Predictors of refill non-adherence in patients with heart failure

Cohort profile: a large EHR-based cohort with linked pharmacy refill and neighbourhood social determinants of health data to assess heart failure medication adherence

PURPOSE

Clinic-based or community-based interventions can improve adherence to guideline-directed medication therapies (GDMTs) among patients with heart failure (HF). However, opportunities for such interventions are frequently missed, as providers may be unable to recognise risk patterns for medication non-adherence. Machine learning algorithms can help in identifying patients with high likelihood of non-adherence. While a number of multilevel factors influence adherence, prior models predicting non-adherence have been limited by data availability. We have established an electronic health record (EHR)-based cohort with comprehensive data elements from multiple sources to improve on existing models. We linked EHR data with pharmacy refill data for real-time incorporation of prescription fills and with social determinants data to incorporate neighbourhood factors.

PARTICIPANTS

Patients seen at a large health system in New York City (NYC), who were >18 years old with diagnosis of HF or reduced ejection fraction (<40%) since 2017, had at least one clinical encounter between 1 April 2021 and 31 October 2022 and active prescriptions for any of the four GDMTs (beta-blocker, ACEi/angiotensin receptor blocker (ARB)/angiotensin receptor neprilysin inhibitor (ARNI), mineralocorticoid receptor antagonist (MRA) and sodium-glucose cotransporter 2 inhibitor (SGLT2i)) during the study period. Patients with non-geocodable address or outside the continental USA were excluded.

FINDINGS TO DATE

Among 39 963 patients in the cohort, the average age was 73±14 years old, 44% were female and 48% were current/former smokers. The common comorbid conditions were hypertension (77%), cardiac arrhythmias (56%), obesity (33%) and valvular disease (33%). During the study period, 33 606 (84%) patients had an active prescription of beta blocker, 32 626 (82%) had ACEi/ARB/ARNI, 11 611 (29%) MRA and 7472 (19%) SGLT2i. Ninety-nine per cent were from urban metropolitan areas.

FUTURE PLANS

We will use the established cohort to develop a machine learning model to predict medication adherence, and to support ancillary studies assessing associates of adherence. For external validation, we will include data from an additional hospital system in NYC.

Decisional Needs and Patient Treatment Preferences for Heart Failure Medications: A Scoping Review

Background

Pharmacologic management of heart failure with reduced ejection fraction (HFrEF) involves several medications. Decision aids informed by patient decisional needs and treatment preferences could assist in making HFrEF medication choices; however, these are largely unknown.

Methods

We searched MEDLINE, Embase, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL), without language restriction, for qualitative, quantitative, and mixed-method studies that included patients with HFrEF or clinicians providing HFrEF care, and reported data on decisional needs or treatment preferences applicable to HFrEF medications. We classified decisional needs using a modified version of the Ottawa Decision Support Framework (ODSF).

Results

From 3996 records, we included 16 reports describing 13 studies (n = 854). No study explicitly assessed ODSF decisional needs; however, 11 studies reported ODSF-classifiable data. Patients commonly reported having inadequate knowledge or information, and difficult decisional roles. No study systematically assessed treatment preferences, but 6 studies reported on attribute preferences. Reducing mortality and improving symptoms frequently were ranked as being important, whereas cost importance rankings varied, and adverse events generally were ranked as being less important.

Conclusion

This scoping review identified key decisional needs regarding HFrEF medications, notably inadequate knowledge or information, and difficult decisional roles, which can readily be addressed by decision aids. Future studies should systematically explore the full scope of ODSF-based decisional needs in patients with HFrEF, along with relative preferences among treatment attributes to further inform development of individualized decision aids.

Eliciting preferences for continuing medication among adult patients and parents of children with attention-deficit hyperactivity disorder

BACKGROUND

Adherence to medication for attention-deficit hyperactivity disorder (ADHD) is less than optimal. Previous studies have primarily focused on qualitative assessment of factors that influence medication adherence.

OBJECTIVE

This study aimed to quantify the factors that influence patient and parent preferences for continuing ADHD medication.

METHOD

A discrete-choice experiment was conducted to investigate preferences. Adults, and parents of children, with ADHD were presented with eight hypothetical choice tasks of three options (Medication A, Medication B, No Medication) described by six attributes related to medication outcomes. Preferences were estimated using a mixed multinomial logit model.

RESULTS

Overall, respondents' preferences (n = 216) for continuing medication were negative (mean [β] = -1.426, p < .001); however, a significant heterogeneity in preferences was observed amongst respondents (standard deviation = 0.805, p < .001). Improvements in education, aggressive behaviour, social behaviour and family functioning, and side effects and stigma, influenced respondents' decision to continue taking medication. The respondents were willing to continue medication if they experienced positive effects, but side effects (even moderate) were the strongest concern for not continuing medication. While side effects were the most important factor for both adult patients and parents of children with ADHD, improvement in education was relatively more important for adults and improvement in aggressive behaviour, social behaviour and family functioning was relatively more important for parents of children with ADHD. Parents were more likely to not continue a medication with severe side effects even at the highest level of improvement in education.

CONCLUSIONS

Side effects are the most important factor that influenced preferences for continuing medication for both adults with ADHD, as well as parents of children with ADHD. While overall the respondents preferred not to take/give medication, discrete-choice experiment showed that the relative importance of factors that influenced continuation of medications was different for the two groups.

PATIENT AND PUBLIC INVOLVEMENT

Adults, and parents of children, with ADHD participated in this study by completing the online questionnaire. The questionnaire was based on findings of research in the literature, as well as earlier focus groups conducted with adults, and parents of children, with ADHD. The face validity of the questionnaire was determined by asking parents of children, and adults, with ADHD (n = 3) to complete the survey and participate in a short discussion on their understanding of the questions and their recommendations on improving the clarity of the survey.

Assisted Living and Medication Adherence in Super-Aged Patients With Heart Failure in the Japanese population

ABSTRACT

Poor adherence to medication in patients with heart failure (HF) is associated with poor clinical outcomes. Although social support has been reported to improve medication adherence in patients with HF, the detailed underlying mechanism of this association is unclear. This study investigated appropriate social support types to ensure medication adherence, as well as patient characteristics that benefit from such social support in patients with HF. This was a retrospective observational study investigating the association of social support with medication adherence in 824 patients with HF who were registered in a prospective multicenter database. First, we analyzed the association between social support types and poor medication adherence leading to hospitalization. An interaction analysis was performed to detect patients' characteristics that benefited most from social support in terms of medical adherence. Fifty (6.1%) patients were hospitalized for poor adherence to medications. Multivariable analysis revealed that not receiving assisted living, which was defined as having supporting individuals at least once a week, was independently associated with poor medication adherence-related hospitalization. An interaction analysis revealed that patients with dementia benefited from assisted living significantly, while male patients or current smokers did not. Summarily, assisted living at least once a week was appropriate for improving medication adherence for patients with HF and was particularly effective for patients with dementia. Performed in a super-aging region in Japan, this study may also suggest the relevance of social support in preventing HF exacerbation in other developed countries that will experience an aging society in the near future.

The Attitude towards Polypills Questionnaire (APPQ): a phase I-III development and validation study in patients with cerebrovascular disease

Background and purpose

The polypill approach has been proposed to reduce patients’ pill burden, increase medication adherence and lower stroke incidence. However, little is known about patients’ attitudes towards polypills for cerebrovascular medication.

Methods

Based on the European Organization for Research and Treatment of Cancer Quality of Life Group questionnaire development guidelines, a questionnaire to measure patients’ attitudes towards polypills for the secondary prevention of stroke (phase I–III) was developed. In phase I, issues were generated via literature review and interviews with patients and healthcare professionals. The issues were operationalized into items in phase II. In phase III the questionnaire was validated in a large single‐centre sample, and test–retest and internal validity were evaluated.

Results

In phase I, 34 relevant issues were identified through literature search and interviews. Pre‐testing the questionnaire indicated high applicability and comprehensibility. The final Attitudes towards Polypills Questionnaire was tested in N = 260 patients and showed a two‐factor structure. The factors were labelled ‘concerns’ and ‘benefits’. The scales showed acceptable and good internal validity (concerns, Cronbach's α = 0.85; benefits, α = 0.93), but the scales’ test–retest validity was ambiguous. On a 0 to 3 rating scale, concerns were rated lower than benefits (mean 1.07, SD 0.69 vs. mean 1.87, SD 0.89).

Conclusions

The Attitudes towards Polypills Questionnaire showed high comprehensibility and content validity to assess German language patients’ attitudes towards a polypill medication. Our data and questionnaire may aid the implementation of polypill treatments in clinical practice and can be used in the design of future clinical trials on polypill therapy. Further validation of the questionnaire is advised.

Examining Adherence to Medication in Patients With Atrial Fibrillation: The Role of Medication Beliefs, Attitudes, and Depression

BACKGROUND/OBJECTIVES

This study examined whether beliefs about medicines, drug attitudes, and depression independently predicted anticoagulant and antiarrhythmic adherence (focusing on the implementation phase of nonadherence) in patients with atrial fibrillation (AF).

METHODS

This cross-sectional study was part of a larger longitudinal study. Patients with AF (N = 118) completed the Patient Health Questionnaire-8. The Beliefs about Medicines Questionnaire, Drug Attitude Inventory, and Morisky-Green-Levine Medication Adherence Scale (self-report adherence measure), related to anticoagulants and antiarrhythmics, were also completed. Correlation and multiple logistic regression analyses were conducted.

RESULTS

There were no significant differences in nonadherence to anticoagulants or antiarrhythmics. Greater concerns (r = 0.23, P = .01) were significantly, positively associated with anticoagulant nonadherence only. Depression and drug attitudes were not significantly associated with anticoagulant/antiarrhythmic adherence. Predictors reliably distinguished adherers and nonadherers to anticoagulant medication in the regression model, explaining 14% of the variance, but only concern beliefs (odds ratio, 1.20) made a significant independent contribution to prediction (χ = 11.40, P = .02, with df = 4). When entered independently into a regression model, concerns (odds ratio, 1.24) significantly explained 10.3% of the variance (χ = 7.97, P = .01, with df = 1). Regressions were not significant for antiarrhythmic medication (P = .30).

CONCLUSIONS

Specifying medication type is important when examining nonadherence in chronic conditions. Concerns about anticoagulants, rather than depression, were significantly associated with nonadherence to anticoagulants but not antiarrhythmics. Anticoagulant concerns should be targeted at AF clinics, with an aim to reduce nonadherence and potentially modifiable adverse outcomes such as stroke.

Exploring Medication Adherence with P2Y12 Inhibitors Using Conditional and Unconditional Quantile Regression Approaches

BACKGROUND

Previous research assessing medication adherence with P2Y₁₂ inhibitors has shown good adherence rates, ranging from 78% to 92%. Studies that used administrative claims data defined adherence using an arbitrary cut point of ≥ 80% medication possession ratio (MPR) or proportion of days covered (PDC). While this method is used frequently, it does not allow the researcher to observe how each factor impacts adherence along the entire distribution. The objective of the study was to use conditional quantile regression (CQR) and unconditional quantile regression (UQR) to assess heterogenous effects of adherence to P2Y₁₂ inhibitors and covariates of interest and compare these results to those from a traditional logistic regression framework.

METHODS AND RESULTS

This study used the commercial claims and encounters databases from IBM^® MarketScan^® from 2010 to 2017. We included patients who had an incident percutaneous coronary intervention, used a drug-eluting stent, and filled an incident prescription for a P2Y₁₂ inhibitor. Adherence was measured for 185 days using PDC. Adherence to branded clopidogrel, generic clopidogrel, branded prasugrel, and branded ticagrelor was assessed, along with factors that could impact adherence, using logistic regression, CQR, and UQR. We found that while adherence to the antiplatelets was generally high, prasugrel and ticagrelor had significantly lower PDC compared to branded clopidogrel, especially around the 30th percentile. Across all quantiles in both the CRQ and UQR frameworks, comorbidities such as diabetes and depression and living in the southern region had significant negative effects on adherence, although the relative impact differed across quantiles.

CONCLUSIONS

Using CQR and UQR allowed for heterogenous assessment of covariates along the adherence distribution, which is not possible with the traditional logistic regression method. The UQR framework revealed patients who initiate prasugrel or ticagrelor generally have lower adherence compared to those treated with branded clopidogrel, especially around the 30th quantile. Using these methods in other types of data sets, such as electronic health records, could help strengthen our results to develop policies to improve antiplatelet adherence in a targeted population.

Homcology: home chemotherapy delivery in a simultaneous care project for frail advanced cancer patients

Homcology is a project that represents both an opportunity for patients who may benefit from chemotherapy so far, but present physical and social problems that prevent day-hospital access, and a model of "no-profit" contribution to the Public Health System. Our medical oncology department conducted the project from May 2014 to January 2019. We included frail patients (G-8 < 14), with advanced disease, treated with oral, subcutaneous, or parenteral biological agents, with limitations to day-hospital access, comorbidities, and at least 6-month life expectancy. A multidisciplinary team included three oncologists, four nurses, an anesthetist, a psychologist, and a physiotherapist. Satisfaction was evaluated with FAMCARE scale. A total of 188 patients (median age of 73 years, 38-87) were enrolled. Ninety percent of patients presented with metastatic disease and a median G-8 score of 8.8 (3-13.5). All of them received anticancer treatment and concomitant supportive care; 24 patients received two or more lines of treatment. The median duration of taking care was 175 days (7-1200). A median number of 254 (195-325) nursing and 164 (139-190) medical visits were performed a year, with an average of 1.9 and 1.2 visits a month per patient respectively. The median number of in-line patients was 20 (17-25). Hospitalization occurred in 18% of cases. One-third of them died at home. The others were referred to hospice. Our experience shows that the integration of home cancer treatment and supportive care is effective. Hospitalization rate is lower than data reported in the literature. Results need to be confirmed in prospective pharmacoeconomics studies.

The use of discrete choice experiments in adherence research: A new solution to an old problem

Theory can play an important role in providing the framework, and underpinning the design and implementation of interventions to improve medication adherence. Interventions that are grounded in a theory are relatively more effective in improving medication adherence than interventions which do not have a theoretical support. However, a large body of adherence research does not appear to be linked to any theory or model, which therefore may have resulted in interventions that are either ineffective or not sustainable. Interventions that are based on theory have mainly employed socio-behavioural models to explain, and design interventions to address, the complex phenomenon of adherence. Yet, the effectiveness of these interventions is inconclusive, supporting the argument that socio-behavioural models alone have limited applicability in explaining behaviour associated with medication-taking. An important reason for this limitation may be the complex and dynamic nature of adherence. There is a need to include a wide variety of factors in a model and examine adherence in the context of its three phases (initiation, implementation, and discontinuation). One possible way forward is to also examine medication-taking behaviour from an economic perspective, for example, by using a discrete choice experiment (DCE), which provides a different approach to understanding human behaviour about medication-taking and the complexities of decision-making in adhering to medication. DCEs can help in understanding how patients decide to initiate, continue or discontinue taking medication, factors that influence their decision, and the relative importance of those factors, which can assist researchers to prioritise interventions to improve medication adherence. Integration of multiple theories is needed to examine adherence from multiple perspectives and design interventions that are effective and sustainable. This commentary focusses on the pros and cons of some of the commonly used socio-behavioural models in adherence research and suggests a way forward by incorporating DCEs in adherence research.

Pulmonary Arterial Hypertension: Combination Therapy in Practice

Combination therapy is now regarded as the standard of care in pulmonary arterial hypertension (PAH) and is becoming widely used in clinical practice. Given the inherent complexities of combining medications, there is a need for practical advice on implementing this treatment strategy in the clinic. Drawing on our experience and expertise, within this review, we discuss some of the challenges associated with administration of combination therapy in PAH and how these can be addressed in the clinic. Despite their differing modes of action, all of the currently available classes of PAH therapy induce systemic vasodilation. In initial combination therapy regimens in particular, this may lead to additive side effects and reduced tolerability compared with monotherapy. However, approaches such as staggered treatment initiation and careful up-titration may reduce the risk of additive side effects and have been used successfully in clinical practice, as well as in clinical trials and registry studies. When combination therapy regimens are initiated, it is important that patients are monitored regularly for the presence of any side effects and that these are then managed promptly and appropriately. For patients to attain the best outcomes, the treatment regimen must be tailored to the individual’s specific needs, including consideration of PAH etiology, the presence of comorbidities and concomitant medications beyond PAH therapy, and patient lifestyle and preference. It is also vital that individuals are managed at expert care centers, where multidisciplinary teams have a wealth of specialist experience in treating PAH patients. Adherence to therapy can be a concern in a chronic disease such as PAH, and as treatment regimens become increasingly complex, maintaining good treatment adherence may become more challenging. It is essential that patients are educated on the importance of treatment adherence, and this is a key role for the PAH nurse specialist. For patients who are managed carefully in expert centers with combination therapy regimens that are tailored to their specific needs, a favorable benefit–risk ratio can be achieved. With individual and carefully managed approaches, the excellent results observed with combination therapy in clinical trials can be obtained by patients in a real-world setting.

Are you more concerned about or relieved by medicines? An explorative randomized study of the impact of telephone counseling by pharmacists on patients' beliefs regarding medicines and blood pressure control

OBJECTIVES

The aim was to determine the impact of a telephone counseling service, provided bi-monthly by pharmacist, on patients' beliefs about antihypertensive medicines and blood pressure (BP) control.

METHODS

Either hypertensive patients were randomly assigned to a control group (CG, usual care) or an intervention group (IG). All patients had BP values registered and filled in the Italian version of the Belief Medicine Questionnaire (BMQ). After 12 months, patients filled in the BMQ again and had their self-reported BP registered. The intervention consisted of an educational/counseling session based on patients' needs assessment provided bi-monthly by a pharmacist for one year via telephone.

RESULTS

80 CG and 84 IG patients were recruited. After 12 months, there were significant differences between IG and CG for both BMQ's Necessity and Concern score (p < 0.001; p < 0.001 respectively) and a significant reduction in BP values in IG (p < 0.001).

CONCLUSIONS

The intervention improves BP control by modifying patients' perception about treatments and involving patients as participants in the management of their health.

PRACTICE IMPLICATIONS

This paper could serve as a guideline for other studies to confirm the effectiveness of this intervention in modifying health behavior, and the role of hospital pharmacist.

Telehealth Protocol to Prevent Readmission Among High-Risk Patients With Congestive Heart Failure

BACKGROUND

Congestive heart failure is the leading cause of hospital readmissions. We aimed to assess adherence to and effectiveness of a telehealth protocol designed to prevent hospital admissions for congestive heart failure.

METHODS

We recruited a random sample of 50 patients with congestive heart failure (mean age 61 years) from a managed care organization. We developed a telehealth platform allowing for daily, real-time reporting of health status and video conferencing. We defined adherence as the percentage of days on which the patient completed the daily check-in protocol. To assess efficacy, we compared admission and readmission rates between the 6-month intervention period and the prior 6 months. Primary outcomes were admissions and readmissions due to congestive heart failure, and secondary outcomes were admissions and readmissions due to any cause.

RESULTS

Forty-eight patients (96%) completed the protocol. Approximately half (46%) were at high risk for readmission according to standardized measures. Median 120-day adherence was 96% (interquartile range, 92%-98%), and adherence did not significantly differ across sex, race, age, living situation, depression, cognitive ability, or risk for readmission. Approximately equal proportions of patients were admitted for all causes during the 6-month intervention period versus the comparison period (37% vs 43%; P = .32). Half as many patients were admitted for congestive heart failure during the 6-month intervention period compared with the comparison period (12% vs 25%; P = .11).

CONCLUSION

Adherence to this telehealth protocol was excellent and consistent, even among high-risk patients. Future research should test the protocol using a more rigorous randomized design.

Medication management strategies used by older adults with heart failure: A systems-based analysis

BACKGROUND

Older adults with heart failure use strategies to cope with the constraining barriers impeding medication management. Strategies are behavioral adaptations that allow goal achievement despite these constraining conditions. When strategies do not exist, are ineffective or maladaptive, medication performance and health outcomes are at risk. While constraints to medication adherence are described in literature, strategies used by patients to manage medications are less well-described or understood.

AIM

Guided by cognitive engineering concepts, the aim of this study was to describe and analyze the strategies used by older adults with heart failure to achieve their medication management goals.

METHODS

This mixed methods study employed an empirical strategies analysis method to elicit medication management strategies used by older adults with heart failure. Observation and interview data collected from 61 older adults with heart failure and 31 caregivers were analyzed using qualitative content analysis to derive categories, patterns and themes within and across cases.

RESULTS

Data derived thematic sub-categories described planned and ad hoc methods of strategic adaptations. Stable strategies proactively adjusted the medication management process, environment, or the patients themselves. Patients applied situational strategies (planned or ad hoc) to irregular or unexpected situations. Medication non-adherence was a strategy employed when life goals conflicted with medication adherence. The health system was a source of constraints without providing commensurate strategies.

CONCLUSIONS

Patients strived to control their medication system and achieve goals using adaptive strategies. Future patient self-mangement research can benefit from methods and theories used to study professional work, such as strategies analysis.

Systolic Blood Pressure and Biochemical Assessment of Adherence: A Cross-Sectional Analysis in the Emergency Department

Elevated blood pressure (BP) is common in the emergency department (ED), but the relationship between antihypertensive medication adherence and BP in the ED is unclear. This cross-sectional study tested the hypothesis that higher antihypertensive adherence is associated with lower systolic BP (SBP) in the ED among adults with hypertension who sought ED care at an academic hospital from July 2012 to April 2013. Biochemical assessment of antihypertensive adherence was performed using a mass spectrometry blood assay, and the primary outcome was average ED SBP. Analyses were stratified by number of prescribed antihypertensives (<3, ≥3) and adjusted for age, sex, race, insurance, literacy, numeracy, education, body mass index, and comorbidities. Among 85 patients prescribed ≥3 antihypertensives, mean SBP for adherent patients was 134.4 mm Hg (±26.1 mm Hg), and in adjusted analysis was -20.8 mm Hg (95% confidence interval, -34.2 to -7.4 mm Hg; P=0.003) different from nonadherent patients. Among 176 patients prescribed <3 antihypertensives, mean SBP was 135.5 mm Hg (±20.6 mm Hg) for adherent patients, with no difference by adherence in adjusted analysis (+2.9 mm Hg; 95% confidence interval, -4.7 to 10.5 mm Hg; P=0.45). Antihypertensive nonadherence identified by biochemical assessment was common and associated with higher SBP in the ED among patients who had a primary care provider and health insurance and who were prescribed ≥3 antihypertensives. Biochemical assessment of antihypertensives could help distinguish medication nonadherence from other contributors to elevated BP and identify target populations for intervention.

A qualitative study examining health literacy and chronic illness self-management in Hispanic and non-Hispanic older adults

PURPOSE

Chronic illness and low levels of health literacy affect health outcomes for many individuals, particularly older adults and racial/ethnic minorities. This study sought to understand the knowledge, strengths, and areas of need regarding self-management of chronic illness in order to lay the groundwork for content development of an intervention to increase health literacy and maximize patient engagement in chronic disease self-care.

PATIENTS AND METHODS

In-depth, qualitative interviews were conducted in Spanish and English with 25 older adults with various chronic illnesses. Topics included knowledge and understanding of chronic conditions, medications, and disease self-management skills. Qualitative data were coded by searching text and conducting cross-case analysis. An inductive analysis was then employed to allow for the patterns and themes to emerge.

RESULTS

Emerged themes included 1) social support, 2) coping strategies, 3) spirituality, 4) chronic disease health literacy, 5) anger, and 6) depression. While participants had a general overall knowledge of chronic illness, they had deficits in knowledge regarding their own illnesses and medications.

CONCLUSION

Chronic illness self-management is a complex and dynamic behavioral process. This study identified themes that leverage patient motivation to engage in self-care in a personalized manner. This information will guide the development of an intervention to promote health literacy and optimal disease self-management.

Identifying psychosocial predictors of medication non-adherence following acute coronary syndrome: A systematic review and meta-analysis

OBJECTIVE

Medication non-adherence following acute coronary syndrome (ACS) is associated with poor clinical outcomes. A systematic review and meta-analysis were undertaken to identify psychosocial factors associated with medication adherence in patients with ACS.

METHODS

A search of electronic databases (Cochrane Library, Medline, EMBASE, PsycINFO, Web of Science, International Pharmaceutical Abstracts, CINAHL, ASSIA, OpenGrey, EthOS and WorldCat) was undertaken to identify relevant articles published in English between 2000 and 2014. Articles were screened against our inclusion criteria and data on study design, sample characteristics, predictors, outcomes, analyses, key findings and study limitations were abstracted.

RESULTS

Our search identified 3609 records, of which 17 articles met our inclusion criteria (15 independent studies). Eight out of ten studies found an association between depression and non-adherence. A meta-analysis revealed that depressed patients were twice as likely to be non-adherent compared to patients without depression (OR=2.00, 95% CI 1.57-3.33, p=0.015). Type D personality was found to predict non-adherence in both studies in which it was measured. Three out of three studies reported that treatment beliefs based on the Necessity-Concerns Framework predicted medication non-adherence and there was some evidence that social support was associated with better adherence. There was insufficient data to meta-analyse all other psychosocial factors identified.

CONCLUSION

There was some evidence that psychosocial factors, particularly depression, were associated with medication adherence following ACS. Targeting depressive symptoms, screening for Type D personality, challenging maladaptive treatment beliefs, and providing better social support for patients may be useful strategies to improve medication adherence.

Long-term use of secondary prevention medications for heart failure in Western Australia: a protocol for a population-based cohort study

INTRODUCTION

Heart failure (HF) is a chronic, debilitating and progressive disease associated with high morbidity and mortality. Evidence-based medications (EBMs) are the cornerstone of management of patients with HF. In Australia, these EBMs are subsidised by the Commonwealth Government under the Pharmaceutical Benefits Scheme. Suboptimal dispensing and non-adherence to these EBMs have been observed in patients with HF. Our study will investigate trends in dispensing patterns, as well as adherence and persistence of EBMs for HF. We will also identify factors influencing these patterns and their impact on long-term clinical outcomes.

METHODS AND ANALYSIS

This whole population-based cohort study will use longitudinal data for people aged 65-84 years who were hospitalised for HF in Western Australia between 2003 and 2008. Linked state-wide and national data will provide patient-level information on medication dispensing, medical visits, hospitalisations and death. Drug dispensing trends will be described, drug adherence and persistence estimated and the association with all-cause/cardiovascular death and hospitalisations reported.

ETHICS AND DISSEMINATION

This project has received approvals from the Western Australian Department of Health Human Research Ethics Committee and the Western Australian Aboriginal Health Ethics Committee. Results will be published in relevant cardiology journals and presented at national and international conferences.

Psychological Determinants of Heart Failure Self-Care: Systematic Review and Meta-Analysis

OBJECTIVE

Psychological distress has been associated with poor outcomes in patients with chronic heart failure (HF), which is assumed to be partly due to poor HF self-care behavior. This systematic review and meta-analysis describes the current evidence concerning psychological determinants of self-care in patients with chronic HF.

METHODS

Eligible studies were systematically identified by searching electronic databases PubMed, PsycINFO, and the Conference Proceedings Citation Index (Web of Science) for relevant literature (1980-October 17, 2014). Study quality was assessed according to the level of risk of bias. Quantitative data were pooled using random-effects models.

RESULTS

Sixty-five studies were identified for inclusion that varied considerably with respect to sample and study characteristics. Risk of bias was high in the reviewed studies and most problematic with regard to selection bias (67%). Depression (r = -0.19, p < .001), self-efficacy (r = 0.37, p < .001), and mental well-being (r = 0.14, p = .030) were significantly associated with self-reported self-care. Anxiety was not significantly associated with either self-reported (r = -0.18, p = .24) or objective self-care (r = -0.04, p = .79), neither was depression associated with objectively measured medication adherence (r = -0.05, p = .44).

CONCLUSIONS

Psychological factors (depression, self-efficacy, and mental well-being) were associated with specific self-care facets in patients with chronic HF. These associations were predominantly observed with self-reported indices of self-care and not objective indices. Methodological heterogeneity and limitations preclude definite conclusions about the association between psychological factors and self-care and should be addressed in future research.

The necessity-concerns framework predicts adherence to medication in multiple illness conditions: A meta-analysis

OBJECTIVE

This meta-analysis investigated whether beliefs in the necessity and concerns of medicine and the necessity-concerns differential are correlated with medication adherence on a population level and in different conditions.

METHODS

An electronic search of Web of Science, EMBASE, PubMed and CINAHL was conducted for manuscripts utilising the Beliefs about Medicines Questionnaire and comparing it to any measure of medication adherence. Studies were pooled using the random-effects model to produce a mean overall effect size correlation. Studies were stratified for condition, adherence measure, power and study design.

RESULTS

Ninety-four papers were included in the meta-analysis. The overall effect size(r) for necessity, concerns, and necessity-concerns differential was 0.17, -0.18 and 0.24 respectively and these were all significant (p<0.0001). Effect size for necessity was stronger in asthma and weaker in the cardiovascular group compared to the overall effect size.

CONCLUSION

Necessity and concerns beliefs and the necessity-concerns differential were correlated with medication adherence on a population level and across the majority of included conditions. The effect sizes were mostly small with a magnitude comparable to other predictors of adherence.

PRACTICE IMPLICATIONS

This meta-analysis suggests that necessity and concern beliefs about medicines are one important factor to consider when understanding reasons for non-adherence.

How do patients' values influence heart failure self-care decision-making?: A mixed-methods systematic review

BACKGROUND

Values are central to ethical and effective nursing and health care. However, in relation to heart failure, an extremely common and burdensome syndrome, the role that patients' values have in influencing self-care is poorly understood.

METHODS

A mixed methods systematic review was conducted using a critical meta-narrative synthesis approach to synthesizing qualitative and qualitized data. Nine databases were searched (14 March 2014). To be included in the review, studies had to contain data on heart failure patients' values and self-care behaviors, include adults aged ≥18 years with symptomatic heart failure, and be published ≥2000 as full articles or theses. Study quality was assessed using a mixed-methods appraisal tool.

FINDINGS

Of 6467 citations identified, 54 studies were included (30 qualitative, 8 mixed methods, and 16 quantitative; 6045 patients, 38 lay caregivers, and 96 health care professionals). The synthesis identified multiple bi-directional interactions between heart failure, patients' values, and self-care. Patients are motivated by self-related and other-related values. Self-related values are tied directly to intimate personal feelings (self-direction, pleasure, and being healthy) or related to individuals' life circumstances (maintaining a healthy lifestyle and financial balance). Other-related values, which are fundamentally socially-based, are related to benefits received from society (social recognition and socialization) and social obligations (responsibility, observing traditions, and obedience). For each decision, several values are involved; some are incompatible and some are in conflict. Patients make their self-care decision based on the values they prioritize and those that are blocked.

CONCLUSION

Values are integral to how patients approach and undertake HF self-care. These values both affect and respond to this self-care and the severity of HF symptoms. Values extend to those relating to the self and others and incorporate a range of personal, life, and social dimensions. Values cannot be assumed to be fixed, normative or similar to those held by nurses and other health professionals. Future interventions to improve HF self-care must address and respond to the complexity of patients' values and how they influence patient behavior in undertaking heart failure self-care.

Rethinking agency and medical adherence technology: applying Actor Network Theory to the case study of Digital Pills

Much literature surrounding medical technology and adherence posits that technology is a mechanism for social control. This assumes that the medical establishment can take away patients' agency. Although power relationships and social control can play a key role, medical technology can also serve as an agentive tool to be utilized. We (1) offer the alternative framework of Actor Network Theory to view medical technology, (2) discuss the literature on medication adherence and technology, (3) delve into the ramifications of looking at adherence as a network and (4) use Digital Pills as a case study of dispersed agency.

Using a collaborative research approach to develop an interdisciplinary research agenda for the study of mobile health interventions for older adults

Background

Seniors with chronic diseases are often called on to self-manage their conditions. Mobile health (mHealth) tools may be a useful strategy to help seniors access health information at the point of decision-making, receive real-time feedback and coaching, and monitor health conditions. However, developing successful mHealth interventions for seniors presents many challenges. One of the key challenges is to ensure the scope of possible research questions includes the diverse views of seniors, experts and the stakeholder groups who support seniors as they manage chronic disease.

Objective

Our primary objective was to present a case-study of a collaborative research approach to the development of an interdisciplinary research agenda. Our secondary objectives were to report on the results of a nominal group technique (NGT) approach used generate research questions and to assess the success of including non-academic researchers to enrich the scope, priority, and total number of possible research questions.

Methods

We invited researchers and stakeholders to participate in a full day meeting that included rapid-style presentations by researchers, health care professionals, technology experts, patients and community groups followed by group discussions. An NGT was used to establish group consensus on the following question: In your opinion, what research needs to be done to better understand the effectiveness, usability and design of mobile health apps and devices for older adults?

Results

Overall, the collaborative approach was a very successful strategy to bring together a diverse group of participants with the same end goal. The 32 participants generated 119 items in total. The top three research questions that emerged from the NGT were related to adoption, the need for high quality tools and the digital divide. Strong sub-themes included privacy and security, engagement and design. The NGT also helped us include the perspectives information from non-academic researchers that would not have been captured if the process had been limited to the research team.

Conclusions

Developing ways for patients and other stakeholders to have a voice when it comes to developing patient awareness as related to mHealth may guide future research into engagement, ownership, usability and design. It is our intention that our paper be used and adapted by other researchers to engage small or vulnerable populations often excluded from mHealth research and design.

Determinants of Patient's Adherence to Hypertension Medications: Application of Health Belief Model Among Rural Patients

Background:

Hypertension is a major health problem in developing and developed countries, and its increasing epidemy is a serious warning to take more attention to this silent disease.

Aim:

This study was aimed to determine the factors of adherence to hypertension medication based on health belief model (HBM).

Subjects and Methods:

A cross-sectional study was conducted in a rural area of the Ardabil city in 2013. This study was carried out using a pre-structured and validated questionnaire. The questionnaire included information on demographic characteristics, lifestyle habits, HBM constructs and adherence to hypertension medication (Morisky 4-Item Self-Report Measure of Medication-taking Behavior [Morisky Medication Adherence Scale]). Data were analyzed with the use of SPSS version 18. P < 0.05 was considered as statistically significant.

Results:

A total of 671 hypertensive patients participated in the study (169 were males and 502 were females). The prevalence of adherence was 24% (161/671)% in the study population. Respondents with regular physical activity and nonsmokers were more adherent to hypertension medication when compared to respondents with sedentary lifestyle and smoking (P < 0.01). Based on HBM constructs, the respondents who perceived high susceptibility, severity, benefit had better adherence compared to moderate and low susceptibility, severity, and benefit.

Conclusion:

The prevalence of adherence to hypertension management was low in study population, this due to inadequate perceived susceptibility, perceived, severity, perceived benefit and poor lifestyle factors. Improving adherence in hypertension patients need to recognize the value and importance of patient perceptions medications.

Predicting adherence to medications using health psychology theories: a systematic review of 20 years of empirical research

OBJECTIVES

This review sought to identify the empirical evidence for the application of models from sociocognitive theory, self-regulation theory, and social support theory at predicting patient adherence to medications.

METHODS

A systematic review of the published literature (1990-2010) using MEDLINE, EMBASE, Cochrane Library, CINAHL, and PsychINFO identified studies examining the application of health psychology theory to adherence to medication in adult patients. Two independent reviewers extracted data on medication, indication, study population, adherence measure, theory, model, survey instruments, and results. Heterogeneity in theoretical model specification and empirical investigation precluded a meta-analysis of data.

RESULTS

Of 1756 unique records, 67 articles were included (sociocognitive = 35, self-regulation = 21, social support = 11). Adherence was most commonly measured by self-report (50 of 67). Synthesis of studies highlighted the significance (P ≤ 0.05) of self-efficacy (17 of 19), perceived barriers (11 of 17), perceived susceptibility (3 of 6), necessity beliefs (8 of 9), and medication concerns (7 of 8).

CONCLUSIONS

The results of this review provide a foundation for the development of theory-led adherence-enhancing interventions that could promote sustainable behavior change in clinical practice.

Medication adherence and quality of life among the elderly with diabetic retinopathy

METHOD

one hundred (n=100) elderly outpatients with diabetic retinopathy taking antihypertensives and/or oral antidiabetics/insulin were interviewed. Adherence was evaluated by the adherence proportion and its association with the care taken in administrating medications and by the Morisky Scale. The National Eye Institute Visual Functioning Questionnaire (NEI VFQ-25) was used to evaluate HRQoL.

RESULTS

most (58%) reported the use of 80% or more of the prescribed dose and care in utilizing the medication. The item "stopping the drug when experiencing an adverse event", from the Morisky Scale, explained 12.8% and 13.5% of the variability of adherence proportion to antihypertensives and oral antidiabetics/insulin, respectively.

CONCLUSION

there was better HRQoL in the Color Vision, Driving and Social Functioning domains of the NEI VFQ-25. Individuals with lower scores on the NEI VFQ-25 and higher scores on the Morisky Scale presented greater chance to be nonadherent to the pharmacological treatment of diabetes and hypertension.

Evaluating user perceptions of mobile medication management applications with older adults: a usability study

BACKGROUND

Medication nonadherence has a significant impact on the health and wellbeing of individuals with chronic disease. Several mobile medication management applications are available to help users track, remember, and read about their medication therapy.

OBJECTIVE

The objective of this study was to explore the usability and usefulness of existing medication management applications for older adults.

METHODS

We recruited 35 participants aged 50 and over to participate in a 2-hour usability session. The average age ranged from 52-78 years (mean 67 years) and 71% (25/35) of participants were female. Each participant was provided with an iPad loaded with four medication management applications: MyMedRec, DrugHub, Pillboxie, and PocketPharmacist. These applications were evaluated using the 10 item System Usability Scale (SUS) and visual analog scale. An investigator-moderated 30-minute discussion followed, and was recorded. We used a grounded theory (GT) approach to analyze qualitative data.

RESULTS

When assessing mobile medication management applications, participants struggled to think of a need for the applications in their own lives. Many were satisfied with their current management system and proposed future use only if cognition and health declined. Most participants felt capable of using the applications after a period of time and training, but were frustrated by their initial experiences with the applications. The early experiences of participants highlighted the benefits of linear navigation and clear wording (eg, "undo" vs "cancel") when designing for older users. While there was no order effect, participants attributed their poor performance to the order in which they tried the applications. They also described being a part of a technology generation that did not encounter the computer until adulthood. Of the four applications, PocketPharmacist was found to be the least usable with a score of 42/100 (P<.0001) though it offered a drug interaction feature that was among the favorite features of participants. The usability scores for MyMedRec (56/100), DrugHub (57/100), and Pillboxie (52/100) were not significantly different and participants preferred MyMedRec and DrugHub for their simple, linear interfaces.

CONCLUSIONS

With training, adults aged 50 and over can be capable and interested in using mHealth applications for their medication management. However, in order to adopt such technology, they must find a need that their current medication management system cannot fill. Interface diversity and multimodal reminder methods should be considered to increase usability for older adults. Lastly, regulation or the involvement of older adults in development may help to alleviate generation bias and mistrust for applications.

How can health literacy influence outcomes in heart failure patients? Mechanisms and interventions

Health literacy is discussed in papers from 25 countries where findings suggest that approximately a third up to one half of the people in developed countries have low health literacy. Specifically, health literacy is the mechanism by which individuals obtain and use health information to make health decisions about individual treatments in the home, access care in the community, promote provider-patient interactions, structure self-care, and navigate health care programs both locally and nationally. Further, health literacy is a key determinant of health and a critical dimension for assessing individuals' needs, and, importantly, their capacity for self-care. Poorer health knowledge/status, more medication errors, costs, and higher rates of morbidity, readmissions, emergency room visits, and mortality among patients with health illiteracy have been demonstrated. Individuals at high risk for low health literacy include the elderly, disabled, Blacks, those with a poverty-level income, some or less high school education, either no insurance or Medicare or Medicaid, and those for whom English is a second language. As a consequence, health literacy is a complex, multifaceted, and evolving construct including aspects of social, psychological, cultural and economic circumstances. The purpose of this paper is to describe the mechanisms and consequences of health illiteracy. Specifically, the prevalence, associated demographics, and models of health literacy are described. The mechanism of health illiteracy's influence on outcomes in heart failure is proposed. Tools for health literacy assessment are described and compared. Finally, the health outcomes and general interventions to enhance the health outcomes in heart failure are discussed.

Understanding patients' adherence-related beliefs about medicines prescribed for long-term conditions: a meta-analytic review of the Necessity-Concerns Framework

BACKGROUND

Patients' beliefs about treatment influence treatment engagement and adherence. The Necessity-Concerns Framework postulates that adherence is influenced by implicit judgements of personal need for the treatment (necessity beliefs) and concerns about the potential adverse consequences of taking it.

OBJECTIVE

To assess the utility of the NCF in explaining nonadherence to prescribed medicines.

DATA SOURCES

We searched EMBASE, Medline, PsycInfo, CDSR/DARE/CCT and CINAHL from January 1999 to April 2013 and handsearched reference sections from relevant articles.

STUDY ELIGIBILITY CRITERIA

Studies using the Beliefs about Medicines Questionnaire (BMQ) to examine perceptions of personal necessity for medication and concerns about potential adverse effects, in relation to a measure of adherence to medication.

PARTICIPANTS

Patients with long-term conditions.

STUDY APPRAISAL AND SYNTHESIS METHODS

Systematic review and meta-analysis of methodological quality was assessed by two independent reviewers. We pooled odds ratios for adherence using random effects models.

RESULTS

We identified 3777 studies, of which 94 (N = 25,072) fulfilled the inclusion criteria. Across studies, higher adherence was associated with stronger perceptions of necessity of treatment, OR = 1.742, 95% CI [1.569, 1.934], p<0.0001, and fewer Concerns about treatment, OR = 0.504, 95% CI: [0.450, 0.564], p<0.0001. These relationships remained significant when data were stratified by study size, the country in which the research was conducted and the type of adherence measure used.

LIMITATIONS

Few prospective longitudinal studies using objective adherence measures were identified.

CONCLUSIONS

The Necessity-Concerns Framework is a useful conceptual model for understanding patients' perspectives on prescribed medicines. Taking account of patients' necessity beliefs and concerns could enhance the quality of prescribing by helping clinicians to engage patients in treatment decisions and support optimal adherence to appropriate prescriptions.

Predictors of non-adherence to systemic oral therapy for advanced hepatocellular carcinoma

OBJECTIVES

With increasing use and cost of oral oncology medications, patient non-adherence with oral therapy is of concern. This study evaluated non-adherence among patients receiving first-line oral therapy for hepatocellular carcinoma (HCC).

METHODS

This retrospective study used the employer-based MarketScan medical and pharmacy claims database (2005-2011) to identify adult patients with two or more diagnoses of HCC (ICD-9 155), and two or more filled prescriptions for sorafenib. Additional eligibility requirements were not having other previous cancers and a 4 month wash-out period prior to the index sorafenib date. Adherence was assessed using a modified proportion of days covered (PDC) measure with patient-specific sorafenib exposure from index date to treatment discontinuation. Non-adherence was categorized as PDC <85% (base case), with sensitivity analyses using an 80% cut-off and allowance for physician-directed therapy gaps. Logistic regression models were estimated to identify predictors of non-adherence.

RESULTS

A total of 1127 patients (median age = 61.0 years; 78.4% male) met eligibility criteria. Median duration of enrollment was 223 days and median sorafenib exposure was 121 days. Between 21.1% (PDC < 0.80) and 28.0% (PDC < 0.85) of patients were non-adherent. Higher age (p = 0.022), number of baseline medications (p = 0.003) and number of baseline comorbidities (p = 0.002) were associated with lower non-adherence, while prior procedures were associated with greater non-adherence (p = 0.002).

LIMITATIONS

In this study using billing claims data, we were unable to evaluate patient severity in terms of clinical characteristics such as the Child-Pugh score. Similarly, we could not assess clinical outcomes such as tumor response, radiological progression or overall survival, although median duration of sorafenib exposure and duration of health plan enrollment respectively were found to be good proxies.

CONCLUSIONS

Using a modified PDC approach, 22-29% of patients were non-adherent. Identified predictors of non-adherence in HCC should be assessed for newly emerging oral therapies, and may be used to guide patient education and other adherence-enhancing initiatives.

Factors influencing adherence in long-term use of statins

PURPOSE

To assess the factors influencing adherence in long-term medication use as exemplified by statins.

METHODS

Data from an in-depth survey of Australians aged 45 years and over were linked to national prescription reimbursement data to assess medication possession ratio (MPR) for statins for the middle two years of a four-year period of statin possession. Poisson regression was used to calculate the relative risk (RR) for adherence (MPR ≥ 80%) for patient characteristics and factors related to access to and need for health care services. Separate models were fit for patients receiving healthcare concession subsidies and those who do not ('general beneficiaries').

RESULTS

In the analysis, 42 492 concessional and 16 110 general beneficiary patients were included, with 80.1% and 56.7% showing MPR ≥ 80%, respectively. In both models, RR for adherence was significantly elevated for older (age 65+) and less healthy (worse self-rated health, pre-existing heart condition or obese) individuals, and for those who had private health insurance. Significantly lower RR (i.e. more non-adherence) was found for individuals reporting speaking a language other than English at home, who were smokers, were employed, and had higher levels of education, and for those who reported psychological distress. Income had no significant relationship with adherence, and the pattern of adherence by remoteness of area of residence was inconsistent.

CONCLUSIONS

Poor adherence in long-term use of statins is commonplace, but a number of key predictors-including age, language other than English spoken at home, smoking status and psychological distress-are readily assessable by the prescribing practice.

Determinants of adherence to heart failure medication: a systematic literature review

A systematic literature review was conducted to summarize the existing evidence on presumed determinants of heart failure (HF) medication adherence. The aim was to assess the evidence and provide directions for future medication adherence interventions for HF patients. Based on a search in relevant databases and a quality assessment, eleven articles were included in the review. A best evidence synthesis was used to combine the results of presumed determinants that were found more than once in the literature. Results were classified according the World Health Organization's (WHO) multidimensional adherence model. Results demonstrated a relationship between having been institutionalized in the past (including hospitalizations and nursing home visits) and higher adherence levels. This finding is related to the healthcare system dimension of the WHO model. The presumed determinants related to the other dimensions, such as social and economic factors, condition-related, therapy-related, and patient-related factors of the multidimensional adherence model all had inconsistent evidence. However, there was also an indication that patients' educational level and the number of healthcare professionals they have visited are not related to higher adherence levels. Based on the current review, HF patients who have been institutionalized in the past are more adherent to HF medication. Many other presumed determinants were investigated, but displayed inconsistent evidence. Due to the lack of evidence, it was not possible to make recommendations for future interventions.

Longitudinal association between medication adherence and glycaemic control in Type 2 diabetes

AIM

Despite the widespread assumption that adherence drives glycaemic control, there is little published support for this in Type 2 diabetes. The study objective was to determine whether self-reported medication adherence predicts future glycaemic control in Type 2 diabetes, after accounting for baseline control.

METHODS

Medication adherence (4-item Morisky scale), glycaemic control (HbA(1c)%), and other variables were assessed in 287 adult primary care patients prescribed oral medication (40% also on insulin) for Type 2 diabetes. Glycaemic control was reassessed 6 months later. Regression analyses examined concurrent and future glycaemic control as a function of baseline medication adherence after adjustment for baseline glycaemia and other potential confounders.

RESULTS

Only half of patients reported high adherence. Cross-sectional adjusted analysis replicated prior reports of an adherence-HbA(1c) association (P = 0.011). Even after adjusting for baseline HbA(1c), each one-point increase in baseline Morisky total score was associated with a 1.8 mmol/mol (or 0.16%) increase in HbA(1c) measured 6 months later. Additionally, baseline endorsement of forgetting to take medication was associated with a 4.7 mmol/mol (or 0.43%) increase in 6-month HbA(1c) (P = 0.005). This effect persisted after adjusting for psychological distress and did not vary by key demographic and medical features.

CONCLUSIONS

Even after stringent adjustment for baseline glycaemic control, self-reported adherence to diabetes medication predicts long-term glycaemic control. The Morisky scale is an easy-to-use clinical tool to identify patients whose glycaemic control will subsequently worsen, regardless of age, gender and psychological distress.

Exploring beliefs about heart failure treatment in adherent and nonadherent patients: use of the repertory grid technique

PURPOSE

Beliefs about medicines impact on adherence, but eliciting core beliefs about medicines in individual patients is difficult. One method that has the potential to elicit individual core beliefs is the "repertory grid technique." This study utilized the repertory grid technique to elicit individuals' beliefs about their heart failure treatment and to investigate whether generated constructs were different between adherent and nonadherent patients.

METHODS

Ninety-two patients with heart failure were interviewed using a structured questionnaire that applied the repertory grid technique. Patients were asked to compare and contrast their medicines and self-care activities for their heart failure. This lead to the generation of individual constructs (perceptions towards medicines), and from these, beliefs were elicited about their heart failure treatment, resulting in the generation of a repertory grid. Adherence was measured using the Medication Adherence Report Scale (MARS). Patients with a MARS score ≥ 23 were categorized as "adherent" and those with a score ≤ 22 as "nonadherent." The generated grids were analyzed descriptively and constructs from all grids themed and the frequency of these constructs compared between adherent and nonadherent patients.

RESULTS

Individual grids provided insight into the different beliefs that patients held about their heart failure treatment. The themed constructs "related to water," "affect the heart," "related to weight," and "benefit to the heart" occurred more frequently in adherent patients compared with nonadherent patients.

CONCLUSION

The repertory grid technique elicited beliefs of individual participants about the treatment of their heart failure. Constructs from self-reported adherent patients were more likely to reflect that their medicines and self-care activities were related to water and weight, and affect and benefit to the heart. Providing clinicians with better insight into individuals' beliefs about their treatment may facilitate the development of tailored interventions to improve adherence.

Patient-reported selective adherence to heart failure self-care recommendations: a prospective cohort study: the Atlanta Cardiomyopathy Consortium

Simultaneous adherence with multiple self-care instructions among heart failure (HF) patients is not well described. Patient-reported adherence to 8 recommendations related to exercise, alcohol, medications, smoking, diet, weight, and symptoms was assessed among 308 HF patients using the Medical Outcomes Study Specific Adherence Scale questionnaire (0="never" to 5="always," maximum score=40). A baseline cumulative score of ≥32/40 (average ≥80%) defined good adherence. Clinical events (death/transplantation/ventricular assist device), resource utilization, functional capacity (6-minute walk distance), and health status (Kansas City Cardiomyopathy Questionnaire [KCCQ]) were compared among patients with and without good adherence. The mean follow-up was 2.0±1.0 years, and adherence ranged from 26.3% (exercise) to 89.9% (medications). A cumulative score indicating good adherence was reported by 35.7%, whereas good adherence with every behavior was reported by 9.1% of patients. Good adherence was associated with fewer hospitalizations (all-cause 87.8 vs 107.6; P=.018; HF 29.6 vs 43.8; P=.007) and hospitalized days (all-cause 422 vs 465; P=.015; HF 228 vs 282; P<.001) per 100-person-years and better health status (KCCQ overall score 70.1±24.6 vs 63.8±22.8; P=.011). Adherence was not associated with clinical events or functional capacity. Patient-reported adherence with HF self-care recommendations is alarmingly low and selective. Good adherence was associated with lower resource utilization and better health status.

Individualised patient care as an adjunct to standard care for promoting adherence to ocular hypotensive therapy: an exploratory randomised controlled trial

PURPOSE

To evaluate the impact of individualised patient care, as an adjunct to standard care, on adherence to ocular hypotensive therapy.

METHODS

A two-arm, single-masked exploratory randomised controlled trial recruited patients newly prescribed ocular hypotensive therapy. The intervention involved an individual assessment of health-care needs and beliefs and a 1-year follow-up period according to need. The primary outcome was refill adherence, measured by collating prescription and dispensing data for 12 months. Secondary outcomes included self-reported adherence, glaucoma knowledge, beliefs about illness and medicines, quality of care, intraocular pressure (IOP) fluctuation, and changes in clinical management assessed at 12 months. The strength of the intervention was measured following withdrawal by reviewing clinical outcomes for a further 12 months.

RESULTS

In all, 127 patients were recruited (91% response rate). Intervention-arm patients collected significantly more prescriptions than control-arm patients. Self-report adherence was significantly better in the intervention-arm for patients who forgot drops and those who intentionally missed drops. The intervention group demonstrated significantly more glaucoma knowledge, expressed a significantly stronger belief in the necessity of eye drops and believed that they had more personal control over managing their condition. Control-arm patients had more IOP fluctuation and changes in clinical management. However, this finding only reached significance at 24 months.

CONCLUSION

Modelling patient care according to health-care needs and beliefs about illness and medicines can have a significant impact on improving adherence to therapy for this patient group, with the potential benefit of improving clinical outcomes.

Mechanisms of pain transmission and pharmacologic management

BACKGROUND

Pain sensation involves multiple signaling and modulatory pathways, employing a variety of neurotransmitters and other mediators. Inhibitory and facilitatory mechanisms affect the perception of stimuli as painful or non-painful, and in addition may affect the perceived intensity of pain. Endogenous opioids are key mediators in the descending pain suppression pathways. Additionally, monoaminergic neurotransmitters such as norepinephrine, serotonin and dopamine positively or negatively modulate pain signaling, depending on receptor type and location. The various mediators involved in pain signaling provide potential targets for pharmacological interventions. Single analgesic therapies may be limited in their ability to comprehensively target these complex pain signaling pathways. Therapeutic approaches acting on multiple pain transmission pathways through different mechanisms of action provide an opportunity to maximize efficacy and tolerability in the treatment of pain.

SCOPE

This article discusses the various physiologic processes involved in pain signaling and modulation, describes the mechanisms by which various classes of analgesic agents are believed to produce their clinical effects, and explores the potential benefits of a multiple-mechanism approach to analgesia. Published articles describing the physiologic processes involved in pain signaling and modulation and the mechanisms of analgesia for different drug classes were reviewed. MEDLINE searches were conducted to identify relevant studies published through August 2009 that evaluated the efficacy and tolerability of multiple-mechanism analgesic regimens. English language-only randomized controlled trials and meta-analyses of randomized controlled trials were considered.

FINDINGS/CONCLUSION

Multiple neurotransmitters and other mediators are involved in the endogenous modulation of pain signaling, providing numerous opportunities for intervention with different classes of analgesics. Data from numerous clinical trials indicate that multiple-mechanism approaches to analgesia provide comparable or superior analgesic efficacy with lower doses of the individual agents and reduced incidence of side effects. These data support current guidelines which endorse multiple-mechanism strategies for both acute and chronic pain management.

Utility of the Millon Behavioral Medicine Diagnostic to predict medication adherence in patients diagnosed with heart failure

Medication non-adherence is common and a primary reason for poor medical outcomes among individuals with heart failure (HF). This study's aims were to determine whether depression, hostility, and the personality-based Millon Behavioral Medicine Diagnostic (MBMD) Medication Abuse scale were associated with medication adherence (e.g., beta-blockers, ACE inhibitors, diuretics, statins) beyond contributions of demographic, medical, and psychosocial variables in an ethnically-diverse sample of 105 men and women diagnosed with HF. In hierarchical regression, greater MBMD Medication Abuse scale scores were associated with poorer adherence above and beyond both depression (β = .236, t[102] = 2.113, p = .037) and hostility (β = .244, t[102] = 2.506, p = .014). The Medication Abuse scale also completely mediated the relationship between adherence and depression. These findings suggest that personality measures such as the MBMD and hostility scales might be utilized in future studies investigating predictors of adherence and also used clinically to predict medication adherence among HF patients.

Medication adherence among community-dwelling patients with heart failure

OBJECTIVE

To determine medication use and adherence among community-dwelling patients with heart failure (HF).

PATIENTS AND METHODS

Residents of Olmsted County, Minnesota, with HF were recruited from October 10, 2007, through February 25, 2009. Pharmacy records were obtained for the 6 months after enrollment. Medication adherence was measured by the proportion of days covered (PDC). A PDC of less than 80% was classified as poor adherence. Factors associated with medication adherence were investigated.

RESULTS

Among the 209 study patients with HF, 123 (59%) were male, and the mean ± SD age was 73.7 ± 13.5 years. The median (interquartile range) number of unique medications filled during the 6-month study period was 11 (8-17). Patients with a documented medication allergy were excluded from eligibility for medication use within that medication class. Most patients received conventional HF therapy: 70% (147/209) were treated with β-blockers and 75% (149/200) with angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers. Most patients (62%; 127/205) also took statins. After exclusion of patients with missing dosage information, the proportion of those with poor adherence was 19% (27/140), 19% (28/144), and 13% (16/121) for β-blockers, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, and statins, respectively. Self-reported data indicated that those with poor adherence experienced more cost-related medication issues. For example, those who adhered poorly to statin therapy more frequently reported stopping a prescription because of cost than those with good adherence (46% vs 6%; P < .001), skipping doses to save money (23% vs 3%; P = .03), and not filling a new prescription because of cost (46% vs 6%; P < .001).

CONCLUSION

Community-dwelling patients with HF take a large number of medications. Medication adherence was suboptimal in many patients, often because of cost.

Changes in adherence to evidence-based medications in the first year after initial hospitalization for heart failure: observational cohort study from 1994 to 2003

BACKGROUND

The use of evidence-based medications in patients with heart failure has increased over the past 10 years. We aimed to determine whether adherence to these medications has also increased during this time.

METHODS AND RESULTS

A retrospective cohort was created using administrative databases from the province of Saskatchewan, Canada. Subjects discharged alive from their first hospitalization for heart failure between 1994 and 2003 were eligible. Those filling a prescription for a beta-blocker (BB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB) within 6 months of discharge were followed for 1 year after the initial prescription. Of 8805 eligible patients, 67% of BB users (941/1414) and 74% of ACEI/ARB users (4441/5991) exhibited optimal adherence at 1 year (defined as >or=80% adherence calculated from pharmacy refill records). When grouped by year of initial heart failure hospitalization, the proportion of optimally adherent patients improved from 54% to 75% with BB and from 67% to 80% with ACEI/ARBs between 1994/1995 and 2002/2003 (P for trend <0.001 for both). Mean 1-year adherence improved from 71% to 83% for BB and 80% to 88% for ACEI/ARBs. After adjustment using multivariable logistic regression, subjects discharged in 2003 were significantly more likely to exhibit optimal adherence to a BB (odds ratio, 2.04; 95% CI, 1.21 to 3.44) or an ACEI/ARB (odds ratio, 1.65; 95% CI, 1.30 to 2.08) than those prescribed therapy in 1994/1995.

CONCLUSIONS

One-year adherence to BB and ACEI/ARB is improving over time in patients discharged after first heart failure hospitalization. Patients taking multiple cardiac medications were not any less likely to exhibit optimal adherence than patients taking only 1 medication.

Defining an evidence-based cutpoint for medication adherence in heart failure

BACKGROUND

Despite the importance of medication adherence in heart failure, clinically relevant cutpoints for distinguishing the level of adherence associated with outcomes are unknown.

OBJECTIVE

The purpose of this study is to determine the cutpoint above which there is a positive relationship between level of medication adherence and event-free survival.

METHODS

This was a longitudinal study of 135 patients with heart failure. Medication adherence was measured using a valid and objective measure, the Medication Event Monitoring System. Two indicators of adherence were assessed by the Medication Event Monitoring System (AARDEX, Union City, CA): (1) dose count, percentage of prescribed doses taken, and (2) dose days, percentage of days the correct number of doses was taken. Patients were followed up to 3.5 years to collect data on outcomes. A series of Kaplan-Meier plots with log-rank tests, Cox survival analyses, and receiver operating characteristic curves were assessed comparing event-free survival in patients divided at one-point incremental cutpoints.

RESULTS

Event-free survival was significantly better when the prescribed number of doses taken (dose count) or the correct dose (dose day) was > or =88%. This level was confirmed in a Cox regression model controlling for age, gender, ejection fraction, New York Heart Association, comorbidity, angiotensin-converting enzyme inhibitor use, and beta-blocker use. Receiver operating characteristic curves showed that adherence rates above 88% produced the optimal combination of sensitivity and specificity with respect to predicting better event-free survival. With 88% as the adherence cutpoint, the hazard ratio for time to first event for the nonadherent group was 2.2 by dose count (P = .021) and 3.2 by dose day (P = .002).

CONCLUSION

The results of this study provide clinicians and researchers with an evidence-based recommendation about the level of adherence needed to achieve optimal clinical outcomes.

Medication adherence self-report instruments: implications for practice and research

BACKGROUND

After an acute cardiac event, adhering to recommendations for pharmacologic therapy is important in achieving optimal health outcomes. Considering the impressive evidence base for cardiovascular pharmacotherapy, strategies for promoting adherence are less well developed. Furthermore, accessing reliable, valid, and cost-effective mechanisms of monitoring adherence in the research and clinical settings is challenging.

AIM

The aim of this article was to review published self-report measures assessing and monitoring medication adherence in cardiovascular disease and provide recommendations for research into medication adherence.

METHODS

The electronic databases CINAHL, Medline, and Science Direct were searched using the key search terms medication adherence and/or compliance, cardiovascular, self-report measures, and questionnaires. The World Wide Web was searched using the Google and Google Scholar search engines, and reference lists of retrieved documents were reviewed. The search strategy was verified by a health librarian. Instruments were included if they specifically addressed medication adherence as a discrete construct rather than a disease-specific or a generic health status measurement.

FINDINGS

Despite of the problems with medication adherence identified in the literature, only 7 instruments met the search criteria. There was limited use of instruments across studies and settings to enable comparison across populations and extensive psychometric evaluation.

CONCLUSIONS

Medication adherence is a complex, multifaceted construct dependent on a range of physical, social, economic, and psychological considerations. In spite of the importance of adherence in ensuring optimal cardiovascular outcomes, conceptual underpinnings and methods of assessing medication adherence require further discussion and debate.

Medication adherence in patients who have heart failure: a review of the literature

Data indicate that nonadherence plays a major role in preventable rehospitalizations. The first step to improving adherence is determining the affecting factor. This article critically reviews the literature on factors affecting medication adherence in heart failure patients. Findings about effects of age, gender, race, and living status on adherence are quite inconsistent. Patients who believe taking medications is beneficial or who have no side effects are more adherent, as are those highly motivated to improve their well-being. Forgetfulness, social support, and patient-provider relationship are related to adherence. Providers seeking to increase adherence must consider patients' expectations for their health, their environment, their barriers to following prescribed regimen, and their understanding of their condition and how it relates to medication taking.

The impact of medication regimen factors on adherence to chronic treatment: a review of literature

This article reviews recent literature in chronic illness or long-term health management including asthma, contraception, diabetes, HIV disease, and hypertension/cardiovascular disease, mental disorders, pain, and other diseases to determine the relationship between regimen factors and adherence to medications. The authors conducted an electronic literature search to detect articles published between 1998 and 2007. Articles were included if they pertained to a chronic illness or to contraception, included a clear definition of how adherence was measured, and included regimen factors as primary or secondary explanatory variables. Methodology of the studies varied greatly, as did methods of measuring adherence and regimen factors. Surprisingly few of these articles concerned (1) chronic treatment, (2) regimen factors such as dosing, pill burden, and regimen complexity, and (3) adherence measured in a clear manner. Most studies failed to use state-of-the-art methods of measuring adherence. Despite these flaws, a suggestive pattern of the importance of regimen factors, specifically dose frequency and regimen complexity, emerged from this review.

Beliefs about medicines predict refill adherence to inhaled corticosteroids

OBJECTIVE

Despite the importance of the chronic use of inhaled corticosteroids (ICS) in maintaining asthma control, reported adherence varies between 40% and 60%. The Beliefs about Medicines Questionnaire (BMQ) has been shown to correlate with self-reported adherence. The aim of this study is to investigate whether beliefs about ICS (necessity and concerns), as measured by the BMQ, relate to adherence objectively measured by prescription-refill records.

METHODS

In a cross-sectional study of patients aged 18-45 years who filled at least two ICS prescriptions in 11 community pharmacies in The Netherlands, perceptions of ICS were assessed using the BMQ. Additionally, self-reported adherence was assessed using the Medication Adherence Report Scale. ICS prescription-refill adherence rates for a 12-month period prior to the survey were obtained from automated pharmacy dispensing records. Four attitudinal groups were defined using the necessity and concerns constructs. Statistical tests were used to examine associations between ICS adherence (assessed by subjective self-report and objective pharmacy records), specific beliefs about and attitudes towards ICS, and more general beliefs about pharmaceuticals.

RESULTS

Questionnaires were returned by 238 patients (51.1%). Both self-reported adherence (r=.38) and adherence by pharmacy records (rho=0.32) correlated with ICS necessity beliefs and concerns. Patients defined as skeptical, indifferent, ambivalent, or accepting, on the basis of these constructs, differed with respect to both their attitudes towards medicines in general and their adherence to medication.

CONCLUSIONS

Patients' beliefs about ICS correlate not only with adherence by self-report but also with a more objective measure of medication adherence calculated by pharmacy dispensing records. The necessity-concerns constructs offer a potentially useful framework to help clinicians elicit key treatment beliefs influencing adherence to ICS.