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Conn VS, Ruppar TM, Chan KC, Dunbar-Jacob J, Pepper GA, De Geest S. Packaging interventions to increase medication adherence: systematic review and meta-analysis. Curr Med Res Opin 2015; 31:145-60. [PMID: 25333709 PMCID: PMC4562676 DOI: 10.1185/03007995.2014.978939] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Inadequate medication adherence is a widespread problem that contributes to increased chronic disease complications and health care expenditures. Packaging interventions using pill boxes and blister packs have been widely recommended to address the medication adherence issue. This meta-analysis review determined the overall effect of packaging interventions on medication adherence and health outcomes. In addition, we tested whether effects vary depending on intervention, sample, and design characteristics. RESEARCH DESIGN AND METHODS Extensive literature search strategies included examination of 13 computerized databases and 19 research registries, hand searches of 57 journals, and author and ancestry searches. Eligible studies included either pill boxes or blister packaging interventions to increase medication adherence. Primary study characteristics and outcomes were reliably coded. Random-effects analyses were used to calculate overall effect sizes and conduct moderator analyses. RESULTS Data were synthesized across 22,858 subjects from 52 reports. The overall mean weighted standardized difference effect size for two-group comparisons was 0.593 (favoring treatment over control), which is consistent with the mean of 71% adherence for treatment subjects compared to 63% among control subjects. We found using moderator analyses that interventions were most effective when they used blister packs and were delivered in pharmacies, while interventions were less effective when studies included older subjects and those with cognitive impairment. Methodological moderator analyses revealed significantly larger effect sizes in studies reporting continuous data outcomes instead of dichotomous results and in studies using pharmacy refill medication adherence measures compared with studies with self-report measures. CONCLUSIONS Overall, meta-analysis findings support the use of packaging interventions to effectively increase medication adherence. Limitations of the study include the exclusion of packaging interventions other than pill boxes and blister packs, evidence of publication bias, and primary study sparse reporting of health outcomes and potentially interesting moderating variables such as the number of prescribed medications.
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McClure EA, Sonne SC, Winhusen T, Carroll KM, Ghitza UE, McRae-Clark AL, Matthews AG, Sharma G, Van Veldhuisen P, Vandrey RG, Levin FR, Weiss RD, Lindblad R, Allen C, Mooney LJ, Haynes L, Brigham GS, Sparenborg S, Hasson AL, Gray KM. Achieving cannabis cessation -- evaluating N-acetylcysteine treatment (ACCENT): design and implementation of a multi-site, randomized controlled study in the National Institute on Drug Abuse Clinical Trials Network. Contemp Clin Trials 2014; 39:211-23. [PMID: 25179587 DOI: 10.1016/j.cct.2014.08.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Revised: 08/21/2014] [Accepted: 08/22/2014] [Indexed: 12/16/2022]
Abstract
Despite recent advances in behavioral interventions for cannabis use disorders, effect sizes remain modest, and few individuals achieve long-term abstinence. One strategy to enhance outcomes is the addition of pharmacotherapy to complement behavioral treatment, but to date no efficacious medications targeting cannabis use disorders in adults through large, randomized controlled trials have been identified. The National Institute on Drug Abuse Clinical Trials Network (NIDA CTN) is currently conducting a study to test the efficacy of N-acetylcysteine (NAC) versus placebo (PBO), added to contingency management, for cannabis cessation in adults (ages 18-50). This study was designed to replicate positive findings from a study in cannabis-dependent adolescents that found greater odds of abstinence with NAC compared to PBO. This paper describes the design and implementation of an ongoing 12-week, intent-to-treat, double-blind, randomized, placebo-controlled study with one follow-up visit four weeks post-treatment. Approximately 300 treatment-seeking cannabis-dependent adults will be randomized to NAC or PBO across six study sites in the United States. The primary objective of this 12-week study is to evaluate the efficacy of twice-daily orally-administered NAC (1200 mg) versus matched PBO, added to contingency management, on cannabis abstinence. NAC is among the first medications to demonstrate increased odds of abstinence in a randomized controlled study among cannabis users in any age group. The current study will assess the cannabis cessation efficacy of NAC combined with a behavioral intervention in adults, providing a novel and timely contribution to the evidence base for the treatment of cannabis use disorders.
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Affiliation(s)
- Erin A McClure
- Medical University of South Carolina College of Medicine, 67 President St., Charleston, SC 29425, United States.
| | - Susan C Sonne
- Medical University of South Carolina College of Medicine, 67 President St., Charleston, SC 29425, United States
| | - Theresa Winhusen
- Addiction Sciences Division, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, United States
| | - Kathleen M Carroll
- Yale University School of Medicine, 950 Campbell Ave, West Haven, CT 06516, United States
| | - Udi E Ghitza
- Center for the Clinical Trials Network, National Institute on Drug Abuse, 6001 Executive Boulevard, MSC 9557, Bethesda, MD 20892, United States
| | - Aimee L McRae-Clark
- Medical University of South Carolina College of Medicine, 67 President St., Charleston, SC 29425, United States
| | - Abigail G Matthews
- The EMMES Corporation, 401 N. Washington St., Rockville, MD 20850, United States
| | - Gaurav Sharma
- The EMMES Corporation, 401 N. Washington St., Rockville, MD 20850, United States
| | - Paul Van Veldhuisen
- The EMMES Corporation, 401 N. Washington St., Rockville, MD 20850, United States
| | - Ryan G Vandrey
- Johns Hopkins University, School of Medicine, 5510 Nathan Shock Dr., Baltimore, MD 21224, United States
| | - Frances R Levin
- Columbia University/New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, United States
| | - Roger D Weiss
- Division of Alcohol and Drug Abuse, McLean Hospital, 115 Mill St., Belmont, MA 02478, United States; Department of Psychiatry, Harvard Medical School, 25 Shattuck St., Boston, MA 02115, United States
| | - Robert Lindblad
- The EMMES Corporation, 401 N. Washington St., Rockville, MD 20850, United States
| | - Colleen Allen
- The EMMES Corporation, 401 N. Washington St., Rockville, MD 20850, United States
| | - Larissa J Mooney
- University of California, Los Angeles, David Geffen School of Medicine, 1640 S. Sepulveda Blvd., Suite 120, Los Angeles, CA 90025, United States
| | - Louise Haynes
- Medical University of South Carolina College of Medicine, 67 President St., Charleston, SC 29425, United States
| | - Gregory S Brigham
- Addiction Sciences Division, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, United States
| | - Steve Sparenborg
- Center for the Clinical Trials Network, National Institute on Drug Abuse, 6001 Executive Boulevard, MSC 9557, Bethesda, MD 20892, United States
| | - Albert L Hasson
- University of California, Los Angeles, David Geffen School of Medicine, 1640 S. Sepulveda Blvd., Suite 120, Los Angeles, CA 90025, United States
| | - Kevin M Gray
- Medical University of South Carolina College of Medicine, 67 President St., Charleston, SC 29425, United States
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Mahtani KR, Heneghan CJ, Glasziou PP, Perera R. Reminder packaging for improving adherence to self-administered long-term medications. Cochrane Database Syst Rev 2011:CD005025. [PMID: 21901694 DOI: 10.1002/14651858.cd005025.pub3] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Current methods of improving medication adherence for health problems are mostly complex, labour-intensive, and not reliably effective. Medication 'reminder packaging', which incorporates a date or time for a medication to be taken in the packaging, can act as a reminder to improve adherence. This review of reminder packaging is an update of our 2006 Cochrane review. OBJECTIVES The objective of this review was to determine the effects of reminder packaging aids for self-administered medication/s taken for at least one month, on adherence and other outcomes. SEARCH STRATEGY We updated searches of the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library Issue 9, 2010), MEDLINE, EMBASE, CINAHL and PsycINFO from the database start dates to September 2010. We searched Current Controlled Trials to identify trials in progress. We performed a cited reference search on the Science Citation Index to identify papers that had cited the original systematic review.We also searched the Internet, contacted packaging manufacturers, and checked abstracts from the Pharm-line database and reference lists from relevant articles. We did not apply any language restrictions. SELECTION CRITERIA We selected randomised controlled trials with at least 80% follow up. We intended to do a sensitivity analysis of those studies that analysed their data on an intention-to-treat basis. Included studies compared a reminder packaging device with no device, for participants taking self-administered medications for at least one month. DATA COLLECTION AND ANALYSIS Three review authors independently assessed studies for inclusion, assessed quality, and extracted data from included studies. Where considered appropriate, data were combined for meta-analysis, or were reported and discussed in a narrative. MAIN RESULTS We included twelve studies containing data on 2196 participants; four of these studies were newly included in this 2011 update of our 2006 Cochrane review.Six intervention groups in four trials provided data on the percentage of pills taken. Reminder packaging increased the percentage of pills taken (mean difference (MD) 11% (95% confidence interval (CI) 6% to 17%)). Notable heterogeneity occurred among these trials (I(2) = 96.3%). Two trials provided data for the proportion of self-reported adherent patients, reporting a reduction in the intervention group which was not statistically significant (odds ratio = 0.89 (95% CI 0.56 to 1.40)). We conducted meta-analysis on data from two trials assessing the effect of reminder packaging on blood pressure measurements. We found that reminder packaging significantly decreased diastolic blood pressure (MD = -5.89 mmHg (95% CI -6.70 to -5.09; P < 0.00001; I(2) = 0%). No effect was seen on systolic blood pressure (mean change -1.01, 95% CI -2.22 to 0.20; P = 0.1, I(2) = 0%). We also conducted meta-analysis on extracted data from two trials that looked at change in glycated haemoglobin. We found that reminder packaging significantly reduced glycated haemoglobin levels (MD -0.72; 95% CI -0.83 to -0.60; P < 0.00001; I(2) = 92%), although there was considerable heterogeneity.No appropriate data were available for meta-analysis of remaining clinical outcomes, which included serum vitamin C and E levels, and self-reported psychological symptoms (one trial each). We reported remaining data narratively. In one study the presence of a reminder packaging aid was found to be preferred by patients with low literacy levels. AUTHORS' CONCLUSIONS Reminder packing may represent a simple method for improving adherence for patients with selected conditions. Further research is warranted to improve the design and targeting of these devices.
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Affiliation(s)
- Kamal R Mahtani
- Department of Primary Care Health Sciences, University of Oxford, 2nd Floor, 23-38 Hythe Bridge Street, Oxford, UK, OX1 2ET
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Bulloch AG, Adair CE, Patten SB. Forgetfulness: a role in noncompliance with antidepressant treatment. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2006; 51:719-22. [PMID: 17121172 DOI: 10.1177/070674370605101110] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To determine the degree of noncompliance with antidepressant treatment in the Alberta population and to investigate the reasons for noncompliance. METHOD We used data from the Alberta Mental Health Survey, a telephone survey conducted in 2003 (n = 5323 adults), to produce population-based estimates of the frequency of noncompliance and the reported reasons for noncompliance. RESULTS Reported noncompliance was 41.7% (95% confidence interval [CI], 36.9% to 46.6%) for respondents taking 1, 2, or 3 antidepressants. Noncompliance for those taking 1 antidepressant was 42.0% (95%CI, 36.9% to 47.2%), whereas noncompliance for those taking 2 or 3 antidepressants was 39.4% (95%CI, 26.7% to 53.6%). Among respondents currently taking at least one antidepressant, 64.9% (95%CI, 57.4% to 71.7%) reported that forgetfulness was the most common reason for noncompliance. Of respondents taking 1 medication, 64.1% (95%CI, 56.0% to 71.4%) reported forgetfulness as did 71.3% (95%CI, 48.3% to 86.8%) of those taking 2 or 3 medications. Both the frequency of noncompliance and the reported reasons for noncompliance were independent of sex and age. CONCLUSION Our study replicates prior reports that indicate that noncompliance is common with antidepressant treatment. Forgetting to take medication is the most important reported reason for this noncompliance.
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Affiliation(s)
- Andrew G Bulloch
- Department of Physiology and Biophysics, Hotchkiss Brain Institute, Faculty of Medicine, University of Calgary, Alberta.
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Heneghan CJ, Glasziou P, Perera R. Reminder packaging for improving adherence to self-administered long-term medications. Cochrane Database Syst Rev 2006:CD005025. [PMID: 16437510 DOI: 10.1002/14651858.cd005025.pub2] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Current methods of improving medication adherence for health problems are mostly complex, labour-intensive, and not reliably effective. Medication 'reminder packaging' which incorporates a date or time for a medication to be taken in the packaging, can act as a reminder system to improve adherence. OBJECTIVES The objective of this review was to determine the effects of reminder packaging to enhance patient adherence with self-administered medications taken for one month or more. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library Issue 3, 2004), MEDLINE, EMBASE, CINAHL and PsycINFO from the start of the databases to 1 September 2004. We also searched the internet, contacted packaging manufacturers, and checked abstracts from the Pharm-line database and reference lists from relevant articles. We did not apply any language restrictions. SELECTION CRITERIA We selected randomised controlled trials with at least 80% follow up, comparing a reminder packaging device with no device in participants taking self-administered medications for a minimum of one month. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed studies for inclusion, assessed quality, and extracted data from included studies. Where considered appropriate, data were combined for meta-analysis, or were reported and discussed in a narrative. MAIN RESULTS Eight studies containing data on 1,137 participants were included. Six intervention groups in four trials provided data on the percentage of pills taken. Reminder packaging showed a significant increase in the percentage of pills taken, weighted mean difference 11% (95% confidence interval (CI) 6% to 17%). Notable heterogeneity occurred among these trials I(2 )= 96.3%. Two trials provided data for the proportion of self-reported adherent patients, reporting a reduction in the intervention group which was not statistically significant, odds ratio = 0.89 (95% CI 0.56 to 1.40). No appropriate data were available for meta-analysis of different clinical outcomes, the most common of these being blood pressure (three out of eight trials). Other clinical outcomes reported were glycated haemoglobin, serum Vitamin C and E levels, and self-reported psychological symptoms (one trial each). AUTHORS' CONCLUSIONS Reminder packing may represent a simple method for improving adherence for patients with selected conditions examined to date. Further research is warranted to improve the design and targeting of these devices.
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Affiliation(s)
- C J Heneghan
- University of Oxford, Department of Primary Health Care, Old Road Campus, Old Road, Headington, Oxford, UK, OX3 7LF. ]
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Kalichman SC, Cain D, Cherry C, Kalichman M, Pope H. Pillboxes and antiretroviral adherence: prevalence of use, perceived benefits, and implications for electronic medication monitoring devices. AIDS Patient Care STDS 2005; 19:833-9. [PMID: 16375615 DOI: 10.1089/apc.2005.19.833] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
HIV treatment adherence is improved by behavioral interventions, including medication organizers such as pillboxes, which can also interfere with adherence electronic monitoring devices (EMD). This study examined the characteristics of pillbox users and the implications of pillbox use for research using EMD adherence research. Men and women (n = 160) currently taking antiretroviral medications (ARVs) completed anonymous surveys in a community research setting. Sixty-three (39%) of individuals taking ARVs were currently using a pillbox. Pillbox users were significantly more likely to have an undetectable viral load and less likely to have missed their medications within a day of the assessment. Pillbox users indicated feeling that they benefited from using their pillbox and 76% reported they would likely stop using their pillbox if required to participate in a research study that paid them. Adherence EMD pose methodological limitations to research when pillbox users are excluded and ethical implications when pillbox users stop using their pillbox to participate.
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Affiliation(s)
- Seth C Kalichman
- Department of Psychology, University of Connecticut, 406 Babbidge Road, Storrs, CT 06269, USA.
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Dunbar-Jacob J, Sereika SM, Foley SM, Bass DC, Ness RB. Adherence to oral therapies in pelvic inflammatory disease. J Womens Health (Larchmt) 2004; 13:285-91. [PMID: 15130257 DOI: 10.1089/154099904323016446] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To assess adherence to oral therapies in pelvic inflammatory disease (PID). METHODS Medication adherence to oral doxycycline therapy (100 mg) was measured using electronic event monitoring (EEM) among adult women with PID. Subjects (n = 91), who were predominantly black and with a high school or lower educational attainment, were randomly selected from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Study, a trial in which subjects were randomized to either (1). initial inpatient then outpatient or (2). fully outpatient treatment with doxycycline and cefoxitin. Summary statistics calculated within treatment groups and in the cohort as a whole included the percentage of administrations taken, percentage of days with correct dosage, percentage of days with no drug taken, time elapsed until the first drug holiday, and percentage of optimal dosing intervals. RESULTS Study subjects took an average of 70% of prescribed doses, took the prescribed two daily doses for less than half of their outpatient days, took an unscheduled drug holiday for almost 25% of their outpatient days, and took only 16.9% of their doses within the optimal timing interval. In general, working, not bleeding with sex, and not drinking hard liquor were positively associated with measures of adherence. Adherence estimates were similar among women in the inpatient and outpatient groups after hospital discharge. CONCLUSIONS The disturbing rates of time interval adherence, even after hospitalization, suggest the need to determine the effectiveness of antibiotic regimens involving shorter courses and longer dosing intervals.
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Kalichman SC, Rompa D. Functional health literacy is associated with health status and health-related knowledge in people living with HIV-AIDS. J Acquir Immune Defic Syndr 2000; 25:337-44. [PMID: 11114834 DOI: 10.1097/00042560-200012010-00007] [Citation(s) in RCA: 128] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Poor health literacy is a prevalent barrier to medical care and people with lower health literacy experience greater illness severity than people with higher health literacy. Health literacy may therefore be an important factor in the health and treatment of people living with HIV-AIDS. METHODS A community-recruited sample of 339 HIV-infected men and women completed surveys and interviews that assessed functional health literacy, health status, AIDS-related disease and treatment knowledge, and health care perceptions and experiences. Medical records were available for chart abstraction of health status for a subsample of participants. RESULTS About 1 of 4 people living with HIV-AIDS demonstrated difficulty comprehending simple medical instructions and therefore lower health literacy. HIV-infected people with lower health literacy had lower CD4 cell counts, higher viral loads, were less likely to be taking antiretroviral medications, reported a greater number of hospitalizations, and reported poorer health than those with higher health literacy. In addition, after adjusting for years of formal education, lower health literacy was associated with poorer knowledge of one's HIV-related health status, poorer AIDS-related disease and treatment knowledge, and more negative health care perceptions and experiences. CONCLUSIONS Health literacy is a significant factor in the health and treatment of persons living with HIV-AIDS. Interventions are needed to improve medical care and the health status of people with lower health literacy that are living with HIV-AIDS.
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Affiliation(s)
- S C Kalichman
- Center for AIDS Intervention Research, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA.
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