (odds ratio, OR 4.86, 3.51–6.8), previous severe exacerbation (OR 4.79, 4.02–5.72), high short-acting beta agonist (SABA) use (OR 4.46, 4.03–4.93), incorrect inhaler technique associated with an exacerbation (OR 3.91, 3.06–5.03), and persistently low forced expiratory volume in 1 s (FEV₁, OR 3.14, 2.8–3.52). The most frequent risk factors were smoking (OR 1.47, 1.36–1.59) and obesity (OR 1.34, 1.24–1.45). Furthermore, high loss of control was associated with an initial low FEV₁ (OR 2.21, 2.01–2.44), frequent oral corticosteroid (OCS) use (OR 1.83, 1.64–2.05), poor adherence to treatment (OR 2.51, 2.21–2.86), and allergen exposure (OR 1.63, 1.47–1.81).

Conclusions

This study indicated that the presence of risk factors for poor asthma outcomes listed by the Global Initiative for Asthma document significantly influenced actual control level in a real-world large patient cohort, with high SABA use, previous severe exacerbation, incorrect inhaler technique, persistently low FEV₁, and poor adherence to treatment having the highest impact.