The modeled lifetime cost-effectiveness of published adherence-improving interventions for antihypertensive and lipid-lowering medications

Effectiveness of a Community Pharmacy-Based Health Promotion Program on Hypertension in Bangladesh and Pakistan: Study Protocol for a Cluster-Randomized Controlled Trial

The aim of this multi-country, cluster-randomized trial is to test the impact of pharmacy-based health promotion to reduce the blood pressure of individuals with hypertension over a 12-month period in Bangladesh and Pakistan. The trial will be implemented with two arms. In Bangladesh, the estimated sample size is around 3600 hypertensive patients. In Pakistan, we will select samples equivalent to 10% of the participants from Bangladesh, comprising 360 hypertensive patients from four pharmacies. Community pharmacies will be randomized into one of two parallel groups (allocation ratio 1:1). Pharmacy professionals in the treatment arm will provide their patients with educational training and counseling, as well as phone calls/mobile text messages and care coordination in the health sector, as part of the intervention. The study will be conducted in three phases: a baseline survey with intervention, a midline survey with intervention and follow-up, and an endline survey with impact evaluation. The primary outcome of the study will be BP. The secondary outcomes will be BP controlled to target, treatment adherence, quality of life, mortality or hospital admission rates resulting from hypertension and its related complications, incremental cost per health-related quality of life gained, knowledge on healthy lifestyle and dietary behavior, and change in the prevalence of current smoking status.

Treatment patterns and adherence to lipid-lowering drugs during eight-year follow-up after a coronary heart disease event

BACKGROUND AND AIMS

Proper prescription and high adherence to intensive lipid lowering drugs (LLD) in patients with coronary heart disease (CHD) are crucial and strongly recommended. The aim of this study is to investigate long-term treatment patterns and adherence to LLD following hospitalization for a CHD event.

METHODS

Patients admitted to two Norwegian hospitals with a CHD event from 2011 to 2014 (N = 1094) attended clinical examination and completed a questionnaire, median 16 months later. Clinical data were linked to pharmacy dispensing data from 2010 to 2020. The proportions using high-intensity statin therapy (atorvastatin 40/80 mg or rosuvastatin 20/40 mg) and non-statin LLD after the CHD event were assessed. Adherence was evaluated by proportion of days covered (PDC) and gaps in treatment.

RESULTS

Median age at hospitalization was 63 (IQR 12) years, 21 % were female. Altogether, 1054 patients (96 %) were discharged with a statin prescription, while treatment was dispensed in 85 % within the following 90 days. During median 8 (SD 2.5) years follow-up, the proportion using high-intensity statin therapy ranged 62-68 %, whereas the use of ezetimibe increased from 4 to 26 %. PDC <0.8 was found in 22 % of statin users and 26 % of ezetimibe users. The proportions with a treatment gap exceeding 180 days were 22 % for statins and 28 % for ezetimibe. Smoking at hospitalization and negative affectivity were significantly associated with reduced statin adherence, regardless of adherence measure.

CONCLUSIONS

In this long-term follow-up of patients with CHD, less than 70 % used high-intensity statin therapy with only small changes over time, and only 25 % used additional treatment with ezetimibe. We identified factors associated with reduced statin adherence that may be target for interventions.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Gaps and discontinuation of statin treatment in Norway: potential for optimizing management of lipid lowering drugs

Aims

In clinical practice, many patients do not reach the recommended treatment targets for LDL-cholesterol levels. We aimed to examine treatment patterns and adherence for patients on lipid lowering drugs in Norway to inform future strategies to improve therapies.

Methods and results

We obtained information on all dispensed statins, ezetimibe, and proprotein convertase subtilisin/-kexin 9 (PCSK9) inhibitors 2010-2019 from the Norwegian Prescription Database. Treatment gaps were assessed assuming patients take one tablet per day and were defined to occur if a patient did not refill a prescription when the previous one should have been depleted. Treatment was defined as discontinued when the preceding prescription would have been used and no new subsequent prescription was filled. The mean proportion of days covered (PDC) was calculated by aggregating the total number of tablets dispensed during each calendar year and dividing by 365. Patients 80 years were excluded. A considerable proportion of statin users in Norway had long treatment gaps or discontinuation in treatment. The 19.6% of the patients had treatment gaps of 180 days or more, and 10.8% had gaps or greater than 365 days. Similar results were found for patients on antidiabetics and hypertensives. PDC ranged from 84.9% for simvastatin to 72.2% for ezetimibe (2019). The most common lipid lowering drugs in 2019 were atorvastatin, simvastatin, and ezetimibe.

Conclusion

There is a great potential for improving drug adherence and optimizing lipid lowering therapy by switching to more effective statins in greater doses, and more often add ezetimibe and PCSK9 inhibitors to treatment.

Medication adherence in hypertension

: Suboptimal adherence to antihypertensive medication is a major contributor to poor blood pressure control. Several methods, direct or indirect, are available for measuring adherence, including the recently developed biochemical screening, although there is no gold-standard method routinely used in clinical practice to accurately assess the different facets of adherence. Adherence to treatment is a complex phenomenon and several of the barriers to adherence will need to be addressed at the healthcare system level; however, when looking at adherence from a more practical side and from the practitioner's perspective, the patient-practitioner relationship is a key element both in detecting adherence and in attempting to choose interventions tailored to the patient's profile. The use of single-pill combinations enabling simplification of treatment regimen, the implementation of a collaborative team-based approach and the development of electronic health tools also hold promise for improving adherence, and thus impacting cardiovascular outcomes and healthcare costs.

Enhancing Primary Adherence to Prescribed Medications through an Organized Health Status Assessment-Based Extension of Primary Healthcare Services

This study was part of monitoring an intervention aimed at developing a general practitioner cluster (GPC) model of primary healthcare (PHC) and testing its effectiveness in delivering preventive services integrated into the PHC system. The aim was to demonstrate whether GPC operation could increase the percentage of drugs actually dispensed. Using national reference data of the National Health Insurance Fund for each anatomical-therapeutic chemical classification ATC group of drugs, dispensed-to-prescribed ratios standardized (sDPR) for age, sex, and exemption certificate were calculated during the first quarter of 2012 (before-intervention) and the third quarter of 2015 (post-intervention). The after-to-before ratios of the sDPR as the relative dispensing ratio (RDR) were calculated to describe the impact of the intervention program. The general medication adherence increased significantly in the intervention area (RDR = 1.064; 95% confidence interval (CI): 1.054-1.073). The most significant changes were observed for cardiovascular system drugs (RDR = 1.062; 95% CI: 1.048-1.077) and for alimentary tract and metabolism-specific drugs (RDR = 1.072; 95% CI: 1.049-1.097). The integration of preventive services into a PHC without any specific medication adherence-increasing activities is beneficial for medication adherence, especially among patients with cardiovascular, alimentary tract, and metabolic disorders. Monitoring the percentage of drugs actually dispensed is a useful element of PHC-oriented intervention evaluation frames.

Hypertension in Developing Countries: A Major Challenge for the Future

PURPOSE OF REVIEW

Outline recent epidemiologic data regarding hypertension in developing countries, distinguish differences from developed countries, and identify challenges in management and future perspectives.

RECENT FINDINGS

Increased sugar intake, air and noise pollution, and low birth weight are emerging hypertension risk factors. The major challenges in management are difficulties in accurate diagnosis of hypertension and adequate blood pressure control. In contrast to developed countries, hypertension prevalence rates are on the rise in developing countries with no improvement in awareness or control rates. The increasing burden of hypertension is largely attributable to behavioral factors, urbanization, unhealthy diet, obesity, social stress, and inactivity. Health authorities, medical societies, and drug industry can collaborate to improve hypertension control through education programs, public awareness campaigns, legislation to limit salt intake, encourage generic drugs, development and dissemination of national guidelines, and involving nurses and pharmacists in hypertension management. More epidemiologic data are needed in the future to identify reasons behind increased prevalence and poor blood pressure control and examine trends in prevalence, awareness, treatment, and control. National programs for better hypertension control based on local culture, economic characteristics, and available resources in the population are needed. The role of new tools for hypertension management should be tested in developing world.

The importance of cholesterol medication adherence: the need for behavioral change intervention programs

Lipid-lowering medications have been shown to be efficacious, but adherence is suboptimal. This is a narrative, perspective review of recently published literature in the field of medication adherence research for lipid-lowering medications. We provide an overview of the impact of suboptimal adherence and use a World Health Organization framework (patient, condition, therapy, socioeconomic, and health system-related systems) to discuss factors that influence hyperlipidemia treatment adherence. Further, the review involves an evaluation of intervention strategies to increase hyperlipidemia treatment adherence with a special focus on mHealth interventions, patient reminders on packaging labels, nurse- and pharmacist-led interventions, and health teams. It also highlights opportunities for pharmaceutical companies to support and scale such behavioral interventions. Medication adherence remains a challenge for the long-term management of chronic conditions, especially those involving asymptomatic disease such as hyperlipidemia. To engage patients and enhance motivation over time, hyperlipidemia interventions must be targeted to individual patients' needs, with sequencing and frequency of contact tailored to the various stages of behavioral change.

Quantity and Quality of Economic Evaluations in U.S. Nursing Research, 1997-2015: A Systematic Review

BACKGROUND

The United States has a complex healthcare system that is undergoing substantial reformations. There is a need for high-quality, economic evaluations of nursing practice. An updated review of completed economic evaluations relevant to the field of nursing within the U.S. healthcare system is timely and needed.

OBJECTIVES

The purpose of this study was to evaluate and describe the quantity and quality of economic evaluations in nursing-relevant research performed in the United States between 1997 and 2015.

METHODS

Four databases were searched. Titles, abstracts, and full-text content were reviewed to identify studies that analyzed both costs and outcomes, relevant to nursing, performed in the United States, and used the quality-adjusted life year to measure effectiveness. For included studies, data were extracted from full-text articles using criteria from U.S. Public Health Service's Panel on Cost-Effectiveness in Health and Medicine.

RESULTS

Twenty-eight studies met the inclusion criteria. Most (n = 25, 89%) were published in the last decade of the analysis, from 2006 to 2015. Assessment of quality, based on selected items from the panel guidelines, found that the evaluations did not consistently use the recommended societal perspective, use multiple resource utilization categories, use constant dollars, discount future costs and outcomes, use a lifetime horizon, or include an indication of uncertainty in results. The only resource utilization category consistently included across studies was healthcare resources.

DISCUSSION

Only 28 nursing-related studies meeting the inclusion criteria were identified as meeting robust health economic evaluation methodological criteria, and most did not include all important guideline items. Despite increases in absolute numbers of published studies over the past decade, economic evaluation has been underutilized in U.S. nursing-relevant research in the past two decades.

A randomized controlled behavioral intervention trial to improve medication adherence in adult stroke patients with prescription tailored Short Messaging Service (SMS)-SMS4Stroke study

BACKGROUND

The effectiveness of mobile technology to improve medication adherence via customized Short Messaging Service (SMS) reminders for stroke has not been tested in resource poor areas. We designed a randomized controlled trial to test the effectiveness of SMS on improving medication adherence in stroke survivors in Pakistan.

METHODS

This was a parallel group, assessor-blinded, randomized, controlled, superiority trial. Participants were centrally randomized in fixed block sizes. Adult participants on multiple medications with access to a cell phone and stroke at least 4 weeks from onset (Onset as defined by last seen normal) were eligible. The intervention group, in addition to usual care, received reminder SMS for 2 months that contained a) Personalized, prescription tailored daily medication reminder(s) b) Twice weekly health information SMS. The Health Belief Model and Social Cognitive theory were used to design the language and content of messages. Frontline SMS software was used for SMS delivery. Medication adherence was self-reported and measured on the validated Urdu version of Morisky Medication Adherence Questionnaire. Multiple linear regression was used to model the outcome against intervention and other covariates. Analysis was conducted by intention-to-treat principle.

RESULTS

Two hundred participants were enrolled. 38 participants were lost to follow-up. After 2 months, the mean medication score was 7.4 (95 % CI: 7.2-7.6) in the intervention group while 6.7 (95 % CI: 6.4-7.02) in the control group. The adjusted mean difference (Δ) was 0.54 (95 % CI: 0.22-0.85). The mean diastolic blood pressure in the intervention group was 2.6 mmHg (95 % CI; -5.5 to 0.15) lower compared to the usual care group.

CONCLUSION

A short intervention of customized SMS can improve medication adherence and effect stroke risk factors like diastolic blood pressure in stroke survivors with complex medication regimens living in resource poor areas.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01986023 last accessed at https://clinicaltrials.gov/ct2/show/NCT01986023.

Improving medication adherence in stroke patients through Short Text Messages (SMS4Stroke)-study protocol for a randomized, controlled trial

Background

Stroke is a major cause of morbidity and mortality, especially in low and middle income countries. Medical management is the mainstay of therapy to prevent recurrence of stroke. Current estimates are that only 1 in 6 patients have perfect adherence to medication schedules. Using SMS (Short Messaging Service) as reminders to take medicines have been used previously for diseases such as diabetes and HIV with moderate success. We aim to explore the effectiveness and acceptability of SMS in increasing adherence to medications in patients with stroke.

Methods

This will be a randomized, controlled, assessor blinded single center superiority trial. Adult participants with access to a cell phone and a history of stroke longer than 1 month on multiple risk modifying medications will be selected from Neurology and Stroke Clinic. They will be randomized into two parallel groups in a 1:1 ratio via block technique with one group receiving the standard of care as per institutional guidelines while the parallel group receiving SMS reminders for each dose of medicine in addition to the standard of care. In addition intervention group will receive messages for lifestyle changes, medication information, risk factors and motivation for medication adherence. These will bemodeled on Social Cognitive Theory and Health Belief Model and will be categorized by Michies Taxonomy of Behavioral Change Communication. Patient compliance to medicines will be measured at baseline and then after 2 months in each group by using the Morisky Medication Adherence Scale. The change in compliance to medication regimen after the intervention and the difference between the two groups will be used to determine the effectiveness of SMS reminders as a tool to increase medication compliance. The acceptability of the SMS will be determined by a tool designed for this study whose attributes are based Rogers Diffusion of innovation theory.

A sample size of 86 participants in each arm will be sufficient to detect a difference of 1 point on the MMAS with a power of 90 % and significance level of 5 % between the two groups; using an attrition rate of 15 %, 200 participants in all will be randomized.

Discussion

The SMS for Stroke Study will provide evidence for feasibility and effectiveness of SMS in improving post stroke medication adherence in an LMIC setting.

Trial registration

https://clinicaltrials.gov/ct2/show/NCT01986023 11 /11/2013

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-015-0413-2) contains supplementary material, which is available to authorized users.

A review of the methodological challenges in assessing the cost effectiveness of pharmacist interventions

Pharmacists' roles are shifting away from medicines supply and the provision of patient education involving acute medications towards consultation-type services for chronic medications. Determining the cost effectiveness of pharmacist interventions has been complicated by methodological challenges. A critique of 31 economic evaluations carried out alongside comparative studies of pharmacist interventions published between 2003 and 2013 (12 from the UK, six from the USA) found a range of disease-specific and cross-therapeutic interventions targeting both patients and prescribers in a range of settings evaluated through a variety of study designs. Only ten were full economic evaluations, five of which were based on randomized controlled trials (RCTs). The intervention was usually quite well described, but the comparator was not always clearly described, and some interventions are very context specific due to the variability in pharmacist services available in different countries and practice settings. Complex multidirectional aims of most pharmacist interventions have led to many process, intermediate and longer-term outcomes being included in any one study. Quality of resource use and cost data varied. Most incremental cost-effectiveness ratios (ICERs) were generated from process indicators such as errors and adherence, with only four studies reporting cost per quality-adjusted life-year (QALY). Very few studies examined the effect of uncertainty, and methods used were not very clear in some cases. The principal finding from our critique is that poor RCT study design or analysis precludes many studies from finding pharmacist interventions effective or cost effective. We conclude with a set of recommendations for future study design.

Commentary: demonstrating cost-effectiveness in pediatric psychology

OBJECTIVE

Changes in the health care system and payment plans will likely require pediatric psychologists to illustrate the impact of their services. Cost-effectiveness analyses are one method of demonstrating the potential economic benefits of our services but are rarely used by pediatric psychologists.

METHOD

A hypothetical cost-effectiveness analysis was conducted, comparing the costs and outcomes between a behavioral adherence intervention and no intervention for youth with acute lymphoblastic leukemia.

RESULTS

Results illustrate how pediatric psychologists can use cost-effectiveness analyses to demonstrate the economic impact of their work.

CONCLUSIONS

Efforts to conduct economic analyses could allow pediatric psychologists to advocate for their services. Implications and future directions are discussed.

Patient Perceptions Regarding Enrollment in Automatic Prescription Refill Programs

Background: Research has shown that medication adherence is strongly associated with improved patient outcomes and lower health care costs. Although adherence strategies, including automatic prescription refill programs, improve medication adherence to varying degrees, no report to date has examined patient perceptions of and barriers to enrollment in automatic refill programs. This study analyzes patient perceptions of and predictors of enrollment in automatic prescription refill programs through a cross-sectional analysis of patients at a grocer-based community pharmacy. Objectives: To determine patient perceptions regarding automatic prescription refill programs and identify potential barriers to enrollment. Methods: Patient perceptions regarding an automatic refill program were gathered through a survey and assessed using exploratory factor analysis and binary logistic regression techniques for significant predictors of program enrollment. A convenience sample of pharmacy patrons 18 years of age and older was identified at a grocer-based community pharmacy. Results: A total of 110 surveys were evaluated. Hypertension and mental health conditions were the most commonly reported disorders (29.1% and 26.4%, respectively). Enrollment in the program more than doubled during the study period, and all participants enrolled at baseline chose to remain in the program. Eight different perceptions were identified that accounted for approximately 79.14% of data variance. Of the perceptions identified, patients’ sense of satisfaction, in terms of receiving timely, convenient medication refills and not running out of medications, significantly predicted enrollment in the automatic refill program ( P = .0036). Conclusions: Automatic prescription refill programs are known to support patient adherence to medications. Promoting a refill program as a timely and convenient means of safeguarding against running out of medications or medication refills may increase program enrollment and, consequently, medication adherence.

Medication adherence and health care utilization in pediatric chronic illness: a systematic review

BACKGROUND AND OBJECTIVE

Advanced understanding of modifiable predictors of health care use in pediatric chronic illness is critical to reducing health care costs. We examined the relationship between medication non-adherence and health care use in children and adolescents who have a chronic medical condition.

METHODS

A systematic review of articles by using PubMed, PsycINFO, and CINAHL was conducted. Additional studies were identified by searching reference sections of relevant manuscripts. Studies that tested the relationship between medication non-adherence and health care use (ie, hospitalizations, emergency department visits, outpatient visits) or cost in children and adolescents (mean age ≤18 years) who have a chronic medical condition were included. Extraction of articles was completed by using predefined data fields.

RESULTS

Ten studies met our inclusion criteria. Nine of the 10 studies reviewed (90%) demonstrated a relationship between medication non-adherence and increased health care use. The directionality of this relationship varied depending on the outcome variable of interest.

CONCLUSIONS

Medication non-adherence is related to increased health care use in children and adolescents who have a chronic medical condition and should be addressed in clinical care. Future studies should include randomized controlled trials examining the impact of adherence promotion efforts on health care use and costs.

Telemonitoring and self-management in the control of hypertension (TASMINH2): a cost-effectiveness analysis

AIMS

Self-monitoring and self-titration of antihypertensives (self-management) is a novel intervention which improves blood pressure control. However, little evidence exists regarding the cost-effectiveness of self-monitoring of blood pressure in general and self-management in particular. This study aimed to evaluate whether self-management of hypertension was cost-effective.

DESIGN AND METHODS

A cohort Markov model-based probabilistic cost-effectiveness analysis was undertaken extrapolating to up to 35 years from cost and outcome data collected from the telemonitoring and self-management in hypertension trial (TASMINH2). Self-management of hypertension was compared with usual care in terms of lifetime costs, quality adjusted life years and cost-effectiveness using a UK Health Service perspective. Sensitivity analyses examined the effect of different time horizons and reduced effectiveness over time from self-management.

RESULTS

In the long-term, when compared with usual care, self-management was more effective by 0.24 and 0.12 quality adjusted life years (QALYs) gained per patient for men and women, respectively. The resultant incremental cost-effectiveness ratio for self-management was £1624 per QALY for men and £4923 per QALY for women. There was at least a 99% chance of the intervention being cost-effective for both sexes at a willingness to pay threshold of £20,000 per QALY gained. These results were robust to sensitivity analyses around the assumptions made, provided that the effects of self-management lasted at least two years for men and five years for women.

CONCLUSION

Self-monitoring with self-titration of antihypertensives and telemonitoring of blood pressure measurements not only reduces blood pressure, compared with usual care, but also represents a cost-effective use of health care resources.

Impact of an integrated intervention program on atorvastatin adherence: a randomized controlled trial

BACKGROUND

This trial evaluated the effectiveness of an integrated intervention program that included a 3-to-5-minute nurse counseling session, copay relief cards, and a monthly newsletter on adherence to atorvastatin treatment.

METHODS AND RESULTS

A prospective, integrated (composed of nurse counseling, adherence tip sheet, copay relief card, opportunity to enroll in 12-week cholesterol management program) randomized interventional study was designed involving patients >21 years of age who were prescribed atorvastatin at a large single-specialty cardiovascular physician practice in Illinois from March 2010 to May 2011. Data from the practice's electronic medical record were matched/merged to IMS Health's longitudinal data. A total of 500 patients were enrolled (125 in the control arm; 375 in the intervention arm). After data linkage, 53 control patients and 155 intervention patients were included in the analysis.

RESULTS

Mean age was 67.8 years (control) and 69.5 years (intervention); 67.9% and 58.7%, respectively, were male. The mean 6-month adherence rate was 0.82 in both arms. The mean proportion of days covered for both the new-user control and intervention groups was the same, averaging 0.70 day (standard deviation [SD], 0.27 day); for continuing users, the proportion of days covered for the control group was 0.83 (SD, 0.24) and for the intervention group was 0.84 (SD, 0.22). For continuing users, the control group had mean persistent days of 151.6 (SD, 50.2) compared with 150.9 days (SD, 50.9) for the intervention group. New users had fewer persistent days (control 111.4 days, SD, 69.6 days; intervention 112.0 days, SD, 58.8 days) compared with continuing users. The Cox proportional hazards model of the risk of discontinuation with index therapy was not significantly different between the intervention and control groups (hazard ratio 0.83, P = 0.55).

CONCLUSION

The integrated intervention program did not significantly improve atorvastatin adherence relative to usual care in the studied patient population.

Persistence with statin therapy in Hungary

INTRODUCTION

Persistence with lipid-lowering drug therapy by cardiovascular patients in Hungary has not been studied previously. This study was designed to determine the rate with which Hungarian patients with hyperlipidemia persist in taking lipid-lowering agents, and to compare this with rates reported from other countries.

MATERIAL AND METHODS

This was a retrospective study that utilized data from the Institutional Database of the National Health Insurance Fund to analyze persistence rates with statins and ezetimibe. The study included data for patients who started lipid-lowering therapy between January 1, 2007, and March 31, 2009. Variables included type of lipid-lowering therapy, year of therapy start, and patient age. Main outcome measures were medians of persistence in months, percentages of patients persisting in therapy for 6 and 12 months, and Kaplan-Meier persistence plots.

RESULTS

The percentage of patients who persisted with overall statin therapy was 46% after 1 month, 40.3% after 2 months, 27% after 6 months, and 20.1% after 12 months. Persistence was slightly greater for statin therapy started during 2008 than during 2007. Older patients were more persistent with therapy than younger patients. Persistence with the combination of ezetimibe-statin therapy was greater than with statin or ezetimibe monotherapy.

CONCLUSIONS

Persistence with statin therapy by patients in Hungary was low compared with other countries. Low persistence may have negated potential clinical benefits of long-term statin therapy.

Cost-effectiveness of a hypertension control intervention in three community health centers in China

BACKGROUND

Hypertension and associated chronic diseases impose enormous and growing health and economic burdens worldwide. The objective of this study was to investigate the cost-effectiveness (CE) of a hypertension control program in China.

METHODS

We collected information on program costs and health outcomes in three community health centers over a 1-year period. The participants were 4902 people with hypertension (systolic blood pressure [SBP] ≥140 mm Hg and/or diastolic blood pressure [DBP] ≥90 mm Hg, or on hypertension medication) aged 18 years and older. The SBP and DBP changes in the populations were estimated from a random sample of 818 participants by conducting face-to-face interviews and physical examinations. We derived CE measures based on the costs and effects on health outcomes.

FINDINGS

The total cost of implementing the intervention was Renminbi (RMB) 240 772 yuan (US$35 252), or 49 yuan (US$7.17) per participant in 2009. On average, SBP decreased from 143 to 131 mm Hg (P < .001) and DBP decreased from 84 to 78 mm Hg (P < .001), the SBP decreases ranged from 7.6 to 17.8 mm Hg and DBP decreases ranged from 3.9 to 8.3 mm Hg. CE ratios ranged from RMB 3.6 to 5.0 yuan (US$0.53-US$0.73) per person per mm Hg SBP decrease, and from RMB 6.3 to 9.7 yuan (US$0.92-US$1.42) per person per mm Hg DBP decrease.

INTERPRETATION

Per capita costs varied widely across the communities, as did changes in SBP and DBP, but CE was similar. The findings suggest (a) a positive correlation between per capita costs and program effectiveness, (b) differences in intervention levels, and (c) differences in health status. CE results could be helpful to policy makers in making resource allocation decisions.

Medication adherence: emerging use of technology

PURPOSE OF REVIEW

Adherence to proven, effective medications remains low, resulting in high rates of clinical complications, hospital readmissions, and death. The use of technology to identify patients at risk and to target interventions for poor adherence has increased. This review focuses on research that tests these emerging technologies and evaluates the effect of technology-based adherence interventions on cardiovascular outcomes.

RECENT FINDINGS

Recent studies have evaluated technology-based interventions to improve medication adherence by using pharmaceutical databases, tailoring educational information to individual patient needs, delivering technology-driven reminders to patients and providers, and integrating in-person interventions with electronic alerts. Cellular phone reminders and in-home electronic technology used to communicate reminder messages have shown mixed results. Only one study has shown improvement in both adherence and clinical outcome. Current trials suggest that increasing automated reminders will complement but not replace the benefits seen with in-person communication for medication taking.

SUMMARY

Integration of in-person contacts with technology-driven medication adherence reminders, electronic medication reconciliation, and pharmaceutical databases may improve medication adherence and have a positive effect on cardiovascular clinical outcomes. Opportunities for providers to monitor the quality of care based on new adherence research are evolving and may be useful as standards for quality improvement emerge.

A look into the future: improving diabetes care by 2015

Insulin initiation, which was traditionally the province of specialists, is increasingly undertaken by primary care. However, significant barriers to appropriate and timely initiation still exist. Whilst insulin is recognized as providing the most effective treatment in type 2 diabetes, it is also widely considered to be the most challenging and time consuming. This editorial identifies that the organization of existing healthcare services, the challenges faced by patients, and the treatments themselves contribute to suboptimal insulin management. In order to improve future diabetes care, it will be necessary to address all three problem areas: (1) re-think the best use of existing human and financial resources to promote and support patient self-management and adherence to treatment; (2) empower patients to participate more actively in treatment decision making; and (3) improve acceptance, persistence and adherence to therapy by continuing to refine insulin therapy and treatment regimens in terms of safety, simplicity and convenience. The principles discussed are also applicable to the successful management of any chronic medical illness.