Medication Adherence Among Recipients with Chronic Diseases Enrolled in a State Medicaid Program

An Effectiveness Study of a Primary Care-embedded Clinical Pharmacist-Led Intervention Among Patients With Diabetes and Medicaid Coverage

Objective: Examine the impact of a primary care-embedded clinical pharmacist-led intervention (UCMyRx) on hemoglobin A1C and blood pressure control, relative to usual care, among patients with Type 2 diabetes (TD2) and Medicaid, in a large healthcare system. Methods: We used data extracted from the Electronic Health Records system and a Difference-In-Differences study design with a 2:1 propensity-matched comparison group to evaluate the impact of UCMyRx on HbA1c and systolic blood pressure among patients with TD2 and Medicaid, relative to usual care. Results: Having at least one UCMyRx clinical pharmacist visit was associated with a significant reduction in HbA1c; (-.27%, P-value= .03) but no impact on SBP. We do not find differential UCMyRx effects on HbA1c or SBP among the subpopulations with baseline HbA1C ≥9% or SBP ≥150 mmHg, respectively. In Charlson Comorbidity Index (CCI)-stratified analyses we found stronger UCMyRx effects on HbA1C (-.47%, P-value< .02) among the CCI tercile with the lowest comorbidity score (CC1 ≤ 5). Significant UCMyRx effects are only observed among the subpopulation of Medicaid beneficiaries without Medicare (-.35%, P-value= .02). Conclusions: The UCMyRx intervention is a useful strategy for improving HbA1c control among patients with TD2 and Medicaid.

Income and antiplatelet adherence following percutaneous coronary intervention

Objective

To investigate the relation of annual household income to antiplatelet adherence following PCI.

Background

Treatment with 6–12 months of dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) is a Class I recommendation. Adherence to these medications is essential to reduce risk of stent thrombosis and recurrent ischemic events. Social risk factors like household income modify how patients access and adhere to essential pharmacologic therapies such as antiplatelet agents.

Methods

We identified individuals presenting with PCI in an administrative claims database of commercially insured and Medicare Advantage beneficiaries from 2017 to 2019. We collected data on age, sex, race, ethnicity, educational attainment, and covariates (prevalent coronary disease, medications, healthcare visits, insurance type, copay, antiplatelet medications, and Elixhauser Comorbidity Index conditions). We related annual household income, categorized as <$40,000; $40–49,999; $50–59,999; $60–74,999; $75–99,999; and ≥$100 K, to proportion of days covered (PDC) in multivariable-adjusted regression models. We defined non-adherence as PDC <80%.

Results

Our dataset included 90,163 individuals (age 69.0 ± 10.9 years, 33.1% women, 25.1% non-White race) who underwent PCI. We observed graded, decreased antiplatelet adherence across income categories: rates of PDC≥80% decreased with successively lower income. Individuals with annual income <$40,000 had 1.5-fold higher odds of non-adherence (95% CI, 1.40–1.56) compared to those with income ≥$100,000 after multivariable adjustment.

Conclusions

In a claims-based analysis, we determined that lower income is associated with decreased likelihood of adherence to antiplatelet agents following PCI. Our results indicate the importance of considering social risk factors in the evaluation of barriers to antiplatelet adherence following PCI.

The Impact of Social Support on Treatment Participation and Completion in a Disability Prevention Intervention for Older Adults

Objectives: This study evaluates the role of emotional and instrumental social support on treatment participation and completion using the Positive Minds-Strong Bodies (PMSB) disability prevention program. Methods: Data from a multisite randomized controlled trial of the PMSB program for older adults (≥60 years) with physical impairment and mild to severe depression and/or anxiety were used. Participants were randomly assigned to receive 10 sessions of cognitive behavior therapy (CBT) plus 36 sessions of group exercise or usual care. Results: Adjusting for covariates, higher levels of emotional social support at baseline were associated with increased odds of completing the recommended number of CBT sessions (6 or more, OR = 2.58, p = .030), attending 5.56 more exercise sessions (p = .006), and increased odds of completing the recommended exercise sessions (25 or more, OR = 2.37, p = .047). Discussion: Emotional social support appears to increase dosage in a disability prevention program.

Changes in chronic medication adherence, costs, and health care use after a cancer diagnosis among low-income patients and the role of patient-centered medical homes

BACKGROUND

Approximately 40% of patients with cancer also have another chronic medical condition. Patient-centered medical homes (PCMHs) have improved outcomes among patients with multiple chronic comorbidities. The authors first evaluated the impact of a cancer diagnosis on chronic medication adherence among patients with Medicaid coverage and, second, whether PCMHs influenced outcomes among patients with cancer.

METHODS

Using linked 2004 to 2010 North Carolina cancer registry and claims data, the authors included Medicaid enrollees who were diagnosed with breast, colorectal, or lung cancer who had hyperlipidemia, hypertension, and/or diabetes mellitus. Using difference-in-difference methods, the authors examined adherence to chronic disease medications as measured by the change in the percentage of days covered over time among patients with and without cancer. The authors then further evaluated whether PCMH enrollment modified the observed differences between those patients with and without cancer using a differences-in-differences-in-differences approach. The authors examined changes in health care expenditures and use as secondary outcomes.

RESULTS

Patients newly diagnosed with cancer who had hyperlipidemia experienced a 7-percentage point to 11-percentage point decrease in the percentage of days covered compared with patients without cancer. Patients with cancer also experienced significant increases in medical expenditures and hospitalizations compared with noncancer controls. Changes in medication adherence over time between patients with and without cancer were not determined to be statistically significantly different by PCMH status. Some PCMH patients with cancer experienced smaller increases in expenditures (diabetes) and emergency department use (hyperlipidemia) but larger increases in their inpatient hospitalization rates (hypertension) compared with non-PCMH patients with cancer relative to patients without cancer.

CONCLUSIONS

PCMHs were not found to be associated with improvements in chronic disease medication adherence, but were associated with lower costs and emergency department visits among some low-income patients with cancer.

Reliability and Validity of the M-MALMAS Instrument to Assess Medication Adherence in Malay-Speaking Patients with Type 2 Diabetes

BACKGROUND

The English Malaysian Medication Adherence Scale (MALMAS) has been validated for assessing medication adherence of people with type 2 diabetes. However, Malay is the national language of Malaysia.

OBJECTIVES

The aim of this study was to cross-culturally adapt and validate the Malay MALMAS (M-MALMAS) in Malaysia.

METHODS

Adults with type 2 diabetes, who could understand Malay, were recruited between May 2016 and February 2017 from a primary care clinic in Kuala Lumpur, Malaysia. The M-MALMAS and the Malay version of the Morisky Medication Adherence Scale (MMAS-8) were administered at baseline to test for convergent validity. Four weeks later, the M-MALMAS was re-administered. Predictive validity of the M-MALMAS was assessed by correlating the medication adherence scores with levels of glycated haemoglobin (HbA_1c).

RESULTS

In total, 100 of 104 people agreed to participate (response rate = 96.2%). The overall Cronbach's α and McDonald's Ω for the M-MALMAS was 0.654 and 0.676, respectively (mean = 0.665). At test-retest, no significant difference was found for all items. The median total score interquartile range (IQR) of the M-MALMAS was 7.0 (6.0-8.0) and this was significantly correlated to the median total score of the Malay MMAS-8 [median (IQR) = 7.0 (5.8-8.0), p < 0.001]. HbA_1c levels were significantly lower among participants who were adherent to their medications (score: 6-8) versus those who were non-adherent (score < 6, p = 0.018). The sensitivity and specificity of the M-MALMAS was 92% and 32.8%, respectively.

CONCLUSIONS

The M-MALMAS was found to be a valid and reliable instrument for assessing medication adherence of people with type 2 diabetes in Malaysia. The M-MALMAS had a high sensitivity but its specificity was not as good.

High Real-World Medication Adherence and Durable Clinical Benefit in Medicare Patients Treated with 5-Alpha Reductase Inhibitors for Benign Prostatic Hyperplasia

PURPOSE

Although clinical trials demonstrate 5-alpha reductase inhibitors are efficacious treatments for benign prostatic hyperplasia, they have low reported medication adherence outside of clinical trials. We evaluated real-world drug adherence and clinical outcomes in Medicare patients with lower urinary tract symptoms from benign prostatic hyperplasia managed with 5-alpha reductase inhibitor therapy.

MATERIALS AND METHODS

Using health care and pharmacy claims from Partners Healthcare Medicare Accountable Care Organization enrollees (January 2009 to July 2018), we identified men initiating a 5-alpha reductase inhibitor for benign prostatic hyperplasia with more than 1 medication dispensation. Adherence was calculated as an 80% or greater proportion of days covered. A Cox proportional hazards model was used to evaluate the primary outcome of treatment failure, defined as any benign prostatic hyperplasia related surgery.

RESULTS

Among 3,107 men initiating 5-alpha reductase inhibitor therapy for benign prostatic hyperplasia and filling at least 2 prescriptions, 74.9% had high medication adherence during the first year. Patients with low adherence had 29% higher hazards of undergoing surgical intervention (95% CI 1.02-1.59, p=0.036) after adjusting for age, benign prostatic hyperplasia severity, presence of hematuria, bladder stones and type of 5-alpha reductase inhibitors. The presence of bladder stones (HR 1.70, 95% CI 1.02-2.86, p=0.04) and finasteride vs dutasteride use (HR 1.41, 95% CI 1.01-1.98, p=0.05) were also risk factors for surgical intervention.

CONCLUSIONS

Among Medicare patients 5-alpha reductase inhibitor treatment adherence was high and associated with lower hazards of surgical intervention. 5-Alpha reductase inhibitor therapy may be more feasible for older men with benign prostatic hyperplasia than previously reported and demonstrates modest clinical benefit.

Social Risk Factors for Medication Nonadherence: Findings from the CARDIA Study

Objectives: Nonadherence to medications has been documented, but the combined effect of social risk factors on medication nonadherence has not been investigated. Methods: We conducted a cross-sectional analysis of data from the Coronary Artery Risk Development in Young Adults (CARDIA) study, a population-based prospective cohort. The sample (N = 1506) included subjects who at Year 20 (2005-06) were taking prescription medications and completed a 4-item Medication Adherence Scale. Social risk factors were education of high school or less, annual household income <$25,000, high financial strain, high chronic stress, low social support, and high social strain. Results: In a fully adjusted logistic regression model, income <$25,000 (OR = 2.37 [95% CI 1.12-4.98], p < .05) and high chronic stress (OR = 2.07 [95% CI 1.09-3.94], p < .05) were significantly associated with medication nonadherence. Individuals with ≥3 social risk factors had >3 times higher odds of nonadherence than counterparts with no social risk factors (OR = 3.26 [95% CI 1.72-6.19], p < .001). Conclusion: Low income and chronic stress are associated with medication nonadherence, and the odds of nonadherence increase with the accumulation of social risk factors. Findings may be used to develop risk prediction tools to identify individuals who can benefit from adherence-promoting interventions.

Development of an algorithm to link electronic health record prescriptions with pharmacy dispense claims

Objective

Medication adherence is an important aspect of chronic disease management. Electronic health record (EHR) data are often not linked to dispensing data, limiting clinicians' understanding of which of their patients fill their medications, and how to tailor care appropriately. We aimed to develop an algorithm to link EHR prescribing to claims-based dispensing data and use the results to quantify how often patients with diabetes filled prescribed chronic disease medications.

Materials and Methods

We developed an algorithm linking EHR prescribing data (RxNorm terminology) to claims-based dispensing data (NDC terminology), within sample of adult (19-64) community health center (CHC) patients with diabetes from a network of CHCs across 12 states. We demonstrate an application of the method by calculating dispense rates for a set of commonly prescribed diabetes and cardio-protective medications. To further inform clinical care, we computed adjusted odds ratios of dispense by patient-, encounter-, and clinic-level characteristics.

Results

Seventy-six percent of cardio-protective medication prescriptions and 74% of diabetes medications were linked to a dispensing record. Age, income, ethnicity, insurance, assigned primary care provider, comorbidity, time on EHR, and clinic size were significantly associated with odds of dispensing.

Discussion

EHR prescriptions and pharmacy dispense data can be linked at the record level across different terminologies. Dispensing rates in this low-income population with diabetes were similar to other populations.

Conclusion

Record linkage resulted in the finding that CHC patients with diabetes largely had their chronic disease medications dispensed. Understanding factors associated with dispensing rates highlight barriers and opportunities for optimal disease management.

Accuracy of Prescription Claims Data in Identifying Truly Nonadherent Patients

BACKGROUND

Administrative claims data are increasingly used to identify nonadherent patients. This necessitates a comprehensive review and assessment of their accuracy in identifying nonadherent patients.

OBJECTIVES

To (a) compare administrative claims-based measures of adherence with nonadherence verified by patient interview; (b) determine if and to what extent patients classified as nonadherent based on prescription claims differ from patients classified as nonadherent based on interventions designed to gather multiple types of medication lists to compare against the prescription fill history; and (c) assess the various patient-reported reasons for nonadherence.

METHODS

A cross-sectional study was used to identify patients from the Southern Piedmont Community Care Network of North Carolina who were enrolled with Medicaid between January 1, 2012, and May 31, 2013, and were using prescription medications for 1 or more chronic conditions. Patients with more than a 30-day gap in refill history were identified using prescription claims and were interviewed by pharmacists to assess the reasons for nonadherence. Based on the patient-reported reasons for a gap in refill, patients were classified as interview-verified nonadherent patients or interview-verified adherent patients. The positive predictive value of prescription claims in identifying nonadherent patients was calculated, and descriptive statistics were reported. Characteristics of interview-verified nonadherent patients were compared with adherent patients using t-tests and chi-square statistics.

RESULTS

1,425 patients representing 2,936 patient-class of medication combinations were included in the final analysis. 824 (28.07%) of the 2,936 records that were flagged as nonadherent using claims analysis were confirmed as adherent during patient interviews. The positive predictive value of claims records in identifying nonadherent patients was 0.72. The 2 most common reasons for patients to be misclassified as nonadherent in claims data following self-report were discontinuation of medication on prescribers' directions (21.93%) and having an alternate channel for receiving the medication (6.13%). Among interview-verified nonadherent patients, side effects, patient beliefs, education, and socioeconomic barriers were the most common patient-reported reasons for gaps in refill.

CONCLUSIONS

Prescription claims may underestimate adherence in patients. When interviewed directly by a pharmacist, most patients reported discontinuation of medication as per prescribers' directions. To determine the overall validity of prescription claims data, further analysis is required to assess its accuracy in identifying truly nonadherent patients among those who are identified as nonadherent by claims data.

DISCLOSURES

No outside funding supported this study. Glassberg and Wei were employees at Community Care of North Carolina when this research was conducted. Trygstad is an employee of Community Care of North Carolina; Robinson is an employee of Community Care of Southern Piedmont, a subsidiary of Community Care of North Carolina. The geographies, health care professionals, and subjects involved in the study were related to the care coordination work that Community Care of North Carolina was charged with implementing through its informatics and subject matter expertise assistance provided to these local entities to augment primary care activities. Farley has received funding from the Agency for Healthcare Research and Quality, Centers for Disease Control and Prevention, American College of Clinical Pharmacy, the National Institutes of Health, and Community Care of North Carolina and has also received consulting funds from UCB. The other authors have nothing additional to report.

Association between adherence to sodium channel blockers and patient-reported outcomes: Analysis of US survey data among patients with epilepsy

OBJECTIVE

The objective of this study was to examine the relationship between adherence to treatment with sodium channel blockers (SCBs) and health-related quality of life (HRQoL), work productivity and activity impairment (WPAI), healthcare resource utilization (HRU), and associated costs among patients with epilepsy.

METHODS

This retrospective cross-sectional study used data from the 2017 US National Health and Wellness Survey (NHWS; N = 75,004). Health-related quality of life (Study Short-Form 36-Item Health Survey version 2 [SF-36v2]), WPAI (Work Productivity and Activity Impairment-General Health [WPAI-GH] questionnaire), HRU, and annual costs were compared among respondents with epilepsy using SCBs categorized as low/medium adherence (n = 120) and high adherence (n = 80) using generalized linear models, controlling for patient characteristics.

RESULTS

Mental component score, Short-Form 6-Dimension (SF-6D) health utility index, bodily pain, mental health, physical functioning, role emotional, social functioning, and vitality scores were significantly lower in low/medium adherence respondents than in high adherence respondents (for all, p < 0.05). Only activity impairment was significantly higher in low/medium adherence respondents compared with the high adherence group (p < 0.001). Healthcare resource utilization did not differ significantly between the two groups; however, the number of emergency room (ER) visits and total costs were lower in the high adherence group (p = 0.038) compared with the low/medium adherence group (p = 0.040).

CONCLUSION

High adherence to SCBs was associated with improved HRQoL, lower WPAI, and lower HRU and associated costs among patients with epilepsy. Therefore, adherence to SCBs may be an important factor in improving the abovementioned patient-reported outcomes. Findings from this study can help provide further impetus to healthcare policymakers and clinicians for addressing the low antiepileptic drug (AED) adherence levels in adult patients with epilepsy.

Health Care Utilization After Paraprofessional-administered Substance Use Screening, Brief Intervention, and Referral to Treatment: A Multi-level Cost-offset Analysis

BACKGROUND

Authorities recommend universal substance use screening, brief intervention, and referral to treatment (SBIRT) for all (ie, universal) adult primary care patients.

OBJECTIVE

The objective of this study was to examine long-term (24-mo) changes in health care utilization and costs associated with receipt of universal substance use SBIRT implemented by paraprofessionals in primary care settings.

RESEARCH DESIGN

This study used a difference-in-differences design and Medicaid administrative data to assess changes in health care use among Medicaid beneficiaries receiving SBIRT. The difference-in-differences estimates were used in a Monte Carlo simulation to estimate potential cost-offsets associated with SBIRT.

SUBJECTS

The treatment patients were Medicaid beneficiaries who completed a 4-question substance use screen as part of an SBIRT demonstration program between 2006 and 2011. Comparison Medicaid patients were randomly selected from matched clinics in Wisconsin.

MEASURES

The study includes 4 health care utilization measures: outpatient days; inpatient length of stay; inpatient admissions; and emergency department admissions. Each outcome was assigned a unit cost based on mean Wisconsin Medicaid fee-for-service reimbursement amounts.

RESULTS

We found an annual increase of 1.68 outpatient days (P=0.027) and a nonsignificant annual decrease in inpatient days of 0.67 days (P=0.087) associated with SBIRT. The estimates indicate that the cost of a universal SBIRT program could be offset by reductions in inpatient utilization with an annual net cost savings of $782 per patient.

CONCLUSIONS

Paraprofessional-delivered universal SBIRT is likely to yield health care cost savings and is a cost-effective mechanism for integrating behavioral health services in primary care settings.

Adherence trajectories of buprenorphine therapy among pregnant women in a large state Medicaid program in the United States

PURPOSE

Little is known about the longitudinal patterns of buprenorphine adherence among pregnant women with opioid use disorder, especially when late initiation, nonadherence, or early discontinuation of buprenorphine during pregnancy may increase the risk of adverse outcomes. We aimed to identify distinct trajectories of buprenorphine use during pregnancy, and factors associated with these trajectories in Medicaid-enrolled pregnant women.

METHODS

A retrospective cohort study included 2361 Pennsylvania Medicaid enrollees aged 15 to 46 having buprenorphine therapy during pregnancy and a live birth between 2008 and 2015. We used group-based trajectory models to identify buprenorphine use patterns in the 40 weeks prior to delivery and 12 weeks postdelivery. Multivariable multinomial logistic regression models were used to identify factors associated with specific trajectories.

RESULTS

Six distinct trajectories were identified. Four groups initiated buprenorphine during the first trimester of the pregnancy (early initiators): 31.6% with persistently high adherence, 15.1% with moderate-to-high adherence, 10.5% with declining adherence, and 16.7% with early discontinuation. Two groups did not initiate buprenorphine until midsecond or third trimester (late initiators): 13.5% had moderate-to-high adherence and 12.6% had low-to-moderate adherence. Factors significantly associated with late initiation and discontinuation were younger age, non-white race, residents of rural counties, fewer outpatient visits, more frequent emergency department visits and hospitalizations, and lower buprenorphine daily dose.

CONCLUSIONS

Six buprenorphine treatment trajectories during pregnancy were identified in this population-based Medicaid cohort, with 25% of women initiating buprenorphine late during pregnancy. Understanding trajectories of buprenorphine use and factors associated with discontinuation/nonadherence may guide integration of behavioral treatment with obstetrical/gynecological care to improve buprenorphine treatment during pregnancy.

The association between adherence to levothyroxine and economic and clinical outcomes in patients with hypothyroidism in the US

OBJECTIVE

To evaluate outcomes associated with adherence to levothyroxine (LT4) in the US adult hypothyroidism population.

METHODS

We used data from Truven's MarketScan databases from 1 July 2011 through 31 December 2015. Patients aged 18 or older were diagnosed with hypothyroidism (confirmed at least twice) and prescribed LT4. Patients were excluded if they did not have continuous insurance coverage or if they received a diagnosis of thyroid cancer or pregnancy during the study period. Multivariable analyses on a matched cohort of adherent and nonadherent patients examined the relationships among patient outcomes and adherence, defined as the proportion of days covered ≥80%. Outcomes included all-cause and hypothyroidism-related medical costs and resource utilization and comorbid diagnoses measured over the 1 year post-period following the first prescription for LT4. The analyses controlled for patient age, sex, region of residence, type of insurance coverage, diagnosing physician and pre-period general health status as proxied by the Charlson Comorbidity Index.

RESULTS

Prior to matching, there were 168,457 patients identified as adherent and 198,443 patients identified as nonadherent. The matched cohort consisted of 318,628 individuals, with equal numbers of adherent and nonadherent patients (n = 159,314). Patients who were adherent used significantly fewer resources and had significantly lower all-cause ($14,136 vs. $14,926; p < .0001) and hypothyroidism-related ($1672 vs. $1709; p < .0001) total costs, although the costs of drugs were higher in the adherent group. Furthermore, adherent patients, compared to nonadherent patients, were significantly less likely to be diagnosed with comorbid Addison's disease, bipolar disorder, chronic kidney disease, depression, migraine, obesity, type 1 diabetes or type 2 diabetes during the follow-up period.

CONCLUSIONS

Compared to nonadherence, adherence to LT4 among patients with hypothyroidism was associated with a significant reduction in all-cause and hypothyroidism-related costs and resource utilization as well as significantly lower rates of many comorbid diagnoses.

Medication adherence in chronic illness: do beliefs about medications play a role?

BACKGROUND

Several medicines are prescribed for chronic disease management; however, adherence to long-term therapy remains poor. Culture influences beliefs about medications and, ultimately, adherence to treatment. There is a paucity of data with regard to beliefs about medications in the Middle East region, and it remains to be determined how these beliefs would impact treatment adherence.

OBJECTIVES

To investigate the relationship between patients' beliefs about medications with self-reported adherence to treatment among a chronically ill multicultural patient population.

METHODS

A prospective cross-sectional study was conducted among patients treated for chronic illnesses in the Ministry of Health primary care clinics in Kuwait. Patients completed a questionnaire that consisted of questions to collect information about their health status and demographics using validated instruments: the Beliefs about Medication, Sensitive Soma Assessment Scale, and Medication Adherence Report Scale-5 items. The main outcome measures were self-reported adherence to medications, beliefs, and perceived sensitivity toward medications.

RESULTS

Of the 1,150 questionnaires distributed, 783 were collected - giving a response rate of 68.1%. Of the 783 patients, 56.7% were male, 73.7% were married, 53.3% were non-Kuwaitis, and 49.4% had low income (<1,000 KD/3,350 USD monthly). Patients self-reported having a cardiovascular illness (80.2%), diabetes mellitus (67.7%), respiratory disease (24.3%), or mood disorder (28.6%). Participants had a mean of two comorbid illnesses and indicated taking an average of four prescription medicines to treat them. A structural equation model analysis showed adherence to medications was negatively impacted by higher negative beliefs toward medications (beta = -0.46). Factors associated with negative beliefs toward medications included marital status (being unmarried; beta = -0.14), nationality (being Kuwaiti; beta = 0.15), having lower education level (beta = -0.14), and higher illness severity (beta = 0.15). Younger age (beta = 0.10) and higher illness severity (beta = -0.9) were independently associated with lower medication adherence. Income and gender did not influence medication adherence or beliefs about medications. The combined effect of variables tested in the model explained 24% of the variance in medication adherence.

CONCLUSION

Medication adherence is a complex, multifaceted issue and patient beliefs about medications contribute significantly, although partially, to adherence among a multicultural Middle Eastern patient population.

Evaluation of medication adherence in chronic disease at a federally qualified health center

BACKGROUND

While medication adherence in chronic disease has been evaluated in the general population, limited data are available among Medicaid recipients, especially within federally qualified health centers (FQHCs). This study determined baseline medication adherence for Medicaid recipients receiving care in an FQHC for first-line medications used in hypertension, hyperlipidemia, and diabetes. Secondary outcomes included baseline adherence for individual patient factors.

METHODS

Patients from the Salud Family Health Centers, an FQHC with a large percentage of both Spanish-speaking patients and providers, were included in this study. Using retrospective prescription claims reports from 1 January 2015 to 1 October 2015, medication possession ratios (MPRs) and proportion of days covered (PDC) were calculated for each medication group. Patients with adherence ⩾0.80 were considered adherent.

RESULTS

From 1034 individual patients, 1788 medications were evaluated. Using MPRs, adherence rates were highest among medications for hypertension (67.2% adherent), followed by hyperlipidemia (67.0%), and lastly diabetes (58.0%); p < 0.001. Likewise, using PDC, adherence rates were highest for medications for hypertension (56.6%), followed by hyperlipidemia (52.2%), and lastly diabetes (45.0%); p = 0.010. Lower rates of adherence were seen among men, patients age 18-29 years old, African Americans, and patients with English documented as their preferred language.

CONCLUSIONS

Although overall medication adherence rates within our FQHC patients were comparable with those in previous literature, differences seen among medication groups and patient individual factors suggest that there is still much to be learned in improving adherence. Future efforts will require a multifaceted approach, tailored to patient-specific needs.

Association between trajectories of buprenorphine treatment and emergency department and in-patient utilization

BACKGROUND AND AIMS

Uncertainty about optimal treatment duration for buprenorphine opioid agonist therapy may lead to substantial variation in provider and payer decision-making regarding treatment course. We aimed to identify distinct trajectories of buprenorphine use and examine outcomes associated with these trajectories to guide health system interventions regarding treatment length.

DESIGN

Retrospective cohort study.

SETTING

US Pennsylvania Medicaid.

PATIENTS

A total of 10 945 enrollees aged 18-64 years initiating buprenorphine treatment between 2007 and 2012.

MEASUREMENTS

Group-based trajectory models were used to identify trajectories based on monthly proportion of days covered with buprenorphine in the 12 months post-treatment initiation. We used separate multivariable Cox proportional hazard models to examine associations between trajectories and time to first all-cause hospitalization and emergency department (ED) visit within 12 months after the first-year treatment.

FINDINGS

Six trajectories [Bayesian information criterion (BIC) = -86 246.70] were identified: 24.9% discontinued buprenorphine < 3 months, 18.7% discontinued between 3 and 5 months, 12.4% discontinued between 5 and 8 months, 13.3% discontinued > 8 months, 9.5% refilled intermittently and 21.2% refilled persistently for 12 months. Persistent refill trajectories were associated with an 18% lower risk of all-cause hospitalizations [hazard ratio (HR) = 0.82, 95% confidence interval (CI) = 0.70-0.95] and 14% lower risk of ED visits (HR = 0.86, 95% CI = 0.78-0.95) in the subsequent year, compared with those discontinuing between 3 and 5 months.

CONCLUSIONS

Six distinct buprenorphine treatment trajectories were identified in this population-based low-income Medicaid cohort in Pennsylvania, USA. There appears to be an association between persistent use of buprenorphine for 12 months and lower risk of all-cause hospitalizations/emergency department visits.

Psychosocial factors associated with medication adherence in ethnically and socioeconomically diverse patients with epilepsy

The current study examined psychosocial correlates of medication adherence in a socioeconomically and racially diverse sample of patients with epilepsy. Fifty-five patients with epilepsy completed standardized self-report questionnaires measuring depression, stress, social support, and medication and illness beliefs. Antiepileptic drug (AED) adherence was measured using the 8-item Morisky Medication Adherence Scale 36% reported poor adherence. We tested which psychosocial factors were independently and most strongly associated with AED adherence. Stress and depression were negatively correlated with adherence, while perceived social support was positively correlated with adherence (Ps<.05). When all three of these variables and relevant covariates in a multiple regression model were included, only perceived social support remained a significant predictor of adherence (P=.015). This study is one of the first to suggest the importance of targeting social support in screening and intervention approaches in order to improve AED adherence among low-income, racially/ethnically diverse patients with epilepsy.

Do medical homes increase medication adherence for persons with multiple chronic conditions?

BACKGROUND

Medications are an integral component of management for many chronic conditions, and suboptimal adherence limits medication effectiveness among persons with multiple chronic conditions (MCC). Medical homes may provide a mechanism for increasing adherence among persons with MCC, thereby enhancing management of chronic conditions.

OBJECTIVE

To examine the association between medical home enrollment and adherence to newly initiated medications among Medicaid enrollees with MCC.

RESEARCH DESIGN

Retrospective cohort study comparing Community Care of North Carolina medical home enrollees to nonenrollees using merged North Carolina Medicaid claims data (fiscal years 2008-2010).

SUBJECTS

Among North Carolina Medicaid-enrolled adults with MCC, we created separate longitudinal cohorts of new users of antidepressants (N=9303), antihypertensive agents (N=12,595), oral diabetic agents (N=6409), and statins (N=9263).

MEASURES

Outcomes were the proportion of days covered (PDC) on treatment medication each month for 12 months and a dichotomous measure of adherence (PDC>0.80). Our primary analysis utilized person-level fixed effects models. Sensitivity analyses included propensity score and person-level random-effect models.

RESULTS

Compared with nonenrollees, medical home enrollees exhibited higher PDC by 4.7, 6.0, 4.8, and 5.1 percentage points for depression, hypertension, diabetes, and hyperlipidemia, respectively (P's<0.001). The dichotomous adherence measure showed similar increases, with absolute differences of 4.1, 4.5, 3.5, and 4.6 percentage points, respectively (P's<0.001).

CONCLUSIONS

Among Medicaid enrollees with MCC, adherence to new medications is greater for those enrolled in medical homes.

Clinical metric and medication persistency effects: evidence from a Medicaid care management program

The objective was to estimate clinical metric and medication persistency impacts of a care management program. The data sources were Medicaid administrative claims for a sample population of 32,334 noninstitutionalized Medicaid-only aged, blind, or disabled patients with diagnosed conditions of asthma, coronary artery disease, chronic obstructive pulmonary disease, diabetes, or heart failure between 2005 and 2009. Multivariate regression analysis was used to test the hypothesis that exposure to a care management intervention increased the likelihood of having the appropriate medication or procedures performed, as well as increased medication persistency. Statistically significant clinical metric improvements occurred in each of the 5 conditions studied. Increased medication persistency was found for beta-blocker medication for members with coronary artery disease, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and diuretic medications for members with heart failure, bronchodilator and corticosteroid medications for members with chronic obstructive pulmonary disease, and aspirin/antiplatelet medications for members with diabetes. This study demonstrates that a care management program increases the likelihood of having an appropriate medication dispensed and/or an appropriate clinical test performed, as well as increased likelihood of medication persistency, in people with chronic conditions.

Willingness to take drugs to prevent serious chronic diseases

BACKGROUND

The aim of this study was to determine an individual's willingness to take a preventive therapy for each of two chronic diseases (type 2 diabetes [T2D] and dementia) when provided with varying likelihoods of acquiring the disease.

METHODS

After reading a description of two chronic diseases (i.e. T2D and dementia), 345 student volunteers at McMaster University rated their likelihood of taking a drug that could halve their chance of developing each disease, assuming a 1-year risk of developing the disease of 50%, 25%, and 10%. A five-point Likert scale was used to collect responses.

RESULTS

Assuming an annual incidence of 50%, 27% of respondents were neither likely nor very likely to take a therapy that halved the annual incidence of T2D and 13% were neither likely nor very likely to take a therapy that halved the annual incidence of dementia. Higher quoted incidence rates of the disease and a personal history of a chronic illness significantly increased willingness to take such therapy.

CONCLUSIONS

A high proportion of young educated adults have ambivalent or negative attitudes regarding the use of pharmacological therapy to prevent serious health outcomes even when the absolute 1-year risk of these outcomes is very high.

Medication adherence and its determinants among psychiatric patients in an Ethiopian referral hospital

BACKGROUND

The degree to which an individual follows medical advice is a major concern in every medical specialty. Non-adherence to psychiatric treatment regimens has a profound impact on the disease course, relapse, future recovery, cost of health care, and the outcome for the patient. The aim of this study was to assess medication adherence and its correlates among psychiatric patients at Ayder Referral Hospital, Northern Ethiopia.

METHODS

A cross-sectional study was conducted from June to September 2013 at Ayder Referral Hospital, where 423 patients were selected by a systematic random sampling technique from all patients attending the psychiatric clinic at the hospital. Data were collected by trained data collectors through interview of the patients using a structured questionnaire. The collected data were entered into Epi Info version 7 and analyzed by Statistical Package for the Social Sciences version 16 software. Logistic regression was used to assess independent predictors of adherence.

RESULTS

A total of 387 patients completed the interview. Two hundred and sixteen (55.8%) and 113 (29.2%) were patients with a diagnosis of schizophrenia and mood disorder, respectively, while 35 (9%) and 23 (5.9%) had a diagnosis of drug addiction and autistic disorder. Two hundred and seven (71.6%) patients were found to be adherent to their medication. When adherence rates were observed according to type of disorder, 60 (53.1%), 24 (68.6%), 149 (69%), and 18 (78.3%) of patients with mood disorder, drug addiction, schizophrenia, and autism, respectively, were adherent to their medications. Female gender (adjusted odds ratio [AOR] 2.34; 95% confidence interval [CI] 1.45-3.74), tertiary education (AOR 2.69; 95% CI 1.46-4.85), living with family (AOR 2.57; 95% CI 1.66-4.58), and shorter treatment duration (AOR 1.82; 95% CI 1.21-2.84) were among the variables associated with better adherence.

CONCLUSION

Suboptimal adherence was observed among psychiatric patients in this study. Health professionals in the psychiatric clinic and pharmacists need to focus on and counsel patients about adherence and its implications for their clinical outcome.