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Senay A, Fernandes JC, Delisle J, Morin SN, Perreault S. Persistence and compliance to osteoporosis therapy in a fracture liaison service: a prospective cohort study. Arch Osteoporos 2019; 14:87. [PMID: 31375983 DOI: 10.1007/s11657-019-0633-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 07/11/2019] [Indexed: 02/03/2023]
Abstract
UNLABELLED Persistence and compliance to osteoporosis medications aiming to prevent fragility fractures are essential for fracture prevention, but are suboptimal in the population. A Fracture Liaison Service with a systematic follow-up led to ongoing therapy and optimal drug compliance for more than half of treated patients over 2 years. PURPOSE Fracture Liaison Services (FLS) have the potential to improve persistence and compliance to osteoporosis therapy. We aimed to assess patterns of drug use in a high-level intervention FLS. METHODS Women and men (> 40 years) with a fragility fracture were recruited in a FLS, where osteoporosis therapy was prescribed if appropriate. Based on claims data, patients who filled their prescription in the 3-month period following baseline were selected. The 1- and 2-year persistence rates were measured using survival analysis. In non-persistent subjects, 1-year treatment re-initiation was measured. The 1- and 2-year compliance levels were measured, using the proportion of days covered (PDC > 80% = compliant). Regression analyses were performed to identify predictors of non-persistence/compliance. RESULTS Out of 332 subjects with complete drug insurance coverage, 297 (89.5%) were prescribed osteoporosis therapy by the FLS, and 275 (92.6%) were dispensed. Two hundred sixty participants (86.9% female; mean age 65.6 years) were selected for having filled a prescription inside 3 months after baseline. The 1- and 2-year persistence rates were 66.4% and 55.6%, respectively. Treatment re-initiation was observed in 56% of non-persistent patients. PDC was > 80% in 64.2% for 1 year and 62.5% for 2 years. Older and younger age, smoking, higher spine bone mineral density, lower major FRAX risk, and missing follow-up visits were predictors of non-persistence and/or non-compliance. CONCLUSIONS After 2 years in a high-level intervention FLS, more than half the treated participants were persistent and compliant to treatment. Comparative effectiveness studies must be undertaken to determine whether this intervention is an improvement over usual care.
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Affiliation(s)
- Andréa Senay
- Faculty of Pharmacy, Université de Montréal, C. P. 6128, Succursale Centre-Ville, Montréal, Québec, H3C 3J7, Canada.,CIUSSS Nord de l'Ile de Montréal, Hôpital du Sacré-Coeur de Montréal, 5400 bl. Gouin ouest, Montréal, Quebec, H4J 1C5, Canada
| | - Julio C Fernandes
- CIUSSS Nord de l'Ile de Montréal, Hôpital du Sacré-Coeur de Montréal, 5400 bl. Gouin ouest, Montréal, Quebec, H4J 1C5, Canada.,Faculty of Medicine, Université de Montréal, 2900 bl. Édouard-Montpetit, Montréal, Quebec, H3T 1J4, Canada.,CIUSSS Nord de l'Ile de Montréal, Hôpital Jean-Talon, 1385 rue Jean-Talon est, Montréal, Quebec, H2E 1S6, Canada
| | - Josée Delisle
- CIUSSS Nord de l'Ile de Montréal, Hôpital du Sacré-Coeur de Montréal, 5400 bl. Gouin ouest, Montréal, Quebec, H4J 1C5, Canada.,CIUSSS Nord de l'Ile de Montréal, Hôpital Jean-Talon, 1385 rue Jean-Talon est, Montréal, Quebec, H2E 1S6, Canada
| | - Suzanne N Morin
- Department of Medicine, Center for Outcomes and Evaluation, McGill University, 5252 de Maisonneuve ouest, Montréal, Quebec, H4A 3S5, Canada
| | - Sylvie Perreault
- Faculty of Pharmacy, Université de Montréal, C. P. 6128, Succursale Centre-Ville, Montréal, Québec, H3C 3J7, Canada. .,Sanofi Aventis endowment Research Chair in Optimal Drug Use, Université de Montréal, Montréal, Quebec, Canada.
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Martín-Merino E, Huerta-Álvarez C, Prieto-Alhambra D, Montero-Corominas D. Cessation rate of anti-osteoporosis treatments and risk factors in Spanish primary care settings: a population-based cohort analysis. Arch Osteoporos 2017; 12:39. [PMID: 28401495 DOI: 10.1007/s11657-017-0331-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 03/29/2017] [Indexed: 02/03/2023]
Abstract
UNLABELLED Among 95,057 patients ≥50 years with new anti-osteoporosis medications (AOM) (2001-2013) in primary care, 1-year cessation was 51% (28%-68%), higher in men, smokers, patients with missing lifestyle data, and out normal BMI, and lower in those aged 60-79, with recent fractures or other anti-osteoporotics, suggesting non-severe osteoporosis and less risk awareness. PURPOSE Low compliance to anti-osteoporosis medications (AOM) has been previously reported. We aimed to estimate 1-year cessation rates of different AOMs as used in Spanish healthcare settings, and to identify associated risk factors. METHODS A cohort study was performed using primary care records data (BIFAP). Patients entered the cohort when aged 50 years in 2001-2013, with ≥1 year of data available, and identified as incident users of AOM (1-year washout). Participants were divided into six cohorts: alendronate, other oral bisphosphonates, selective oestrogen receptor modulators, strontium ranelate, teriparatide, and denosumab. Patients were followed from therapy initiation to the earliest of cessation (90-day refill gap), switching (to alternative AOM), loss to follow-up, death, or end of 2013. One-year therapy cessation was estimated using life tables. Hazard ratios (of cessation) according to age, sex, lifestyle factors, morbidity, and co-medication were estimated after stepwise backwards selection. RESULTS A total of 95,057 AOM users were identified (91% women; mean age 68). One-year cessation was 51% overall, highest for strontium ranelate (68%), and lowest for denosumab (28%). Cessation probability was higher in men (14% to 2.1-fold), smokers (>6%), and patients with missing BMI (19-28%) or smoking (6-20%) data, and overweight/obese/underweight (7% to 2.6-fold increase compared to normal weight). Patients aged 60-79 years, with a recent fracture or other drugs used for osteoporosis, had better persistence. CONCLUSIONS Over half of the patients initiating AOM stopped therapy within the first year after initiation. The described risk factors for cessation could be proxies for non-severe osteoporosis, and/or disease/risk awareness, which could inform the targeting of high-risk patients for monitoring and/or interventions aimed at improving persistence.
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Affiliation(s)
- Elisa Martín-Merino
- Division of Pharmacoepidemiology and Pharmacovigilance, Spanish Agency of Medicines and Medical Devices (AEMPS), Madrid, Spain.
| | - Consuelo Huerta-Álvarez
- Division of Pharmacoepidemiology and Pharmacovigilance, Spanish Agency of Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - Daniel Prieto-Alhambra
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Grup de Recerca en Malalties Prevalents de l'Aparell Locomotor (GREMPAL) Research Group, IDIAP Jordi Gol Primary Care Research Institute, and CIBERFES, Universitat Autònoma de Barcelona and Instituto de Salud Carlos III, Universitat Autònoma de Barcelona, Instituto de Salud Carlos III, Barcelona, Spain
| | - Dolores Montero-Corominas
- Division of Pharmacoepidemiology and Pharmacovigilance, Spanish Agency of Medicines and Medical Devices (AEMPS), Madrid, Spain
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Mitchell P, Åkesson K, Chandran M, Cooper C, Ganda K, Schneider M. Implementation of Models of Care for secondary osteoporotic fracture prevention and orthogeriatric Models of Care for osteoporotic hip fracture. Best Pract Res Clin Rheumatol 2017; 30:536-558. [PMID: 27886945 DOI: 10.1016/j.berh.2016.09.008] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 09/09/2016] [Accepted: 09/10/2016] [Indexed: 12/29/2022]
Abstract
As the world's population ages, the prevalence of osteoporosis and its resultant fragility fractures is set to increase dramatically. This chapter focuses on current frameworks and major initiatives related to the implementation of fracture liaison services (FLS) and orthogeriatrics services (OGS), Models of Care designed to reliably implement secondary fracture prevention measures for individuals presenting to health services with fragility fractures. The current evidence base regarding the impact and effectiveness of FLS and OGS is also considered.
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Affiliation(s)
- Paul Mitchell
- Synthesis Medical NZ Limited, Pukekohe, New Zealand; University of Notre Dame Australia, Sydney, Australia; Osteoporosis New Zealand, Wellington, New Zealand.
| | - Kristina Åkesson
- Department of Orthopaedics, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Manju Chandran
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, ACADEMIA, 20 College Road, 169856, Singapore
| | - Cyrus Cooper
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK; National Institute of Health Research (NIHR) Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK; NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, The Botnar Research Centre, University of Oxford, Oxford, UK
| | - Kirtan Ganda
- The University of Sydney, Concord Clinical School and Concord Repatriation General Hospital, 1A Hospital Road, Concord Hospital, NSW, 2139, Australia
| | - Muriel Schneider
- International Osteoporosis Foundation, 9, Rue Juste-Olivier, 1260, Nyon, Switzerland
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Judge A, Javaid MK, Leal J, Hawley S, Drew S, Sheard S, Prieto-Alhambra D, Gooberman-Hill R, Lippett J, Farmer A, Arden N, Gray A, Goldacre M, Delmestri A, Cooper C. Models of care for the delivery of secondary fracture prevention after hip fracture: a health service cost, clinical outcomes and cost-effectiveness study within a region of England. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04280] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BackgroundProfessional bodies have produced comprehensive guidance about the management of hip fracture. They recommend orthogeriatric services focusing on achieving optimal recovery, and fracture liaison services (FLSs) focusing on secondary fracture prevention. Despite such guidelines being in place, there is significant variation in how services are structured and organised between hospitals.ObjectivesTo establish the clinical effectiveness and cost-effectiveness of changes to the delivery of secondary fracture prevention services, and to identify barriers and facilitators to changes.DesignA service evaluation to identify each hospital’s current models of care and changes in service delivery. A qualitative study to identify barriers and facilitators to change. Health economics analysis to establish NHS costs and cost-effectiveness. A natural experimental study to determine clinical effectiveness of changes to a hospital’s model of care.SettingEleven acute hospitals in a region of England.ParticipantsQualitative study – 43 health professionals working in fracture prevention services in secondary care.InterventionsChanges made to secondary fracture prevention services at each hospital between 2003 and 2012.Main outcome measuresThe primary outcome is secondary hip fracture. Secondary outcomes include mortality, non-hip fragility fracture and the overall rate of hip fracture.Data sourcesClinical effectiveness/cost-effectiveness analyses – primary hip fracture patients identified from (1) Hospital Episode Statistics (2003–13,n = 33,152); and (2) Clinical Practice Research Datalink (1999–2013,n = 11,243).ResultsService evaluation – there was significant variation in the organisation of secondary fracture prevention services, including staffing levels, type of service model (consultant vs. nurse led) and underlying processes. Qualitative – fracture prevention co-ordinators gave multidisciplinary health professionals capacity to work together, but communication with general practitioners was challenging. The intervention was easily integrated into practice but some participants felt that implementation was undermined by under-resourced services. Making business cases for a service was particularly challenging. Natural experiment – the impact of introducing an orthogeriatrician on 30-day and 1-year mortality was hazard ratio (HR) 0.73 [95% confidence interval (CI) 0.65 to 0.82] and HR 0.81 (95% CI 0.75 to 0.87), respectively. Thirty-day and 1-year mortality were likewise reduced following the introduction or expansion of a FLS: HR 0.80 (95% CI 0.71 to 0.91) and HR 0.84 (95% CI 0.77 to 0.93), respectively. There was no significant impact on time to secondary hip fracture. Health economics – the annual cost in the year of hip fracture was estimated at £10,964 (95% CI £10,767 to £11,161) higher than the previous year. The annual cost associated with all incident hip fractures in the UK among those aged ≥ 50 years (n = 79,243) was estimated at £1215M. At a £30,000 per quality-adjusted life-year threshold, the most cost-effective model was introducing an orthogeriatrician.ConclusionIn hip fracture patients, orthogeriatrician and nurse-led FLS models are associated with reductions in mortality rates and are cost-effective, the orthogeriatrician model being the most cost-effective. There was no evidence for a reduction in second hip fracture. Qualitative data suggest that weaknesses lie in treatment adherence/monitoring, a possible reason for the lack of effectiveness on second hip fracture outcome. The effectiveness on non-hip fracture outcomes remains unanswered.Future workReliable estimates of health state utility values for patients with hip and non-hip fractures are required to reduce uncertainty in health economic models. A clinical trial is needed to assess the clinical effectiveness and cost-effectiveness of a FLS for non-hip fracture patients.FundingThe National Institute for Health Research (NIHR) Health Services and Delivery Research programme and the NIHR Musculoskeletal Biomedical Research Unit, University of Oxford.
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Affiliation(s)
- Andrew Judge
- Oxford National Institute for Health Research (NIHR) Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Medical Research Council (MRC) Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - M Kassim Javaid
- Oxford National Institute for Health Research (NIHR) Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Medical Research Council (MRC) Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - José Leal
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Samuel Hawley
- Oxford National Institute for Health Research (NIHR) Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah Drew
- Oxford National Institute for Health Research (NIHR) Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sally Sheard
- Oxford National Institute for Health Research (NIHR) Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Daniel Prieto-Alhambra
- Oxford National Institute for Health Research (NIHR) Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Medical Research Council (MRC) Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
- GREMPAL Research Group (IDIAP Jordi Gol) and Musculoskeletal Research Unit (Fundació IMIM-Parc Salut Mar), Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Janet Lippett
- Elderly Care Unit, Royal Berkshire Hospital, Reading, UK
| | - Andrew Farmer
- Nuffield Department of Primary Care Health Sciences, Oxford, UK
| | - Nigel Arden
- Oxford National Institute for Health Research (NIHR) Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Medical Research Council (MRC) Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Alastair Gray
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Michael Goldacre
- Unit of Health Care Epidemiology, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Antonella Delmestri
- Oxford National Institute for Health Research (NIHR) Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Cyrus Cooper
- Oxford National Institute for Health Research (NIHR) Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Medical Research Council (MRC) Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
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Rance K, Javaid MK. Commissioning, implementation and delivery of an interface secondary fracture prevention service within the NHS: Lessons learnt from the Oxfordshire Fracture Prevention Service. Int J Orthop Trauma Nurs 2015; 19:207-13. [PMID: 26547683 DOI: 10.1016/j.ijotn.2015.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 12/08/2014] [Accepted: 03/16/2015] [Indexed: 11/18/2022]
Abstract
AIMS To provide a case history of the service model, commissioning, implementation and delivery of an interface secondary fracture prevention service. BACKGROUND Fracture Prevention has been identified as key to reducing the burden on the NHS from an ageing population. The need to have a systematic process for identifying, assessing and ensuring treatment adherence is vital. RATIONALE Delivering the service to identify patients at risk and initiate treatment is important as is the use of a database for patient tracking and the need to ensure that patients remain on treatment to ensure maximum fracture prevention benefit, and cost savings are seen. The process for implementing a Fracture Prevention service can be challenging but identifying the components and working closely with local commissioners can provide the evidence and release the resource required. SUMMARY The key components of a Fracture Prevention Service should include robust case-finding, assessment, treatment initiation, patient education and monitoring.
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Affiliation(s)
- Kerri Rance
- Oxford University Hospitals NHS Trust, Oxford, UK.
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Javaid MK, Kyer C, Mitchell PJ, Chana J, Moss C, Edwards MH, McLellan AR, Stenmark J, Pierroz DD, Schneider MC, Kanis JA, Akesson K, Cooper C. Effective secondary fracture prevention: implementation of a global benchmarking of clinical quality using the IOF Capture the Fracture® Best Practice Framework tool. Osteoporos Int 2015; 26:2573-8. [PMID: 26070301 DOI: 10.1007/s00198-015-3192-0] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 05/27/2015] [Indexed: 12/20/2022]
Abstract
UNLABELLED Fracture Liaison Services are the best model to prevent secondary fractures. The International Osteoporosis Foundation developed a Best Practice Framework to provide a quality benchmark. After a year of implementation, we confirmed that a single framework with set criteria is able to benchmark services across healthcare systems worldwide. INTRODUCTION Despite evidence for the clinical effectiveness of secondary fracture prevention, translation in the real-world setting remains disappointing. Where implemented, a wide variety of service models are used to deliver effective secondary fracture prevention. To support use of effective models of care across the globe, the International Osteoporosis Foundation's Capture the Fracture® programme developed a Best Practice Framework (BPF) tool of criteria and standards to provide a quality benchmark. We now report findings after the first 12 months of implementation. METHODS A questionnaire for the BPF was created and made available to institutions on the Capture the Fracture website. Responses from institutions were used to assign gold, silver, bronze or black (insufficient) level of achievements mapped across five domains. Through an interactive process with the institution, a final score was determined and published on the Capture the Fracture website Fracture Liaison Service (FLS) map. RESULTS Sixty hospitals across six continents submitted their questionnaires. The hospitals served populations from 20,000 to 15 million and were a mix of private and publicly funded. Each FLS managed 146 to 6200 fragility fracture patients per year with a total of 55,160 patients across all sites. Overall, 27 hospitals scored gold, 23 silver and 10 bronze. The pathway for the hip fracture patients had the highest proportion of gold grading while vertebral fracture the lowest. CONCLUSION In the first 12 months, we have successfully tested the BPF tool in a range of health settings across the globe. Initial findings confirm a significant heterogeneity in service provision and highlight the importance of a global approach to ensure high quality secondary fracture prevention services.
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Affiliation(s)
- M K Javaid
- NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, University of Oxford, Oxford, UK
| | - C Kyer
- International Osteoporosis Foundation (IOF), Nyon, Switzerland
| | - P J Mitchell
- Synthesis Medical NZ Ltd, Auckland, New Zealand
- University of Notre Dame Australia, Sydney, Australia
| | - J Chana
- Stoke Mandeville Hospital, Aylesbury, Buckinghamshire, UK
| | - C Moss
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - M H Edwards
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | | | - J Stenmark
- International Osteoporosis Foundation (IOF), Nyon, Switzerland
| | - D D Pierroz
- International Osteoporosis Foundation (IOF), Nyon, Switzerland
| | - M C Schneider
- International Osteoporosis Foundation (IOF), Nyon, Switzerland
| | - J A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
| | - K Akesson
- Department of Orthopaedics, Lund University, Skåne University Hospital, Malmö, Sweden
| | - C Cooper
- NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, University of Oxford, Oxford, UK.
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK.
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Ryan R, Santesso N, Lowe D, Hill S, Grimshaw J, Prictor M, Kaufman C, Cowie G, Taylor M. Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews. Cochrane Database Syst Rev 2014; 2022:CD007768. [PMID: 24777444 PMCID: PMC6491214 DOI: 10.1002/14651858.cd007768.pub3] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Many systematic reviews exist on interventions to improve safe and effective medicines use by consumers, but research is distributed across diseases, populations and settings. The scope and focus of such reviews also vary widely, creating challenges for decision-makers seeking to inform decisions by using the evidence on consumers' medicines use.This is an update of a 2011 overview of systematic reviews, which synthesises the evidence, irrespective of disease, medicine type, population or setting, on the effectiveness of interventions to improve consumers' medicines use. OBJECTIVES To assess the effects of interventions which target healthcare consumers to promote safe and effective medicines use, by synthesising review-level evidence. METHODS SEARCH METHODS We included systematic reviews published on the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects. We identified relevant reviews by handsearching databases from their start dates to March 2012. SELECTION CRITERIA We screened and ranked reviews based on relevance to consumers' medicines use, using criteria developed for this overview. DATA COLLECTION AND ANALYSIS We used standardised forms to extract data, and assessed reviews for methodological quality using the AMSTAR tool. We used standardised language to summarise results within and across reviews; and gave bottom-line statements about intervention effectiveness. Two review authors screened and selected reviews, and extracted and analysed data. We used a taxonomy of interventions to categorise reviews and guide syntheses. MAIN RESULTS We included 75 systematic reviews of varied methodological quality. Reviews assessed interventions with diverse aims including support for behaviour change, risk minimisation and skills acquisition. No reviews aimed to promote systems-level consumer participation in medicines-related activities. Medicines adherence was the most frequently-reported outcome, but others such as knowledge, clinical and service-use outcomes were also reported. Adverse events were less commonly identified, while those associated with the interventions themselves, or costs, were rarely reported.Looking across reviews, for most outcomes, medicines self-monitoring and self-management programmes appear generally effective to improve medicines use, adherence, adverse events and clinical outcomes; and to reduce mortality in people self-managing antithrombotic therapy. However, some participants were unable to complete these interventions, suggesting they may not be suitable for everyone.Other promising interventions to improve adherence and other key medicines-use outcomes, which require further investigation to be more certain of their effects, include:· simplified dosing regimens: with positive effects on adherence;· interventions involving pharmacists in medicines management, such as medicines reviews (with positive effects on adherence and use, medicines problems and clinical outcomes) and pharmaceutical care services (consultation between pharmacist and patient to resolve medicines problems, develop a care plan and provide follow-up; with positive effects on adherence and knowledge).Several other strategies showed some positive effects, particularly relating to adherence, and other outcomes, but their effects were less consistent overall and so need further study. These included:· delayed antibiotic prescriptions: effective to decrease antibiotic use but with mixed effects on clinical outcomes, adverse effects and satisfaction;· practical strategies like reminders, cues and/or organisers, reminder packaging and material incentives: with positive, although somewhat mixed effects on adherence;· education delivered with self-management skills training, counselling, support, training or enhanced follow-up; information and counselling delivered together; or education/information as part of pharmacist-delivered packages of care: with positive effects on adherence, medicines use, clinical outcomes and knowledge, but with mixed effects in some studies;· financial incentives: with positive, but mixed, effects on adherence.Several strategies also showed promise in promoting immunisation uptake, but require further study to be more certain of their effects. These included organisational interventions; reminders and recall; financial incentives; home visits; free vaccination; lay health worker interventions; and facilitators working with physicians to promote immunisation uptake. Education and/or information strategies also showed some positive but even less consistent effects on immunisation uptake, and need further assessment of effectiveness and investigation of heterogeneity.There are many different potential pathways through which consumers' use of medicines could be targeted to improve outcomes, and simple interventions may be as effective as complex strategies. However, no single intervention assessed was effective to improve all medicines-use outcomes across all diseases, medicines, populations or settings.Even where interventions showed promise, the assembled evidence often only provided part of the picture: for example, simplified dosing regimens seem effective for improving adherence, but there is not yet sufficient information to identify an optimal regimen.In some instances interventions appear ineffective: for example, the evidence suggests that directly observed therapy may be generally ineffective for improving treatment completion, adherence or clinical outcomes.In other cases, interventions may have variable effects across outcomes. As an example, strategies providing information or education as single interventions appear ineffective to improve medicines adherence or clinical outcomes, but may be effective to improve knowledge; an important outcome for promoting consumers' informed medicines choices.Despite a doubling in the number of reviews included in this updated overview, uncertainty still exists about the effectiveness of many interventions, and the evidence on what works remains sparse for several populations, including children and young people, carers, and people with multimorbidity. AUTHORS' CONCLUSIONS This overview presents evidence from 75 reviews that have synthesised trials and other studies evaluating the effects of interventions to improve consumers' medicines use.Systematically assembling the evidence across reviews allows identification of effective or promising interventions to improve consumers' medicines use, as well as those for which the evidence indicates ineffectiveness or uncertainty.Decision makers faced with implementing interventions to improve consumers' medicines use can use this overview to inform decisions about which interventions may be most promising to improve particular outcomes. The intervention taxonomy may also assist people to consider the strategies available in relation to specific purposes, for example, gaining skills or being involved in decision making. Researchers and funders can use this overview to identify where more research is needed and assess its priority. The limitations of the available literature due to the lack of evidence for important outcomes and important populations, such as people with multimorbidity, should also be considered in practice and policy decisions.
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Affiliation(s)
- Rebecca Ryan
- Centre for Health Communication and Participation, School of Public Health and Human Biosciences, La Trobe University, Bundoora, VIC, Australia, 3086
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Kinov P, Boyanov M. Clinical utility of risedronate in postmenopausal osteoporosis: patient considerations with delayed-release formulation. Int J Womens Health 2012; 4:167-74. [PMID: 22532780 PMCID: PMC3333827 DOI: 10.2147/ijwh.s18209] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Bisphosphonates are the most widely prescribed treatment for postmenopausal osteoporosis, secondary osteoporosis, and male osteoporosis. Notwithstanding their high effectiveness and favorable safety profile, the adherence to bisphosphonate treatment remains low. Different treatment strategies aim to improve the clinical effectiveness of bisphosphonate therapy. This review paper assesses the clinical utility of oral intermittent risedronate in the treatment of postmenopausal osteoporosis. The new delayed-release risedronate formulation is a safer and easy to use alternative to other risedronate therapy. Oral risedronate, a potent nitrogen-containing bisphosphonate, has been extensively studied using daily regimens. A new intermittent (weekly) dosing regimen confirmed its clinical effectiveness in relation to vertebral and nonvertebral fracture prevention. The absence of significant differences in the incidence of adverse effects confirmed the favorable tolerability of the weekly dosage. In efforts to improve patient adherence to treatment, an innovative, delayed-release formulation of risedronate, which ensures adequate bioavailability of the active compound when taken with food, was introduced. The once-weekly delayed-release formulation of risedronate proved to be noninferior to the daily dosage of risedronate in terms of bone mineral density and markers of bone turnover. In addition, the incidence of new morphometric vertebral fractures was comparable in both treatment regimens. The new delayed-release formulation of risedronate showed a favorable safety profile. Delayed-release risedronate is a promising, new, effective, and convenient alternative to current bisphosphonate treatments. It appears to allow better patient adherence to antiresorptive treatment.
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Affiliation(s)
- Plamen Kinov
- Department of Orthopedics and Traumatology, University Hospital Queen Giovanna – ISUL
| | - Mihail Boyanov
- Department of Internal Medicine, Clinic of Endocrinology, University Hospital Alexandrovska, Medical University of Sofia, Sofia, Bulgaria
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Current world literature. Curr Opin Cardiol 2011; 26:356-61. [PMID: 21654380 DOI: 10.1097/hco.0b013e328348da50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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