What do we mean by adherence to treatment and advice for living with diabetes? A review of the literature on definitions and measurements

Determinants of poor glycemic control among type 2 diabetes mellitus patients at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia: Unmatched case-control study

BACKGROUND

Poor glycemic control is one of the most determinant factors for type 2 diabetes-related morbidity and mortality. The proportion of type 2 diabetes mellitus patients with poor glycemic control remains high. Yet evidence on factors contributing to poor glycemic control remains scarce. The aim of this study is to identify determinants of poor glycemic control among type 2 diabetes mellitus patients at a diabetes mellitus clinic in University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia Determinants of Poor Glycemic Control among Type 2 Diabetes mellitus Patients at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia: Unmatched Case-Control Study.

METHODS

A hospital-based case-control study was conducted from June to September 2020. Using convenience sampling techniques, a total of 90 cases and 90 controls with type 2 diabetes were recruited. The data were entered into Epidata version 4.6.0.2 and analyzed by Stata version 14. A multivariable logistic regression analysis was performed to assess the association between independent variables and glycemic control. Both 95% CI and p-value<0.05 were used to determine the level and significance, respectively.

RESULTS

The mean age ( ± standard deviations) for the cases and controls were 57.55± 10.42 and 61.03± 8.93% respectively. The determinants of poor glycemic control were age (Adjusted odd ratio (AOR)= 0.08; 95% CI= 0.02-0.33), inadequate physical exercise (AOR = 5.05; 95% CI = 1.99-11.98), presence of comorbidities (AOR = 5.50; 95% CI = 2.06-14.66), non-adherence to anti-diabetes medications (AOR= 2.76; 95% CI= 1.19-6.40), persistent proteinuria (AOR=4.95; 95% CI=1.83-13.36) and high-density lipoprotein less than 40 mg/dl (AOR=3.08; 95% CI= 1.30-7.31).

CONCLUSIONS

Age less than 65 years, inadequate physical exercise, presence of comorbidities, non-adherence to anti-diabetes medications, persistent proteinuria, and high-density lipoprotein less than 40 mg/dl were the determinants of poor glycemic control. Therefore, targeted educational and behavioral modification programs on adequate exercise and medication adherence should be routinely practiced. Furthermore, early guideline-based screening and treatment of comorbidities and complications is required to effectively manage diabetes mellitus.

Memory complaints moderate the concordance between self-report and electronically monitored adherence in adults with type 2 diabetes

AIMS

We examined the impact of memory complaints on the concordance between self-report (SR) and electronically monitored (EM) medication adherence, independent of depression symptoms, among adults with type 2 diabetes (T2D).

METHODS

Adults (N = 104, age = 56.6 ± 9.2; 64% female) completed a prospective and retrospective memory questionnaire (PRMQ) and a depression symptom interview at baseline. EM was tracked over 3 months and participants rated adherence using SR. Multiple linear regression evaluated PRMQ as a moderator of the relationship between EM and SR, adjusting for depression and other covariates.

RESULTS

PRMQ was correlated with lower SR (r = -0.31, p = 0.001), but not with EM. PRMQ moderated the relationship between SR and EM, independent of depression symptoms. At low levels of PRMQ, SR and EM were closely related (β = 0.76, p < 0.001); at high levels of PRMQ the relationship was weaker (β = 0.28, p = 0.02). Participants who under-reported their adherence (SR < EM) had higher PRMQ scores than more concordant reporters (p = 0.016).

CONCLUSIONS

SR and EM measures were less concordant among adults with T2D who endorsed higher PRMQ scores. Memory complaints may contribute to under-reporting of medication adherence in adults with T2D.

From Compliance to Adherence in Diabetes Self-care: Examining the Role of Patient's Potential for Mindful Non-Adherence and Physician-Patient Communication

PURPOSE

To examine the roles of patient mindful non-adherence and physician-patient communication as important factors that facilitate an understanding of the relationship between compliance and adherence in diabetes management.

DESIGN

A cross-sectional survey Setting: Online data collection Subjects: 365 respondents at least 18 years of age and currently in treatment for diabetes Measures: We measured patients' compliance, adherence, mindfulness, and perceptions about physician-patient communication, as well as their demographic characteristics.

ANALYSIS

A moderated mediation analysis was conducted to examine the conditioned indirect effect of compliance on adherence.

RESULTS

The direct effect of compliance on adherence was positive and significant (β = .378, SE = .073, p < .05, BootCI [.234, .521]), but the compliance-adherence association was also partially mediated by patient's potential for mindful non-adherence. A higher level of compliance increased potential for mindful non-adherence (β = .716, SE = .082, p < .05, BootCI [.555, .876]), and, in turn, the increased potential for mindful non-adherence reduced adherence (β = -.107, SE = .045, p < .05, BootCI [-.196, -.018]). This detrimental mediating effect of potential for mindful non-adherence was contingent on the perceived quality of physician-patient communication (index = .076, SE = .038, 95% BootCI [.003, .153]), indicating that the positive perception significantly reduced the negative mediating effect of potential for mindful non-adherence on adherence.

Determining the Optimal Cognitive Screening Tool in Older People With Diabetes

Background: Self-care is an important perspective to aging and transitional states in diabetes management. Population studies have shown that lower cognitive function is associated with worse self-care abilities. Several guidelines have emphasized the importance of assessing cognitive function in older people with diabetes and tailoring treatment plan accordingly. Those guidelines do not specify which tools are the most appropriate for this population. One approach to delineate which tools should be used is to assess which tools best correlate with self-care capacity. Objective: To assess which cognitive assessment tools best correlate with self-care capacity in older people with type 2 diabetes. Methods: Cross-sectional study, conducted amongst individuals with diabetes over the age of 60. The association between self-care capacity indices and different cognitive assessment tools was examined. Principal Component self-care constructs were determined and the association between these and the different cognitive assessment tools was examined. Results: A significant association was found between the Principal Component self-care construct and the Montreal Cognitive Assessment and MindstreamsTM scores. In a stepwise regression model including only the Montreal Cognitive Assessment score, a significant association was found between this score and the Principal Component self-care construct. The same was not found in a model that included only the MindstreamsTM scores. Conclusions: The Montreal Cognitive Assessment, previously validated as a brief cognitive screening tool, may be useful as an adjunct to assess the self-care capacity of older individuals with diabetes. Future studies in the clinic are needed to evaluate if using this tool may improve treatment plans.

Effects of eHealth-Based Interventions on Adherence to Components of Cardiac Rehabilitation: A Systematic Review

OBJECTIVE

The aim of this study was to determine the effects of eHealth-based interventions on patient adherence to components of cardiac rehabilitation (CR).

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guided this review. Medline, CINAHL, Embase, and Cochrane Library databases were searched for studies published from January 1996 to December 2017. All studies were included in which eHealth-based components of CR and its effects on patient adherence were measured. Because this review included a heterogeneous group of study designs, the authors qualitatively described the effect of eHealth on adherence into a narrative approach.

RESULTS

A total of 1520 studies were identified, with 1415 excluded after screening. Of the remaining 105 studies, 90 were excluded after full text assessment, leaving 15 studies for analysis. Most (11) of the 15 studies reported on medication adherence. Other studies focused on adherence to diet, physical activity, vital signs, weight, step counts, smoking, and fluid restriction. The type of eHealth used also varied, ranging from telemonitoring and web-based applications to telephone calls. Of the 15 studies, 7 reported significant improvements with eHealth-based components of CR on adherence.

DISCUSSION AND CONCLUSION

This review summarizes the effects of eHealth on components of CR and revealed variations in measurement and evaluation methods. The telemonitoring and web-based applications for self-care behaviors were most effective in promoting adherence. The measurement of adherence should be based on an explicit definition of adherence and should be measured with validated scales tested in the CR population.

A systematic review of factors influencing treatment adherence in chronic inflammatory skin disease - strategies for optimizing treatment outcome

Adherence describes how a patient follows a medical regime recommended by a healthcare provider. Poor treatment adherence represents a complex and challenging problem of international healthcare systems, as it has a substantial impact on clinical outcomes and patient safety and constitutes an important financial burden. Since it is one of the most common causes of treatment failure, it is extremely important for physicians to reliably distinguish between non-adherence and non-response. This systematic review aims to summarize the current literature on treatment adherence in dermatology, focusing on chronic inflammatory skin diseases such as psoriasis, atopic dermatitis and acne. A systematic literature search was performed using the PubMed Database, including articles from 2008 to 2018. Low treatment adherence is a multidimensional phenomenon defined by the interplay of numerous factors and should under no circumstances be considered as the patient's fault alone. Factors influencing treatment adherence in dermatology include patient characteristics and beliefs, treatment efficacy and duration, administration routes, disease chronicity and the disease itself. Moreover, the quality of the physician-patient relationship including physician-time available for the patient plays an important role. Understanding patients' adherence patterns and the main drivers of non-adherence creates opportunities to improve adherence in the future. Strategies to increase treatment adherence range from reminder programs to simplifying prescriptions or educational interventions. Absolute adherence to treatment may not be realistically achievable, but efforts need to be made to raise awareness in order to maximize adherence as far as possible.

Development and psychometric evaluation of the Treatment Adherence Questionnaire for Patients with Combat Post-traumatic Stress Disorder

PURPOSE

Treatment adherence is one of the major strategies in treating post-traumatic stress disorder (PTSD) in combat veterans. This study developed and psychometrically assessed the Treatment Adherence Questionnaire for Patients with Combat Post-Traumatic Stress Disorder.

PARTICIPANTS AND METHODS

This methodological study was conducted in Tehran, Iran, during 2016-2017 in two phases. First, the concept of treatment adherence in combatants with PTSD was analyzed using a hybrid model. This model consisted of three phases: literature review phase, fieldwork phase, and final analysis phase. The consequences and attributes of the concept of treatment adherence in combatants with PTSD were identified, and based on the findings, the Treatment Adherence Questionnaire for PTSD veterans was developed. In the second stage, the face and content validities of the questionnaire were investigated both quantitatively and qualitatively. Exploratory factor analysis and confirmatory factor analysis were used to determine the questionnaire's validity. Internal consistency correlation coefficient of the questionnaire was estimated with Cronbach's alpha coefficient, while the reliability of the questionnaire was established using intra-class test-retest correlation coefficient. Study participants were selected from inpatients and outpatients referred to a hospital, clinic, and health center in Tehran and Kashan, Iran. All patients were diagnosed with combat PTSD by a psychiatrist, based on psychiatric interview and other clinical findings.

RESULTS

The Persian version of the Treatment Adherence Questionnaire for Patients with Combat Post-Traumatic Stress Disorder included 17 items. Exploratory factor analysis identified three factors which accounted for a total of 87.57% of the total variance of treatment adherence score. The identified factors were labeled as "maintenance of treatment", "follow-up and treatment contribution", and "purposefulness and responsibility". The Cronbach's alpha correlation coefficient was 0.92 and the intra-class correlation coefficient of the questionnaire's reliability was estimated at 0.92 (P<0.001).

CONCLUSION

The data obtained confirmed the hypothesis of the factor structure model with a latent second-order variable. The final version of the Treatment Adherence Questionnaire for Iranian combatants with PTSD can be applied as a valid and reliable questionnaire for measuring treatment adherence in these patients.

Patients' Perspectives of Oral and Injectable Type 2 Diabetes Medicines, Their Body Weight and Medicine-Taking Behavior in the UK: A Systematic Review and Meta-Ethnography

The aim of this review is to identify peoples' perspectives of their glucose-lowering and anti-obesity drugs in relation to diabetes and weight control and to explore how these views affect medication adherence. Theoretical perspectives associated with medicine-taking behavior are also explored. The systematic review was based on a meta-ethnography of qualitative studies identified through a search of 12 medical and social science databases and subsequent citation searches. The quality of all studies was assessed. Sixteen studies were included with data from 360 UK individuals. No relevant studies were identified which focused on anti-obesity and non-insulin injectable drugs. The review revealed that the patients' perspectives and emotional state were influenced by starting and/or changing to a new glucose-lowering medicine. These were also influenced by prior medication experience, disease perceptions and interactions with clinicians. Despite reports of positive experiences with and positive perceptions of medicines, and of participation in strategies to regain life control, medication non-adherence was common. Accepting glucose-lowering medicines impacted on the individual's perception of lifestyle changes, and it was notable that weight loss was not perceived as a strategy to support diabetes management. Synthesis revealed that more than one theory is required to explain medicine-taking behavior. New insights into the underlying factors of poor adherence and the specific practical issues identified in this review can help in the development of patient-centered interventions.

FUNDING

Diabetes UK.

Self-reported treatment adherence among psychiatric in- and outpatients

BACKGROUND

Poor adherence to psychiatric treatment is a common clinical problem, leading to unfavourable treatment outcome and increased healthcare costs.

AIM

The aim of this study was to investigate the self-reported adherence and attitudes to outpatient visits and pharmacotherapy in specialized care psychiatric patients.

METHODS

Within the Helsinki University Psychiatric Consortium (HUPC) pilot study, in- and outpatients with schizophrenia or schizoaffective disorder (SSA, n  =  113), bipolar disorder (BD, n  =  99), or depressive disorder (DD, n  =  188) were surveyed about their adherence and attitudes towards outpatient visits and pharmacotherapy. Correlates of self-reported adherence to outpatient and drug treatment were investigated using regression analysis.

RESULTS

The majority (78.5%) of patients reported having attended outpatient visits regularly or only partly irregularly. Most patients (79.2%) also reported regular use of pharmacotherapy. Self-reported non-adherence to preceding outpatient visits was consistently and significantly more common among inpatients than outpatients across all diagnostic groups (p < .001). Across all groups, hospital setting was the strongest independent correlate of poor adherence to outpatient visits (SSA β = -2.418, BD β = -3.417, DD β = -2.766; p < .001 in all). Another independent correlate of non-adherence was substance use disorder (SSA β = -1.555, p = .001; BD β = -1.535, p = .006; DD β = -2.258, p < .000). No other socio-demographic or clinical factor was significantly associated with poor adherence in multivariate regression models.

CONCLUSIONS

Irrespective of diagnosis, self-reported adherence to outpatient care among patients with schizophrenia or schizoaffective disorder, bipolar disorder, and depression is associated strongly with two factors: hospital setting and substance use disorders. Thus, detection of adherence problems among former inpatients and recognition and treatment of substance misuse are important to ensure proper outpatient care.

Effect of medication adherence on long-term all-cause-mortality and hospitalization for cardiovascular disease in 65,067 newly diagnosed type 2 diabetes patients

This study determined the effects of anti-diabetic medication adherence on the long-term all-cause mortality and hospitalization for cerebrovascular disease and myocardial infarction among newly diagnosed patients. The study used retrospective cohort from the National Health Insurance Service. Study participants were 65,076 newly diagnosed type 2 diabetes mellitus patients aged ≥40 years. The medication adherence was evaluated from the proportion of days covered (PDC) between 2006 and 2007. Outcome variables were mortality, newly diagnosed cerebrovascular disease (CVD) and myocardial infarction (MI) in 2008–2017. Cox-proportional hazard regression analysis was performed. After adjusting for sex, age, monthly contribution, insurance type, medical institution type, Charlson comorbidity index score, disability, hypertension, and active ingredients of oral hypoglycemic agents, the adjusted hazard ratio (aHR) for all-cause-mortality of the lowest PDC group (<0.20) was 1.45 (95% confidence interval [CI] = 1.36–1.54) as compared to the highest PDC (≥0.8). The aHR for all-cause-mortality associated with PDC levels of 0.60–0.79, 0.40–0.59, and 0.20–0.39 were 1.19, 1.26, and 1.34, respectively (P_trend < 0.001). Compared to the highest PDC group, diabetic patients with the lowest PDC had elevated risk for CVD (aHR = 1.41; 95% CI = 1.30–1.52; P_trend < 0.001). Improving anti-diabetic medication adherence among newly diagnosed type 2 diabetes mellitus patients is essential to the reduce risk for cardiovascular disease and long-term all-cause mortality.

Associations Among Depressive Symptoms, Wellness, Patient Involvement, Provider Cultural Competency, and Treatment Nonadherence: A Pilot Study Among Community Patients Seen at a University Medical Center

Treatment nonadherence is a pernicious problem associated with increasing rates of chronic diseases, escalating healthcare costs, and rising mortality in some patients. Although researchers have suggested numerous factors related to treatment nonadherence, several understudied aspects warrant attention, such as primary-care settings, provider cultural competence, and patient involvement. Adding to the research base, the present pilot study examined 88 primarily Black American and White American community patients from a large university medical center in the southern part of the United States. The study explored two research questions: (a) To what extent are there associations among depressive symptoms, wellness, patient involvement, cultural competency, and treatment nonadherence in a racially diverse community patient population? And (b) to what extent do the study exploratory variables and background characteristics predict treatment nonadherence, both separately and jointly? Depressive symptoms, the patient's perception of a provider's cultural competence, and marital/partnered status were found to be statistically significantly associated with treatment nonadherence, but not entirely in the directions expected.

An Exploratory Study of the Impact of Gender on Health Behavior Among African American and Latino Men With Type 2 Diabetes

This study explores gender values and beliefs among Latino and African American men with diabetes and examines how these values and beliefs may influence their health behaviors. Participants were recruited from individuals who participated in one of three Racial and Ethnic Approaches to Community Health Detroit Partnership diabetes self-management interventions. One focus group was conducted with African American men ( n = 10) and two focus groups were conducted with Latino men ( n = 12) over a 3-month period. Sessions lasted 90 minutes, were audiotaped, and analyzed using thematic content analysis techniques. Two themes emerged that characterize gender identity and its relationship to health behavior in men: (a) men's beliefs about being men (i.e., key aspects of being a man including having respect for themselves, authority figures, and peers; fulfilling the role as breadwinner; being responsible for serving as the leader of the family; and maintaining a sense of chivalry) and (b) influence of gender values and beliefs on health behavior (i.e., the need to maintain a strong image to the outside world, and the need to maintain control of themselves served as barriers to seeking out and engaging in diabetes self-management behaviors). Results suggest that gender values and beliefs may have implications for how health behaviors among men with diabetes. Future research should study the direct impact masculine identity has on health behaviors among men with diabetes.

Nonadherence of Oral Antihyperglycemic Medication Will Increase Risk of End-Stage Renal Disease

Poor glycemic control is related to an increased risk of end-stage renal disease (ESRD). This study investigated the association between medication adherence and the risk of ESRD in patients with newly diagnosed diabetes mellitus.In this population-based cohort study, we used the Taiwan National Health Insurance Research Database (NHIRD) to identify 559,864 patients with newly diagnosed or treated diabetes mellitus who were ages from 20 to 85 years between 2001 and 2008. We identified 1695 patients with ESRD during the study period. The mean follow-up time of the patients with ESRD was 5.7 years. Time-dependent Cox proportional hazards regression was performed to estimate the hazard ratios for ESRD among the patients with newly diagnosed diabetes mellitus.After adjustment for various covariates, nonadherence to oral antihyperglycemic medication (OAM) was associated with a higher risk of ESRD compared with adherence to OAM (hazard ratio [HR], 1.11; 95% confidence interval [CI], 1.01-1.23). The effects of nonadherence to OAM on the risk of ESRD were significant for patients without hypertension, without gout, without chronic kidney disease, undergoing OAM polytherapy, and undergoing metformin polytherapy (HR [95% CIs], 1.18 [1.00-1.39], 1.13 [1.02-1.26], 1.17 [1.03-1.33], 1.22 [1.08-1.38], and 1.13 [1.02-1.25], respectively).In conclusion, nonadherence to OAM therapy is associated with ESRD. Adherence to medication therapy can prevent the progressive loss of renal function and ESRD for patients with diabetes.

Adherence to insulin treatment in diabetes: can it be improved?

Insulin is used in all subjects with Type 1 diabetes, and when Type 2 diabetes is not controlled by oral anti-diabetic medicines, insulin is also used in Type 2 diabetes. However, despite this use, there is still increased mortality and morbidity in subjects with diabetes, compared to subjects without diabetes. One of the factors, which may be involved in this increased mortality and morbidity in subjects with diabetes, is nonadherence to insulin. Nonadherence rates to insulin are in the range of 20-38%, and many factors contribute to the nonadherence. The major aim of the review was to determine whether interventions to improve adherence to insulin do actually improve adherence to insulin. Most studies have shown that adherence to insulin was improved by changing from the vial-and-syringe approach to prefilled insulin pens, but not all studies have shown that this translated into better glycemic control and clinical outcomes. The results of studies using automatic telephone messages to improve adherence to insulin to date are inconclusive. There is limited and variable evidence that an intervention by a nurse/educator, which discusses adherence to medicines, does improve adherence to insulin. In contrast, there is little or no evidence that an extra intervention by a doctor or an intervention by a pharmacist, which discusses adherence to insulin, does actually improve the measured adherence to insulin. In conclusion, rather than assuming that an intervention by a health professional discussing adherence to insulin actually improves adherence to insulin, long-term studies investigating this are required.

Development and validation of the Hypertension Self-care Profile: a practical tool to measure hypertension self-care

BACKGROUND

Adequate self-care is crucial for blood pressure control. A number of hypertension (HBP) self-care instruments are available, but existing tools do not capture all the critical domains of HBP self-care and have limited evidence of reliability and validity.

OBJECTIVE

The purpose of this study was to develop and validate a new tool--the HBP Self-Care Profile (HBP SCP)--in a sample of inner-city residents.

METHODS

The HBP SCP encompasses comprehensive domains of HBP self-care behaviors. Guided by 2 validated theoretical approaches--Orem's self-care model and Motivational Interviewing--the HBP SCP includes 3 scales that can be used together or independently: Behavior, Motivation, and Self-efficacy. The sample included 213 English-speaking inner-city residents with HBP (mean age, 68.6 years; 76.1% women; 81.7% African American).

RESULTS

Item-total correlations ranged from 0.20 to 0.63 for Behavior, 0.46 to 0.70 for Motivation, and 0.40 to 0.74 for Self-efficacy, meeting the cutoff set a priori at 0.15. Internal consistency reliability coefficients ranged from 0.83 to 0.93. Concurrent and construct validities of the HBP SCP were achieved by significant correlations between HBP SCP scales and theoretically selected instruments (P < .05 for all correlation coefficients). The HBP SCP-Behavior scale also successfully discriminated between those with or without blood pressure control (P < .05).

CONCLUSIONS

The reliability and validity of the HBP SCP were supported in this sample of inner-city residents with HBP. The high reliability estimates and strong evidence of validity should allow researchers to use the HBP SCP to assess and identify gaps in HBP self-care behavior, motivation, and self-efficacy. Future research is warranted to evaluate the HBP SCP in diverse ethnic and age samples of hypertensive patient populations.

Relationship between continuity of ambulatory care and medication adherence in adult patients with type 2 diabetes in Korea: a longitudinal analysis

BACKGROUND

Medication adherence is the most important factor in the proper management of patients with diabetes. Considering the importance of informational continuity in a changing world, it could be meaningful to improve institution-level continuity of care and its positive relationship with medication adherence.

OBJECTIVES

We examined the relationship between institution-level continuity of ambulatory care and medication adherence in adult patients with type 2 diabetes receiving a new hypoglycemic prescription and sought to determine whether an improvement in medication adherence could be achieved through an ongoing relationship between the patient and the medical care institution.

RESEARCH DESIGN AND SUBJECTS

This was a longitudinal study of 23,034 patients aged 20 years and older enrolled in the Korea National Health Insurance (KNHI) program and first diagnosed with type 2 diabetes in 2004. The patients were followed-up for 4 years using claims data to measure continuity of ambulatory care and adherence to oral antihyperglycemic medications. The Continuity of Care Index (COCI) was calculated on the institution level as a measure of continuity and the medication possession ratio (MPR) was used as a measure of adherence.

RESULTS

After adjusting for confounding variables, the odds of being medication adherent (MPR ≥ 0.8) increased as the COCI increased [0.2≤COCI<0.4, odds ratio (OR)=2.20; 0.4≤COCI<0.6, OR=3.46; 0.6≤COCI<0.8, OR=4.76; 0.8≤COCI<1.0, OR=4.43; COCI=1.0, OR=7.24].

CONCLUSIONS

Institution-level continuity of ambulatory care was positively associated with medication adherence, which suggested that a high concentration of ambulatory care visits, whether it's a physician or an institution, could facilitate delivery of proper medical services to and increases medication adherence among patients with type 2 diabetes, and that institution-level continuity of ambulatory care could be an effective index for assessing the quality of chronic care in the fragmented health care delivery system as in Korea.

The dynamic process of adherence to a renal therapeutic regimen: perspectives of patients undergoing continuous ambulatory peritoneal dialysis

BACKGROUND

The nature of end-stage renal disease and the need for continuous ambulatory peritoneal dialysis require patients to manage various aspects of the disease, its symptoms and treatment. After attending a training programme, patients are expected to adhere to the renal therapeutic regimen and manage their disease with the knowledge and skills learned. While patients are the stakeholders of their health and related behaviour, their perceptions of adherence and how they adhere to their renal therapeutic regimen remains unexplored.

AIMS

To understand adherence from patients' perspectives and to describe changes in adherence to a therapeutic regimen among patients undergoing continuous ambulatory peritoneal dialysis.

DESIGN

This study used a mixed methods design with two phases - a survey in phase I and semi-structured interviews in phase II. This paper presents phase II of the study.

SETTINGS

The study was conducted at a renal unit of an acute hospital in Hong Kong.

PARTICIPANTS

Based on the phase I survey results, maximum variation sampling was employed to purposively recruit 36 participants of different genders (18 males, 18 females), ages (35-76 years), and lengths of dialysis experience (11-103 months) for the phase II interviews.

METHODS

Data were collected by tape-recorded semi-structured interviews. Content analysis was employed to analyse the transcribed data. Data collection and analysis were conducted simultaneously.

FINDINGS

Adherence was a dynamic process with three stages. At the stage of initial adherence, participants attempted to follow instructions but found that strict persistent adherence was impossible. After the first 2-6 months of dialysis, participants entered the stage of subsequent adherence, when they adopted selective adherence through experimenting, monitoring and making continuous adjustments. The stage of long-term adherence commenced after 3-5 years of dialysis, when participants were able to assimilate the modified therapeutic regimen into everyday life.

CONCLUSIONS

The process of adherence was dynamic as there were fluctuations at each stage of the participants' adherence. With reference to each stage identified, nursing interventions can be developed to help patients achieve smooth transition throughout all the stages.

Demographic and personal factors associated with metabolic control and self-care in youth with type 1 diabetes: a systematic review

Optimal use of recent technological advances in insulin delivery and glucose monitoring remain limited by the impact of behaviour on self-care. In recent years, there has been a resurgence of interest in psychosocial methods of optimizing care in youth with type 1 diabetes. We therefore sought to examine the literature for demographic, interpersonal and intrapersonal correlates of self-care and/or metabolic control. Studies for this systematic review were obtained via an electronic search of Medline, Embase, Cumulative Index to Nursing and Allied Health Literature and PsycINFO databases. Seventy studies fulfilled the inclusion criteria. These studies have indicated that identifiable individual characteristics in each domain are robustly associated with metabolic control and/or self-care in children and adolescents. We present these characteristics and propose a theoretical model of their interactions and effect on diabetes outcomes. There is currently no consensus regarding patient selection for insulin pump therapy. In this era of scarce healthcare resources, it may be prudent to identify youth requiring increased psychosocial support prior to regimen intensification. The importance of this review lies in its potential to create a framework for rationally utilizing resources by stratifying costly therapeutic options to those who, in the first instance, will be most likely to benefit from them.

Continuity of care, medication adherence, and health care outcomes among patients with newly diagnosed type 2 diabetes: a longitudinal analysis

BACKGROUND

The effects of continuity of care (COC) on health care outcomes are well established. However, the mechanism of this association is not fully understood.

OBJECTIVE

The objective of this study was to examine the relationship between COC and medication adherence, as well as to investigate the mediating effect of medication adherence on the association between COC and health care outcomes, in patients with newly diagnosed type 2 diabetes.

RESEARCH DESIGN AND SUBJECTS

This study utilized a longitudinal design and included a 7-year follow-up period from 2002 to 2009 under a universal health insurance program in Taiwan. Patients aged 18 years or older who were first diagnosed with type 2 diabetes in 2002 were included in the study. Random intercept models were conducted to assess the temporal relationship between COC, medication adherence, and health care outcomes.

RESULTS

Patients with high or intermediate COC scores were more likely to be adherent to medications than those with low COC scores [odds ratio (OR), 3.37; 95% confidence interval (CI), 3.15-3.60 and OR, 1.84; 95% CI, 1.74-1.94, respectively]. In addition, the association between COC and health care outcomes was partly mediated by better medication adherence in patients with newly diagnosed type 2 diabetes.

CONCLUSIONS

Improving the COC for patients with type 2 diabetes may result in higher medication adherence and better health care outcomes.

Promoting patient empowerment in the healthcare system: highlighting the need for patient-centered drug policy

In recent years the term 'patient empowerment' has increasingly been used among healthcare policy makers; however, discussions have focused on narrow activities that as stand-alone activities would be unlikely to give patients power. This paper presents findings from a systematic review of the medical literature. After offering a new definition of patient empowerment, we review the literature behind the concept, aided by a conceptual model. The model is derived from our review of all papers published in medicine (Medline) between 1980 and 2005, and is focused around issues related to the antecedents, activities and outcomes of patient empowerment, especially as they relate to researchers who may need to formulate or evaluate public policies aimed at the issue. We strive to stimulate more discussion of the linkages between public policy and patient empowerment, identifying a need to take a holistic approach, especially when policies are aimed at empowering patients in the area of personal drug management.

Medication adherence in diabetes mellitus and self management practices among type-2 diabetics in Ethiopia

BACKGROUND

Type-2 diabetes mellitus and its complication are becoming more prevalent in Ethiopia. Evidence abound that the most important predictor of reduction of morbidity and mortality due to diabetes complication is the level of glycemic control achieved.

AIMS

The aim is to assess adherence to anti diabetic drug therapy and self management practice among type-2 diabetic patient in Ethiopia.

PATIENTS AND METHOD

The study consists of two phases. A cross-sectional review of randomly selected 384 case notes of type-2 diabetic patient that attend diabetes mellitus clinic over 3 month and cross-sectional interview, with pre tested adherence and self management and monitoring tool questioner of 347 consecutive patients that attend in Jimma university specialized hospital diabetic clinic.

RESULT

Oral hypoglycemic agent were prescribed for 351(91.4) of the patient while insulin and oral hypoglycemic agent was prescribed in 33(8.6%). About 312 (88.9%) patients on oral hypoglycemic agent were on mono therapy, the most frequently prescribed oral hypoglycemic agent was glibenclamide 232(74.3%) and metformine 80(25.7%). Only 41.8% of the patient had adequate glycemic control. The main external factors for non adherence were lack of finance (37.1%) followed by perceived side effect of drug 29.2%. Only 6.5% patient who missed their medications disclosed to physician during consultation. The knowledge and practice of critical component of diabetes self management behavior were generally low among the patient studied.

CONCLUSION

Majority of the patient with type 2 diabetes in Ethiopia are managed by OHA monotherapy mainly glybenclamide and metformine. While the current prescribing strategy do not achieve glycemic control on majority of the patient. This is due to poor adherence with the prescribed drug regimen and poor knowledge and practice of successful self management.

The impact of decision aids to enhance shared decision making for diabetes (the DAD study): protocol of a cluster randomized trial

Background

Shared decision making contributes to high quality healthcare by promoting a patient-centered approach. Patient involvement in selecting the components of a diabetes medication program that best match the patient’s values and preferences may also enhance medication adherence and improve outcomes. Decision aids are tools designed to involve patients in shared decision making, but their adoption in practice has been limited. In this study, we propose to obtain a preliminary estimate of the impact of patient decision aids vs. usual care on measures of patient involvement in decision making, diabetes care processes, medication adherence, glycemic and cardiovascular risk factor control, and resource utilization. In addition, we propose to identify, describe, and explain factors that promote or inhibit the routine embedding of decision aids in practice.

Methods/Design

We will be conducting a mixed-methods study comprised of a cluster-randomized, practical, multicentered trial enrolling clinicians and their patients (n = 240) with type 2 diabetes from rural and suburban primary care practices (n = 8), with an embedded qualitative study to examine factors that influence the incorporation of decision aids into routine practice. The intervention will consist of the use of a decision aid (Statin Choice and Aspirin Choice, or Diabetes Medication Choice) during the clinical encounter. The qualitative study will include analysis of video recordings of clinical encounters and in-depth, semi-structured interviews with participating patients, clinicians, and clinic support staff, in both trial arms.

Discussion

Upon completion of this trial, we will have new knowledge about the effectiveness of diabetes decision aids in these practices. We will also better understand the factors that promote or inhibit the successful implementation and normalization of medication choice decision aids in the care of chronic patients in primary care practices.

Trial registration

NCT00388050

A new taxonomy for describing and defining adherence to medications

Interest in patient adherence has increased in recent years, with a growing literature that shows the pervasiveness of poor adherence to appropriately prescribed medications. However, four decades of adherence research has not resulted in uniformity in the terminology used to describe deviations from prescribed therapies. The aim of this review was to propose a new taxonomy, in which adherence to medications is conceptualized, based on behavioural and pharmacological science, and which will support quantifiable parameters. A systematic literature review was performed using MEDLINE, EMBASE, CINAHL, the Cochrane Library and PsycINFO from database inception to 1 April 2009. The objective was to identify the different conceptual approaches to adherence research. Definitions were analyzed according to time and methodological perspectives. A taxonomic approach was subsequently derived, evaluated and discussed with international experts. More than 10 different terms describing medication-taking behaviour were identified through the literature review, often with differing meanings. The conceptual foundation for a new, transparent taxonomy relies on three elements, which make a clear distinction between processes that describe actions through established routines ('Adherence to medications', 'Management of adherence') and the discipline that studies those processes ('Adherence-related sciences'). 'Adherence to medications' is the process by which patients take their medication as prescribed, further divided into three quantifiable phases: 'Initiation', 'Implementation' and 'Discontinuation'. In response to the proliferation of ambiguous or unquantifiable terms in the literature on medication adherence, this research has resulted in a new conceptual foundation for a transparent taxonomy. The terms and definitions are focused on promoting consistency and quantification in terminology and methods to aid in the conduct, analysis and interpretation of scientific studies of medication adherence.

A new taxonomy for describing and defining adherence to medications

Interest in patient adherence has increased in recent years, with a growing literature that shows the pervasiveness of poor adherence to appropriately prescribed medications. However, four decades of adherence research has not resulted in uniformity in the terminology used to describe deviations from prescribed therapies. The aim of this review was to propose a new taxonomy, in which adherence to medications is conceptualized, based on behavioural and pharmacological science, and which will support quantifiable parameters. A systematic literature review was performed using MEDLINE, EMBASE, CINAHL, the Cochrane Library and PsycINFO from database inception to 1 April 2009. The objective was to identify the different conceptual approaches to adherence research. Definitions were analyzed according to time and methodological perspectives. A taxonomic approach was subsequently derived, evaluated and discussed with international experts. More than 10 different terms describing medication-taking behaviour were identified through the literature review, often with differing meanings. The conceptual foundation for a new, transparent taxonomy relies on three elements, which make a clear distinction between processes that describe actions through established routines ('Adherence to medications', 'Management of adherence') and the discipline that studies those processes ('Adherence-related sciences'). 'Adherence to medications' is the process by which patients take their medication as prescribed, further divided into three quantifiable phases: 'Initiation', 'Implementation' and 'Discontinuation'. In response to the proliferation of ambiguous or unquantifiable terms in the literature on medication adherence, this research has resulted in a new conceptual foundation for a transparent taxonomy. The terms and definitions are focused on promoting consistency and quantification in terminology and methods to aid in the conduct, analysis and interpretation of scientific studies of medication adherence.

Methodological issues in the assessment of diabetes treatment adherence

Improving treatment adherence in patients with diabetes remains an important objective of behavioral science research. However, progress is often limited by the heterogeneity in methods used to measure treatment adherence and difficulties in generalizing across methodologies. Various measurement methods are often used with little attention paid to questions regarding validity. Doubts about validity of adherence measurement often lead investigators to measure distal clinical outcomes instead, such as glycemic control, resulting in a loss of information. This article provides an overview of the literature on diabetes medication adherence, with a focus on measurement issues. We also consider work conducted in other chronic illnesses, particularly HIV/AIDS, that may have value in guiding future directions of diabetes medication adherence research. We highlight the need for focused investigation on how characteristics of self-report methodologies affect the validity of patient responses and conclude with practical recommendations based on the current state of the science.

Does intervention by an allied health professional discussing adherence to medicines improve this adherence in Type 2 diabetes?

AIMS

Increasing adherence to medicines should improve glycaemic control and be cost effective in patients with Type 2 diabetes. It is assumed that the intervention of an allied health professional will improve adherence to medicines, but this has not been well documented. The aim of this review was to determine whether an intervention by an allied health professional, including a discussion of adherence to medicines, improved adherence to medicines in these subjects.

METHODS

A comprehensive review of the literature was undertaken to determine this. All available studies were included and critically reviewed.

RESULTS

When adherence to medicines was high in the treatment of Type 2 diabetes, an intervention by an allied health professional did not improve adherence. In studies in which the adherence could be improved the results were varied, with some studies showing improvement and some not. This variation existed whether the allied health professional was a nurse, a pharmacist or a diabetes educator, and whether the intervention was by phone or by counselling in person.

CONCLUSIONS

In conclusion, prior to undertaking an intervention to improve adherence to medicines in Type 2 diabetes, it is necessary to know the baseline level of adherence, and if adherence is already high there is no point in undertaking an intervention. When adherence to medicines is low, it is not clear which interventions will improve adherence, and further studies are needed to clarify this.

The reality of dietary compliance in the management of phenylketonuria

In phenylketonuria (PKU), it is common for blood phenylalanine (Phe) concentrations to be outside optimal target ranges, particularly in teenagers and adults, indicating inadequate compliance. It is well known that significant noncompliance exists, and the situation in PKU would appear no different than other chronic conditions. In PKU, compliance is complex, being subject to diverse definitions, and factors influencing compliance include the nature and nurture of the patient, as well as the inconvenience, cost and availability of dietary treatment. It is also a dynamic process, with many patients changing between a state of compliance and partial and noncompliance. In PKU, compliance has received little rigorous study, and there have been few observational reports identifying barriers and behaviors impacting dietary compliance. Compliance assessment measures remain inadequately defined. The direct assessment of blood Phe concentration is perhaps the best overall measure, but there is no universal agreement about the number of Phe concentrations that should be within target range and frequency or timing of measurement. Although no one strategy for improving compliance is universally effective, and an individualized approach to noncompliance is essential, it is important to have clear evidence about the most effective strategies in achieving long-term dietary adherence in PKU.

"Patients don't lie"; a view on adherence in asthma

OBJECTIVE

The primary objective of this article is to examine the extent of self-reported non-adherence among patients participating in a controlled trial of an asthma compliance optimization intervention. The secondary objective is to introduce a two-question questionnaire that is, in wording and design, a neutral tool for disclosure of non-adherence behaviour.

METHOD

Data in this study was obtained as part of a controlled trial on an SMS monitoring and compliance intervention developed for Danish asthma patients. The trial was conducted from November 2007 to May 2008. A total of 244 patients participated in the study. Two new designed nonadherence questions were asked in immediate succession. This practice, along with the wording of the questions and use of the Web as medium, constitute a new approach to self-reported adherence assessment.

RESULTS

A total of 43.9% of the participants in the trial reported non-adherence to the medical dosage regime for which they had, only one question earlier, documented their awareness.

CONCLUSION

This illustrates that at least 43.9% of the participants in the trial dared to report nonadherence to asthma medication.

Self-reported adherence to a therapeutic regimen among patients undergoing continuous ambulatory peritoneal dialysis

AIM

This paper is a report of a study conducted to examine self-reported adherence to a therapeutic regimen for continuous ambulatory peritoneal dialysis.

BACKGROUND

Studies of patients' adherence during dialysis have primarily focused on haemodialysis and have frequently yielded inconsistent results, which are attributed to the inconsistent tools used to measure adherence. Levels of adherence to all four components of the therapeutic regimen (i.e. dietary and fluid restrictions, medication, and the dialysis regimen) among patients receiving peritoneal dialysis have not been examined, especially from a patient perspective.

METHODS

A total population sample was used. A cross-sectional survey was carried out by face-to-face interviews in 2005 in one renal clinic in Hong Kong. A total of 173 patients undergoing peritoneal dialysis (56% of the total population) participated in the study.

RESULTS

Patients perceived themselves as more adherent to medication (83%; 95% confidence interval 77-88%) and dialysis (93%; 95% confidence interval 88-96%) prescriptions than to fluid (64%; 95% confidence interval 56-71%) and dietary (38%; 95% confidence interval 30-45%) restrictions. Those who were male, younger or had received dialysis for 1-3 years saw themselves as more non-adherent compared with other patients.

CONCLUSION

Healthcare professionals should take cultural issues into consideration when setting dietary and fluid restriction guidelines. Additional attention and support are required for patients who identify themselves as more non-adherent. To help patients live with end-stage renal disease and its treatment, qualitative research is required to understand how they go through the dynamic process of adherence.

Living with type 1 diabetes: a by-person qualitative exploration

Type 1 diabetes is a chronic condition which places enormous demands on the individual diabetic. A strict care routine is necessitated, yet even the most controlled and disciplined diabetic is likely to experience associated health problems and automatically faces a reduced life expectancy. The current study explores the psychological repercussions of this situation via a small scale qualitative study which focuses on the very different viewpoints and experiences of four adults living with Type 1 diabetes. A new and original form of by-person (or by-case) qualitative analysis is employed in order to capture, in a rich and holistic fashion, each participant's current relationship with their condition, their experience of living and dealing with diabetes and the ways in which diabetes is integrated within their lives and identities. The findings have implications for, and are discussed in relation to, issues of control, regimen adherence, and what it means to be a 'good' or 'successful' diabetic. The conclusion is drawn that the satisfaction of personal goals and a focus on psychological as well as physical health may be very important if positive quality of life outcomes are to be attained in the context of Type 1 diabetes.

Can primary care professionals' adherence to Evidence Based Medicine tools improve quality of care in type 2 diabetes mellitus? A systematic review

BACKGROUND

Our aim is to review the effectiveness of EBM tools available to primary care professionals to improve the quality of Type 2 diabetes disease management.

METHODS

A systematic review of RCT was performed according to the Cochrane methods.

RESULTS

Starting from an overall number of 1737 references found, a total of 13 studies met all the inclusion criteria.

CONCLUSIONS

The adherence to EBM instruments is likely to improve process of care, rather than patient outcomes. In addition, our review outlines that feedback reports and use of ICT devices are likely to be effective in diabetes disease management.

Concept analysis of adherence in the context of cardiovascular risk reduction

TOPIC

Cardiovascular disease is the number one cause of death in the United States. Examination of the concept of adherence is essential to provide informed patient-centered care to prevent the development and progression of this largely preventable disease.

OBJECTIVE

The purpose of this concept analysis is to explore and clarify the concept of adherence. This analysis will provide a framework for those seeking a better understanding of patient decision-making, reduction of relapse to unhealthy behaviors, and increased long-term adherence to cardiovascular health recommendations. Reviews of major theories related to health behavior are reviewed in the second part of the article and are linked to the concept of adherence.

METHOD

Following a review of the literature, Morse's guidelines were utilized to present a concept analysis of adherence and the related terms concordance and compliance from the disciplines of nursing, health psychology, ethics, pharmacy, and medicine.

RESULTS

Adherence is dependent on the collaborative relationship between patient and healthcare provider. Adherence is influenced by the meaning of health, heart disease, and sense of personal risk as well as socioeconomic status, decision support, motivation, and desire for change, self-efficacy, and sources of credible health information. Attributes of successful adherence include alignment of patient behavior and health recommendations, mastery of new health knowledge and behavior, continued collaborative relationships between the patient and healthcare provider, and ability to meet outcome targets.

CONCLUSION

Adherence is defined as persistence in the practice and maintenance of desired health behaviors and is the result of active participation and agreement. Adherence is dependent on the development of a concordant relationship and its measurement should be specific utilizing the correct tools. Special attention should be paid to shared decision-making between patient and healthcare provider.

Are we losing the battle against cardiometabolic disease? The case for a paradigm shift in primary prevention

Background

Cardiovascular and diabetic disease are the leading and preventable causes of death worldwide. The currently prognosticated dramatic increase in disease burden over the next two decades, however, bespeaks a low confidence in our prevention ability. This conflicts with the almost enthusiastic reporting of study results, which demonstrate substantial risk reductions secondary to simple lifestyle changes.

Discussion

There is a case to be made for a disregard of the difference between statistical significance and clinical relevance of the reported data. Nevertheless, lifestyle change remains the main weapon in our battle against the epidemic of cardiometabolic disease. But along the way from risk screening to intervention to maintenance the compound inefficiencies of current primary preventive strategies marginalize their impact.

Summary

Unless we dramatically change the ways in which we deploy preventive interventions we will inevitably lose the battle. In this paper we will argue for three provocative strategy changes, namely (a) the disbanding of screening in favor of population-wide enrollment into preventive interventions, (b) the substitution of the current cost utility analysis for a return-on-investment centered appraisal of interventions, and (c) the replacement of standardized programs modeled around acute care by individualized and perpetual interventions.

Validation of the Diabetes Obstacles Questionnaire (DOQ) to assess obstacles in living with type 2 diabetes in a Belgian population

AIMS

The aim of this study was to validate the Dutch version of the Diabetes Obstacles Questionnaire (DOQ) [H. Hearnshaw, K. Wright, J. Dale, J. Sturt, E. Vermeire, P. Van Royen, Development and validation of the Diabetes Obstacles Questionnaire (DOQ) to assess obstacles in living with Type 2 diabetes, Diabetic Med. 24 (2007) 878-882] assessing people living with type 2 diabetes' obstacles to adhere to treatment recommendations. The goal is to have at one's disposal an instrument to identify obstacles to adhering to treatment recommendations for people living with type 2 diabetes in a Dutch speaking population.

METHODS

Participants were recruited from a pragmatic sample of general practices in Flanders (Belgium). In accordance with the validation procedure in the UK [H. Hearnshaw, K. Wright, J. Dale, J. Sturt, E. Vermeire, P. Van Royen, Development and validation of the Diabetes Obstacles Questionnaire (DOQ) to assess obstacles in living with Type 2 diabetes, Diabetic Med. 24 (2007) 878-882], responders also completed the Dutch version of a quality of life questionnaire (ADDQoL) [C. Bradley, C. Todd, T. Gorton, E. Symonds, A. Martin, R. Plowright, The development of an individualised questionnaire measure of perceived impact of diabetes on quality of life: the ADDQoL. Qual. Life Res. 8 (1999) 79-91] and the Problem Areas in Diabetes (PAID) scale as golden standard [G. Welch, A.M. Jacobson, W.H. Polowsky, The Problem Areas in Diabetes (PAID) scale. An evaluation of its utility. Diabetes Care 20 (1997) 760-766]. Some biomedical variables such as HbA1c were collected also.

RESULTS

Each scale showed sufficient reliability with Cronbach's alpha (>0.76). Each subscale had a factor structure of no more than 4, and a Kaiser-Meyer-Olkin measure of 0.75. Criterion validity was shown by significant correlation with the PAID and construct validity by a correlation with HbA1c. Construct validity has also been shown by significant correlations between ADDQoL and the DOQ Obstacles of Lifestyle changes scale.

CONCLUSIONS

The Dutch version of the DOQ is a feasible and valid instrument for the assessment of obstacles to adherence to treatment recommendations in people living with type 2 diabetes.

Contrasting measures of adherence with simple drug use, medication switching, and therapeutic duplication

BACKGROUND

Multiple measures of adherence have been reported in the research literature and it is difficult to determine which is best, as each is nuanced. Occurrences of medication switching and polypharmacy or therapeutic duplication can substantially complicate adherence calculations when adherence to a therapeutic class is sought.

OBJECTIVE

To contrast the Proportion of Days Covered (PDC) adherence metric with 2 variants of the Medication Possession Ratio (MPR, truncated MPR).

METHODS

This study was a retrospective analysis of the North Carolina Medicaid administrative claims data from July 1999 to June 2000. Data for patients with schizophrenia (ICD-9-CM code 295.xx) who were not part of a health maintenance organization, not hospitalized, and not pregnant, taking at least one antipsychotic, were aggregated for each person into person-quarters. The numerator for PDC was defined as the number of days one or more antipsychotics was available and the MPR numerator was defined as the total days' supply of antipsychotics; both were divided by the total days in each person-quarter. Adherence rates were estimated for subjects who used only one antipsychotic, switched medications, or had therapeutic duplication in the quarter.

RESULTS

The final sample consisted of 25,200 person-quarters from 7069 individuals. For person-quarters with single antipsychotic use, adherence to antipsychotics as a class was: PDC 0.607, truncated MPR 0.640, and MPR 0.695 (p < 0.001). For person-quarters with switching, the average MPR was 0.690, truncated MPR was 0.624, and PDC was 0.562 (p < 0.001). In the presence of therapeutic duplication, the PDC was 0.669, truncated MPR was 0.774, and MPR was 1.238 (p < 0.001).

CONCLUSIONS

The PDC provides a more conservative estimate of adherence than the MPR across all types of users; however, the differences between the 2 methods are more substantial for persons switching therapy and prescribed therapeutic duplication, where MPR may overstate true adherence. The PDC should be considered when a measure of adherence to a class of medications is sought, particularly in clinical situations in which multiple medications within a class are often used concurrently.

"Medication career" or "moral career"? The two sides of managing antidepressants: a meta-ethnography of patients' experience of antidepressants

The UK National Institute for Clinical Excellence (NICE) Clinical Guidelines recommend routine prescription of antidepressants for moderate to severe depression. While many patients accept a prescription, one in three do not complete treatment. We carried out a meta-ethnography of published qualitative papers since 1990 whose focus is patients' experience of antidepressant use for depression, in order to understand barriers and facilitators to concordance and inform a larger qualitative study investigating antidepressant use over time. A systematic search of five databases was carried out, supported by hand searches of key journals, writing to first authors and examining reference lists. After piloting three critical appraisal tools, a modified version of the CASP (Critical Appraisal Skills Programme) checklist was used to appraise potentially relevant and qualitative papers. We carried out a synthesis using techniques of meta-ethnography involving translation and re-interpretation. Sixteen papers were included in the meta-ethnography. The papers fall into two related groups: (1) Papers whose focus is the decision-making relationship and the ways patients manage their use of antidepressants, and (2) Papers whose focus is antidepressants' effect on self-concept, ideas of stigma and its management. We found that patients' experience of antidepressants is characterised by the decision-making process and the meaning-making process, conceptualised here as the 'medication career' and 'moral career'. Our synthesis indicates ways in which general practitioners (GPs) can facilitate concordant relationships with patients regarding antidepressant use. First, GPs can enhance the potential for shared decision-making by reviewing patients' changing preferences for involvement in decision-making regularly throughout the patient's 'medication career'. Second, if GPs familiarise themselves with the competing demands that patients may experience at each decision-making juncture, they will be better placed to explore their patients' preferences and concerns--i.e. their 'moral career' of medication use. This may lead to valuable discussion of what taking antidepressants means for patients' sense of self and how their treatment decisions may be influenced by a felt sense of stigma.

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.

Adherence: a concept analysis

AIM

This paper is a report of an analysis of the concept of adherence.

BACKGROUND

The transition in terminology from compliance to adherence, and more recently to concordance, requires re-clarification of 'adherence' as a concept in nursing practice. Differences exist in the use of the term adherence and how or if it differs from compliance or concordance.

DATA SOURCES

Using the Medical Subject Headings terms adherence, non-adherence and treatment refusal, the Cumulative Index to Nursing and Allied Health Literature, Medline, PsychINFO and Cochrane library databases were searched for publications between 1970 and 2007. Method. The evolutionary analytic method was used to identify and explore transitions in the concept of adherence over time and across healthcare disciplines. A representative sample of papers was identified from the disciplines of nursing, medicine, psychology and pharmacy.

RESULTS

We identified 114 papers: 27 from nursing, 39 from psychology, 33 from general medicine and 15 from pharmacology sources. The final sample included eight from pharmacy and 15 from mental health, medicine and nursing. We found no distinct differentiation between adherence and compliance. The surrogate terms serving as manifestations of adherence are concordance, agreement, cooperation and partnership. The most common definition found was as follows: 'Adherence can be defined as the extent to which patients follow the instructions they are given for prescribed treatments'. No definition of adherence exists that reflects a patient-centred approach, the dynamic nature of adherence behaviour and the power imbalance implied by these terms.

CONCLUSION

This concept analysis of adherence is a preliminary step towards broadening nurses' appreciation of the complexity of patient adherence behaviour.

An empirical basis for standardizing adherence measures derived from administrative claims data among diabetic patients

OBJECTIVE

To compare the predictive validity of 8 different adherence measures by studying the variability explained between each measure and 2 outcome measures: hospitalization episodes and total nonpharmacy cost among Medicaid eligible persons diagnosed with diabetes.

RESEARCH DESIGN

This study was a retrospective analysis of the Arkansas Medicaid administrative claims data from January 2000 to December 2006.

SUBJECTS

Diabetic (ICD-9-CM = 250.0 x - 250.9 x, where x = 0 or 2) patients were identified in the recruitment period July 2000 through April 2004. Patients had to be >or=18 years old and have at least 2 prescription fills in the index period for an oral antidiabetic drug.

MEASURES

: Adherence rates to oral antidiabetic therapy were contrasted using the following 8 measures; including the medication possession ratio (MPR), proportion of days covered (PDC), refill compliance rate (RCR), compliance ratio (CR), medication possession ratio, modified (MPRm), continuous measure of medication gaps (CMG), and continuous multiple interval measure of oversupply (CMOS and continuous, single interval measure of medication acquisition (CSA). Multivariate and univariate linear and logistic regression models were used to prospectively predict nonpharmacy costs and hospitalizations in the follow-up year.

RESULTS

A total of 4943 diabetic patients were studied. In predicting any cause hospitalization, univariate models with PDC and CMG had the highest predictive validity (C-statistic: 0.544). Multivariate models with MPR, PDC, CMG or continuous multiple interval measure of oversupply (CMOS) as adherence measures had the highest C-statistics of 0.701 in predicting diabetes specific hospitalizations. None of the adherence measures were significantly associated with nonpharmacy cost.

CONCLUSIONS

MPR and PDC had the highest predictive validity for hospitalization episodes. These 2 measures should be considered first when selecting among adherence measures when using administrative prescription claims data.

Improving treatment adherence in bipolar disorder: a review of current psychosocial treatment efficacy and recommendations for future treatment development

Treatment adherence is a frequent problem in bipolar disorder, with research showing that more than 60% of bipolar patients are at least partially nonadherent to medications. Treatment nonadherence is consistently predictive of a number of negative outcomes in bipolar samples, and the discontinuation of mood stabilizers places these patients at high risk for relapse. Several types of adjunctive treatment (family, psychoeducational, cognitive-behavioral) have been investigated for improving symptoms and functioning in bipolar patients with some success. To date, less attention has been paid to developing treatments specifically to promote treatment adherence to and engagement with pharmacological as well as behavioral treatments in patients with bipolar disorder. First, we review the effects of adjunctive interventions specifically on treatment adherence outcomes in 14 published clinical trials. Based on this empirical knowledge base, we present a preliminary description of the treatment strategies that appear most promising for improving adherence. The article also provides research recommendations for developing more effective interventions for the purpose of improving bipolar treatment adherence. Finally, special treatment considerations, including the potential impact of comorbid substance abuse and bipolar depression, are discussed.

Creating a conversation: insights from the development of a decision aid

The authors share lessons learned from their development ofStatin Choice, a decision aid for patients with diabetes who are considering using statins to reduce their cardiovascular risk.