Factors Associated With Nonadherence to Cardiovascular Medications: A Cross-sectional Study

The Polypill: A New Alternative in the Prevention and Treatment of Cardiovascular Disease

Cardiovascular disease (CVD) is the primary cause of death and disability worldwide. Although age-standardized CVD mortality rates decreased globally by 14.5% between 2006 and 2016, the burden of CVD remains disproportionately higher in low- and middle-income countries compared to high-income countries. Even though proven, effective approaches based on multiple-drug intake aimed at the prevention and treatment of CVD are currently available, poor adherence, early discontinuation of treatment, and suboptimal daily execution of the prescribed therapeutic regimes give rise to shortfalls in drug exposure, leading to high variability in the responses to the prescribed medications. Wald and Law, in their landmark paper published in BMJ 2003, hypothesized that the use of a fixed-dose combination of statins, β-blockers, angiotensin receptor blockers, angiotensin-converting enzyme inhibitors, and aspirin (classic Polypill composition) may increase adherence and decrease CVD by up to 80% when prescribed as primary prevention or in substitution of traditional protocols. Since then, many clinical trials have tested this hypothesis, with comparable results. This review aims to describe the available clinical trials performed to assess the impact of fixed-dose combinations on adherence, cost-effectiveness, and the risk factors critical to the onset of CVD.

Effect on medication adherence of applying a specialty pharmacy care model to nonspecialty medications: A quasi-experimental cohort study

PURPOSE

Medication nonadherence is a multifactorial healthcare problem that contributes to increased healthcare costs and morbidity. To improve medication adherence, specialty pharmacies offer services not typically provided by retail pharmacies such as benefits investigation, financial assistance, medication synchronization, and proactive refill reminders. This study assessed the impact of the specialty pharmacy care model on medication adherence for patients on nonspecialty medications.

METHODS

This study was a quasi-experimental cohort comparison of patients who were transferred from a health-system retail pharmacy to a health-system specialty pharmacy between April 1, 2020, and June 30, 2021. The primary endpoint in this study was the difference in mean medication adherence proportion of days covered (PDC) between the post-transfer and pretransfer periods. Secondary outcomes included the proportion of patients with PDC of greater than 80%, medication adherence by drug group, shipment volumes, number of medications per shipment, and the mean copay per medication.

RESULTS

In this study of 163 patients, use of a specialty pharmacy care model led to a significant increase of 7.0% in mean PDC, a significant increase in the percentage of patients with PDC of greater than 80%, a significant decrease in the number of shipments per 30 days per patient, a significant increase in the number of medications included per shipment, and a significant reduction in the mean copay per medication.

CONCLUSION

The findings in this study suggest that the application of the specialty pharmacy care model to nonspecialty pharmacy patients may improve medication adherence, decrease the number of shipments per patient sent from the pharmacy, and reduce patient copays.

Understanding reasons and determinants of medication non-adherence in community-dwelling adults: a cross-sectional study comparing young and older age groups

BACKGROUND

Medication non-adherence has become a striking problem among patients with chronic diseases worldwide. However, literature on prevalence, reasons and factors associated with medication non-adherence in Singapore general population is still lacking. This study aimed to (1) estimate the prevalence of intentional and unintentional medication non-adherence in young (aged 21-64 years) and older adults (aged ≥ 65 years), respectively; (2) identify and compare the main reasons for non-adherence; and (3) examine the association between potential factors and non-adherence in each group.

METHODS

This study sampled 1,528 community-dwelling adults on medications (young adults:766, older adults: 762) from a cross-sectional population health survey conducted in the northern and central regions of Singapore in 2018/2019. Self-reported medication non-adherence and its reasons were collected using a modified questionnaire and compared between the two groups. Multiple logistic regressions were conducted to examine the association between potential factors (e.g., social-demographic factors, smoking and drinking status, presence of diabetes, hypertension, or dyslipidaemia, and presence of depressive symptoms) and medication non-adherence in each group.

RESULTS

The prevalence of non-adherence was 38.4% and 22.3% in young and older adults, respectively, with young adults reporting higher unintentional and intentional non-adherence rates than older adults. "Afraid of developing drug dependence" was the most common reason in both groups (young:74.8% vs. old:73.5%). Compared to young adults (3.7%), "Not understanding medication labels" was more prevalent in older adults (8.8%). Presence of depressive symptoms was associated with non-adherence in both young (odds ratio [95% confidence interval]: 3.00 [1.79, 5.05]) and older adults (4.16 [2.31, 7.51]). Being employed (2.92 [1.76, 4.84]) and taking ≥ 2 medications (1.42 [1.04, 1.95]) had positive association while personal income of SGD1,000-4,000 (0.53 [0.36, 0.77]) and current smoking (0.61 [0.39, 0.95]) had inverse association with non-compliance in young adults. Diagnosis of diabetes, hypertension, or dyslipidaemia (2.63 [1.25, 5.53]) was associated with higher odds of non-compliance in older adults.

CONCLUSIONS

Young adults had higher prevalence of medication non-adherence than older adults. The main reasons for non-adherence reported by young and older adults were generally comparable. Presence of depressive symptoms was a risk factor of medication non-adherence in both groups.

Patients' Perceived Importance of Medication and Adherence in Polypharmacy, a Quantitative, Cross-Sectional Study Using a Questionnaire Administered in Three Doctors' Private Practices in France

BACKGROUND

Among the determinants of nonadherence, polypharmacy (common in people with multiple pathologies and especially in elderly patients), plays a major role.

OBJECTIVE

In patients who are subject to polypharmacy involving different classes of medications, the first aim is to assess the impact of medication importance given by patients on (i) medication adherence and (ii) the respective effect of intentionality and habit in medication importance and medication adherence. The second objective is to compare the importance given to medication and adherence in the different therapeutic classes.

PATIENTS AND METHODS

Patients taking 5-10 different medications for at least 1 month were included in a cross-sectional survey in three private practices in one region in France.

RESULTS

This study included 130 patients (59.2 % female) with 851 medications in total. The mean ± standard deviation (SD) age was 70.5 ± 12.2 years. The mean ± SD of medications taken was 6.9 ± 1.7. Treatment adherence had a strong positive correlation with the patient-perceived medication importance (p < 0.001). Counter-intuitively, taking a large number of medications (≥7) was associated with being fully adherent (p = 0.02). A high intentional nonadherence score was negatively associated with high medication importance (p = 0.003). Furthermore, patient-perceived medication importance was positively associated with taking treatment by habit (p = 0.03). Overall nonadherence more strongly correlated with unintentional nonadherence (p < 0.001) than with intentional nonadherence (p = 0.02). Compared to the antihypertensive class, a decrease in adherence by medication was observed in psychoanaleptics (p < 0.0001) and drugs used in diabetes class (p = 0.002), and a decrease in importance in lipid-modifying agents class (p = 0.001) and psychoanaleptics (p < 0.0001).

CONCLUSION

The perception of the importance of a medicine is associated with the place of intentionality and habit in patient adherence. Therefore, explaining the importance of a medicine should become an important part of patient education.

Experiences of Facilitators and Inhibitors to Treatment Adherence in Patients with Heart Failure

Treatment adherence is a fundamental aspect of heart failure (HF) management. This study aimed to explore the experiences of facilitators and inhibitors of treatment adherence in patients with HF. This descriptive qualitative study was conducted from May 2020 to June 2021. Participants including people with HF, their family caregivers and physicians, and nurses were selected purposefully, with the aim of obtaining sufficient information power. Semi-structured interviews were used to collect data. Data were analyzed using thematic analysis. Two main themes "the driving forces behind treatment adherence" and "the deterrent forces behind treatment adherence" emerged from the analysis. The first theme contained the following subthemes: "supportive family," "positive personality characteristics," and "having health literacy." The second theme consisted of "negligence," "psychological problems," "cultural, social, and economic problems," "physical limitations," and "lack of self-care management knowledge." Nurses can consider facilitators and inhibitors of treatment adherence in designing educational and care programs for patients with HF.

How to optimize the adherence to a guideline-directed medical therapy in the secondary prevention of cardiovascular diseases: a clinical consensus statement from the European Association of Preventive Cardiology

A key factor to successful secondary prevention of cardiovascular disease (CVD) is optimal patient adherence to treatment. However, unsatisfactory rates of adherence to treatment for CVD risk factors and CVD have been observed consistently over the last few decades. Hence, achieving optimal adherence to lifestyle measures and guideline-directed medical therapy in secondary prevention and rehabilitation is a great challenge to many healthcare professionals. Therefore, in this European Association of Preventive Cardiology clinical consensus document, a modern reappraisal of the adherence to optimal treatment is provided, together with simple, practical, and feasible suggestions to achieve this goal in the clinical setting, focusing on evidence-based concepts.

A Brief mHealth-Based Psychological Intervention in Emotion Regulation to Promote Positive Subjective Well-Being in Cardiovascular Disease Patients: A Non-Randomized Controlled Trial

The emotional impact that a cardiovascular disease may have on a person’s life can affect the prognosis and comorbidity of the disease. Therefore, emotion regulation is most important for the management of the disease. The aim of this study was to analyze the effectiveness of a brief mHealth psychological intervention in emotion regulation to promote positive subjective well-being in cardiovascular disease patients. The study sample (N = 69, 63.7 ± 11.5 years) was allocated to either the experimental group (n = 34) or control group (n = 35). The intervention consisted of a psychoeducational session in emotion regulation and an mHealth-based intervention for 2 weeks. Positive subjective well-being as a primary outcome and self-efficacy to manage the disease as a secondary outcome were assessed at five time points evaluated over a period of 6 weeks. The experimental group showed higher improvement in positive subjective well-being and self-efficacy for managing the disease compared to the control group over time. The experimental group also improved after the intervention on all outcome measures. Brief mHealth interventions in emotion regulation might be effective for improving positive subjective well-being and self-efficacy to manage the disease in cardiovascular patients.

Effect of the Implementation of Interdisciplinary Discharge Planning on Treatment Adherence and Readmission in Patients Undergoing Coronary Artery Angioplasty

OBJECTIVES

To determine the effect of interdisciplinary discharge planning on treatment adherence and readmission in the patients undergoing coronary artery angioplasty in the south of Iran in 2020.

METHODS

This experimental study had an intervention group and a control group with pre-test and post-test. 70 patients participated in the study who were randomly divided into the groups (intervention group (n=35) and control group (n=35)). In the intervention group, discharge planning was performed based on an interdisciplinary approach. Treatment adherence before, immediately, and one month after the intervention was evaluated with a 10-question survey scored from 1 to 5 (maximum score = 50), as well as readmission three months after the discharge was examined in both groups.

RESULTS

Before the intervention, there was no statistically significant difference between the intervention and the control groups in the treatment adherence score (18.22 versus 17.37; p=0.84) but immediately and one month after the intervention statistically significant differences between the groups were showed (21.51 versus 46.14 and 23.28 versus 43.12, respectively; p<0.001). Within three months after discharge, the readmission rate was 11.4% in the control group, while no readmission was reported in the intervention group. Within three months after discharge, the readmission rate was 11.4% in the control group, while no readmission was reported in the intervention group.

CONCLUSIONS

The implementation of interdisciplinary discharge planning had positive effects on treatment adherence and readmission rate in patients undergoing coronary artery angioplasty; therefore, it is suggested that health care system managers make the necessary plans to institutionalize this new educational approach for other patients discharge planning.

The Influence of Selected Psychological Factors on Medication Adherence in Patients with Chronic Diseases

Background: Insufficient adherence to treatment is a relevant problem. This study aims to determine the impact of health locus of control, stress coping style and level of mindfulness on medication adherence in patients with a chronic illness. Methods: The study included 768 people. The diagnostic survey involved the use of: Medication Adherence Questionnaire (MAQ), Multidimensional Health Locus of Control Scale (MHLC), The Coping Inventory for Stressful Situations (CISS), and The Mindful Attention Awareness Scale (MAAS). Results: Participants were divided into two subgroups, i.e., adherent (n = 219) and non-adherent (n = 549). We observed significant differences between the subgroups in age, BMI, sex, place of residence, education, and for all MHLC subscales, two CISS subscales and MAAS. The identified medication adherence variables were: female gender (OR = 1.55), BMI (OR = 0.95), MHLC/Internal (OR = 0.95), CISS/Emotional (OR = 1.03), MAAS (OR = 0.97). Conclusions: A strong internal health locus of control, a higher level of mindfulness and a lower level of emotional-stress coping style increase the likelihood of adherence with medication recommendations in patients with chronic diseases.

Exploring variables associated with medication non-adherence in patients with type 2 diabetes mellitus

Objective

This study aims to assess medication adherence and explore its predictors in outpatients with type 2 diabetes.

Method

This cross-sectional study collected socio-demographics, disease-related information, and different biomedical variables for type 2 diabetes patients attending a Jordanian Diabetes center. The four-item medication adherence scale (4-IMAS) and the beliefs about medications questionnaire (BMQ) which includes necessity and concerns were used. Stepwise backward quartile regression models were conducted to evaluate variables associated with the Necessity and Concerns scores. Stepwise ordinal regression was conducted to evaluate variables associated with adherence.

Results

287 diabetic patients participated in the study. Almost half of the participants (46.5%) reported moderate adherence and 12.2% reported low adherence. Significant predictors of the adherence were necessity score (OR = 14.86, p <0.01), concern score (OR = 0.36, p <0.05), and frequency of medication administration (OR = 0.88, p- <0.01). Education was a significant predictor of Necessity and Concerns scores (β = 0.48, -0.2, respectively).

Conclusion

Simplifying the medication regimen, emphasizing medication necessity and overcoming medication concerns should be targeted in future diabetes intervention programs to improve medication adherence and hence glycemic control among diabetic patients.

Patients' Perception of Factors Influencing Noncompliance with Medication among Cardiac Patients in Fiji: A Qualitative Study

BACKGROUND

Noncompliance with prescribed medication leads to disease progression, which often leads to premature deaths. It often leads to worsening symptoms of cardiac conditions and hospitalization. Due to the lack of previous research, this study aimed to explore the factors contributing to noncompliance with medication in cardiac patients in Fiji.

METHODS

This qualitative study was conducted among 25 cardiac patients with congestive heart failure and coronary heart disease who attended special outpatient department (SOPD) clinics at Sigatoka Subdivisional Hospital in Fiji. Purposive sampling was used to select the study sample, and in-depth face-to-face interviews were conducted using a semistructured, open-ended questionnaire. Data were analyzed using thematic analysis, whereby the data collected were grouped in subthemes and then common themes related to the topic.

RESULTS

A total of 25 patients were interviewed, with a majority (n=14) being men and 15 Fijian of Indian descent. A greater number (n=17) of participants were above the age of 60 years, 19 had had primary education, while 12 were unemployed. Eight themes were identified as factors affecting noncompliance with medication: scarcity of knowledge, patients' negative attitudes, poor family support, financial constraints, forgetfulness, irregular clinic attendance, heavy alcohol use, and alternative treatment vs pharmaceutical medication.

CONCLUSION

Noncompliance with medication in cardiac patients contributes to worsening cardiac disease and premature deaths. For factors related to noncompliance, awareness can be raised in SOPD clinics for patients to realize the effects of noncompliance and provide ways to improve compliance. Providing professional counseling services for all SOPD patients would greatly help in increasing compliance with medication in Fiji.

Effectiveness of a targeted and tailored pharmacist-led intervention to improve adherence to antihypertensive drugs among patients with type 2 diabetes in Indonesia: A cluster randomised controlled trial

Aim

To assess the effects of a targeted and tailored pharmacist‐led intervention among patients with type 2 diabetes (T2DM) who are nonadherent to antihypertensive drugs.

Methods

A cluster‐randomised controlled trial was conducted in 10 community health centres (CHCs) in Indonesia among T2DM patients aged ≥18 years who reported nonadherence to antihypertensive drugs according to the Medication Adherence Report Scale (MARS‐5). Patients in CHCs randomised to the intervention group received a tailored intervention based on their adherence barriers (eg, forgetfulness, lack of knowledge, lack of motivation and/or other drug‐related problems) using a simple question‐based flowchart at baseline and 1‐month follow‐up. Patients in control CHCs received usual care. Primary outcome was the between‐group difference in change in MARS‐5 score from baseline to 3‐month follow‐up. Secondary outcomes included changes in patients' blood pressure and their medication beliefs. Differences in difference in primary and secondary outcomes between groups were assessed using general linear models.

Results

In total, 201 patients were screened for eligibility, 113 met the inclusion criteria and participated, and 89 (79%) patients had complete follow‐up. Forgetfulness (42%) and lack of knowledge (18%) were the most common adherence barriers identified at baseline. The intervention improved medication adherence by 4.62 points on the MARS‐5 scale (95% CI 0.93 to 8.34, P value = 0.008). There were no significant changes in blood pressure levels and beliefs about antihypertensive drugs.

Conclusion

A tailored low‐cost pharmacist‐led intervention aimed at nonadherent T2DM patients resulted in an improvement in medication adherence to antihypertensive drugs. There were no significant changes in secondary outcomes.

The Development and Proof of Principle Test of TRIAGE: A Practical Question Set to Identify and Discuss Medication-Related Problems in Community Pharmacy

The pharmacy counter is a good place to identify and discuss medication-related problems. However, there is a lack of practical communication tools to support pharmacy technicians (PTs) in initiating a conversation with patients. This study aimed to develop and test a practical set of questions for PTs, called TRIAGE, to identify problems during encounters. TRIAGE was developed based on insight from the literature, focus groups with PTs and pharmacists, and input from patients and experts. In 10 community pharmacies, 17 PTs used TRIAGE during encounters with patients who collected their cardiovascular medication. For each encounter, PTs registered the identified problems and suggested solutions. A total of 105 TRIAGE conversations were held, 66 for first refill and 39 for follow-up refill prescriptions. In 15 (23%) first refill prescription encounters, a problem was identified. These problems concerned forgetting to take the medication, a complex medication regime or (fear of) side effects. In three (8%) follow-up refill prescription encounters, a problem was identified. Most of the problems were solved on the spot. Pharmacy technicians indicated that they identified medication-related problems with TRIAGE that otherwise would be left unnoticed. They appreciated TRIAGE as a useful instrument for starting the conversation with patients about medication use.

Targeted and tailored pharmacist-led intervention to improve adherence to antihypertensive drugs among patients with type 2 diabetes in Indonesia: study protocol of a cluster randomised controlled trial

INTRODUCTION

Current intervention programme to improve drug adherence are either too complex or expensive for implementation and scale-up in low-middle-income countries. The aim of this study is to assess the process and effects of implementing a low-cost, targeted and tailored pharmacist intervention among patients with type 2 diabetes who are non-adherent to antihypertensive drugs in a real-world primary care Indonesian setting.

METHODS AND ANALYSIS

A cluster randomised controlled trial with a 3-month follow-up will be conducted in 10 community health centres (CHCs) in Indonesia. Type 2 diabetes patients aged 18 years and older who reported non-adherence to antihypertensive drugs according to the Medication Adherence Report Scale (MARS) are eligible to participate. Patients in CHCs randomised to the intervention group will receive a tailored intervention based on their personal adherence barriers. Interventions may include reminders, habit-based strategies, family support, counselling to educate and motivate patients, and strategies to address other drug-related problems. Interventions will be provided at baseline and at a 1-month follow-up. Simple question-based flowcharts and an innovative adherence intervention wheel are provided to support the pharmacy staff. Patients in CHCs randomised to the control group will receive usual care based on the Indonesian guideline. The primary outcome is the between-group difference in medication adherence change from baseline to 3-month follow-up assessed by MARS. Secondary outcomes include changes in patients' blood pressure, their medication beliefs assessed by the Beliefs about Medicines Questionnaire (BMQ)-specific, as well as process characteristics of the intervention programme from a pharmacist and patient perspective.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Ethical Committee of Universitas Padjadjaran, Indonesia (No. 859/UN6.KEP/EC/2019) and all patients will provide written informed consent prior to participation. The findings of the study will be disseminated through international conferences, one or more peer-reviewed journals and reports to key stakeholders.

TRIAL REGISTRATION NUMBER

NCT04023734.