Adherence to controller asthma medications: 6-month prevalence across a US community pharmacy chain

Heritable Risk and Protective Genetic Components of Glaucoma Medication Non-Adherence

Glaucoma is the leading cause of irreversible blindness, affecting 76 million globally. It is characterized by irreversible damage to the optic nerve. Pharmacotherapy manages intraocular pressure (IOP) and slows disease progression. However, non-adherence to glaucoma medications remains problematic, with 41–71% of patients being non-adherent to their prescribed medication. Despite substantial investment in research, clinical effort, and patient education protocols, non-adherence remains high. Therefore, we aimed to determine if there is a substantive genetic component behind patients’ glaucoma medication non-adherence. We assessed glaucoma medication non-adherence with prescription refill data from the Marshfield Clinic Healthcare System’s pharmacy dispensing database. Two standard measures were calculated: the medication possession ratio (MPR) and the proportion of days covered (PDC). Non-adherence on each metric was defined as less than 80% medication coverage over 12 months. Genotyping was done using the Illumina HumanCoreExome BeadChip in addition to exome sequencing on the 230 patients (1) to calculate the heritability of glaucoma medication non-adherence and (2) to identify SNPs and/or coding variants in genes associated with medication non-adherence. Ingenuity pathway analysis (IPA) was utilized to derive biological meaning from any significant genes in aggregate. Over 12 months, 59% of patients were found to be non-adherent as measured by the MPR80, and 67% were non-adherent as measured by the PDC80. Genome-wide complex trait analysis (GCTA) suggested that 57% (MPR80) and 48% (PDC80) of glaucoma medication non-adherence could be attributed to a genetic component. Missense mutations in TTC28, KIAA1731, ADAMTS5, OR2W3, OR10A6, SAXO2, KCTD18, CHCHD6, and UPK1A were all found to be significantly associated with glaucoma medication non-adherence by whole exome sequencing after Bonferroni correction (p < 10−3) (PDC80). While missense mutations in TINAG, CHCHD6, GSTZ1, and SEMA4G were found to be significantly associated with medication non-adherence by whole exome sequencing after Bonferroni correction (p < 10−3) (MPR80). The same coding SNP in CHCHD6 which functions in Alzheimer’s disease pathophysiology was significant by both measures and increased risk for glaucoma medication non-adherence by three-fold (95% CI, 1.62–5.8). Although our study was underpowered for genome-wide significance, SNP rs6474264 within ZMAT4 (p = 5.54 × 10–6) was found to be nominally significant, with a decreased risk for glaucoma medication non-adherence (OR, 0.22; 95% CI, 0.11–0.42)). IPA demonstrated significant overlap, utilizing, both standard measures including opioid signaling, drug metabolism, and synaptogenesis signaling. CREB signaling in neurons (which is associated with enhancing the baseline firing rate for the formation of long-term potentiation in nerve fibers) was shown to have protective associations. Our results suggest a substantial heritable genetic component to glaucoma medication non-adherence (47–58%). This finding is in line with genetic studies of other conditions with a psychiatric component (e.g., post-traumatic stress disorder (PTSD) or alcohol dependence). Our findings suggest both risk and protective statistically significant genes/pathways underlying glaucoma medication non-adherence for the first time. Further studies investigating more diverse populations with larger sample sizes are needed to validate these findings.

Artificial Intelligence, Heuristic Biases, and the Optimization of Health Outcomes: Cautionary Optimism

The use of artificial intelligence (AI) and machine learning (ML) in clinical care offers great promise to improve patient health outcomes and reduce health inequity across patient populations. However, inherent biases in these applications, and the subsequent potential risk of harm can limit current use. Multi-modal workflows designed to minimize these limitations in the development, implementation, and evaluation of ML systems in real-world settings are needed to improve efficacy while reducing bias and the risk of potential harms. Comprehensive consideration of rapidly evolving AI technologies and the inherent risks of bias, the expanding volume and nature of data sources, and the evolving regulatory landscapes, can contribute meaningfully to the development of AI-enhanced clinical decision making and the reduction in health inequity.

Measuring Medication Adherence in a Population-Based Asthma Administrative Pharmacy Database: A Systematic Review and Meta-Analysis

Background

Limited studies have systematically reviewed the literature to identify and compare the various database methods and optimal thresholds for measuring medication adherence specific to adolescents and adults with asthma. In the present study, we aim to identify the methods and optimal thresholds for measuring medication adherence in population-based pharmacy databases.

Methods

We searched PubMed, Embase, International Pharmaceutical Abstracts (IPA), Web of Science, Google Scholar, and grey literature from January 1, 1998, to March 16, 2021. Two independent reviewers screened the studies, extracted the data, and assessed the quality of the studies. A quantitative knowledge synthesis was employed.

Results

Thirty-eight (38) retrospective cohort studies were eligible. This review identified 20 methods for measuring medication adherence in adolescent and adult asthma administrative health records. Two measures namely the medication possession ratio (MPR) and proportion of days covered (PDC) were commonly reported in 87% of the literature included in this study. From the meta-analysis, asthma patients who achieved adherence threshold of "0.75-1.00" [OR: 0.56, 95% CI: 0.41 to 0.77] and ">0.5" [OR: 0.71, 95% CI: 0.54 to 0.94] were less likely to experience asthma exacerbation.

Conclusion

Despite their limitations, the PDC and the MPR still remain the most common measures for assessing adherence in asthma pharmacy claim databases. The evidence synthesis showed that an adherence threshold of at least 0.75 is optimal for classifying adherent and non-adherent asthma patients.

Influence of social support on asthma self-management in adolescents

OBJECTIVE

Adolescents with asthma are influenced by peers and family. The objective was to better understand family social support and test its association with medication adherence, asthma control, and Emergency Department (ED) use.

METHODS

This study is a cross-sectional secondary data analysis from a randomized controlled trial with urban adolescents from three U.S. cities. Participants (12-20 years old) with asthma completed the Perceived Family Support Scale (PFS) and Horne's Medication Adherence Report Scale (MARS). Data from both tools were classified into 2 categories- high and low (< 25th percentile) perceived family support and high (total score >10) and low medication adherence, respectively. Chi-square statistic and logistic regression were used for analysis.

RESULTS

Of the 371 participants, the majority were young (96% ≤ 17 years), African American or Bi-racial (85%), and Medicaid-insured (72%); over one-third had maternal family history of asthma. Among those on a controller medication (n = 270), only 37% reported its use ≥8 days over 2 weeks. Asthma control was poor with 50% categorized "not well controlled," 34% "very poorly controlled." Participants responded positively to most social support items. One item, providing and receiving social support to and from family members, was less often positively reported. Low medication adherence was significantly associated with lower perceived social support (p = 0.018).

CONCLUSION

This study underscores the importance of family social support in understanding the extent of adolescents' self-management, particularly medication adherence.

Extent of non-adherence and non-persistence in asthma patients: analysis of a large claims data set

OBJECTIVE

The objective of this study was to assess non-adherence (NA) and non-persistence (NP) to long-acting asthma medications in Germany by differentiating between measurement of NA in periods of therapy continuation and measurement of NP in therapy-naïve patients.

METHODS

We analyzed treatment adherence to long-acting asthma medication using German claims data for periods of treatment continuation based on the medication possession ratio (MPR) and the proportion of days covered. Persistence was assessed in treatment-naïve patients. Outcomes were observed from the date of the first to the last prescription within a 12-month period. Both NA and NP analyses considered prescription supply, using either defined daily dosages, or prescribed daily dosages derived from a medical chart review.

RESULTS

We identified 52,508 asthma patients (mean age: 40.1, 58.4% female) who received at least two long-acting asthma prescriptions within 12 months; 50,660 treatment-naïve patients were included in the NP analysis (mean age: 39.7, 58.8% female). The mean 12-month MPR was 38.5% (89.4% NA according to MPR ≤ 80%) and the average proportion of days covered was 40.4% (85.9% NA). Agent-specific MPR and NA rates varied between 31.8% (91.8% NA) and 56.2% (71.6% NA). The average weighted-MPR increased to 53.1% when using the prescribed daily dosage. Based on a > 90-day gap definition, 86.7% of patients were considered non-persistent after 12 months (>180: 72.3%). When using prescribed daily dosages, NP rates ranged from 66.7 to 78.5%.

CONCLUSION

High levels of treatment NA and NP indicate a substantial need to improve adherence and persistence to long-acting asthma medication in Germany.

Linkage of primary care prescribing records and pharmacy dispensing Records in the Salford Lung Study: application in asthma

BACKGROUND

Records of medication prescriptions can be used in conjunction with pharmacy dispensing records to investigate the incidence of adherence, which is defined as observing the treatment plans agreed between a patient and their clinician. Using prescribing records alone fails to identify primary non-adherence; medications not being collected from the dispensary. Using dispensing records alone means that cases of conditions that resolve and/or treatments that are discontinued will be unaccounted for. While using a linked prescribing and dispensing dataset to measure medication non-adherence is optimal, this linkage is not routinely conducted. Furthermore, without a unique common event identifier, linkage between these two datasets is not straightforward.

METHODS

We undertook a secondary analysis of the Salford Lung Study dataset. A novel probabilistic record linkage methodology was developed matching asthma medication pharmacy dispensing records and primary care prescribing records, using semantic (meaning) and syntactic (structure) harmonization, domain knowledge integration, and natural language feature extraction. Cox survival analysis was conducted to assess factors associated with the time to medication dispensing after the prescription was written. Finally, we used a simplified record linkage algorithm in which only identical records were matched, for a naïve benchmarking to compare against the results of our proposed methodology.

RESULTS

We matched 83% of pharmacy dispensing records to primary care prescribing records. Missing data were prevalent in the dispensing records which were not matched - approximately 60% for both medication strength and quantity. A naïve benchmarking approach, requiring perfect matching, identified one-quarter as many matching prescribing records as our methodology. Factors associated with delay (or failure) to collect the prescribed medication from a pharmacy included season, quantity of medication prescribed, previous dispensing history and class of medication. Our findings indicate that over 30% of prescriptions issued were not collected from a dispensary (primary non-adherence).

CONCLUSIONS

We have developed a probabilistic record linkage methodology matching a large percentage of pharmacy dispensing records with primary care prescribing records for asthma medications. This will allow researchers to link datasets in order to extract information about asthma medication non-adherence.

A data-driven typology of asthma medication adherence using cluster analysis

Asthma preventer medication non-adherence is strongly associated with poor asthma control. One-dimensional measures of adherence may ignore clinically important patterns of medication-taking behavior. We sought to construct a data-driven multi-dimensional typology of medication non-adherence in children with asthma. We analyzed data from an intervention study of electronic inhaler monitoring devices, comprising 211 patients yielding 35,161 person-days of data. Five adherence measures were extracted: the percentage of doses taken, the percentage of days on which zero doses were taken, the percentage of days on which both doses were taken, the number of treatment intermissions per 100 study days, and the duration of treatment intermissions per 100 study days. We applied principal component analysis on the measures and subsequently applied k-means to determine cluster membership. Decision trees identified the measure that could predict cluster assignment with the highest accuracy, increasing interpretability and increasing clinical utility. We demonstrate the use of adherence measures towards a three-group categorization of medication non-adherence, which succinctly describes the diversity of patient medication taking patterns in asthma. The percentage of prescribed doses taken during the study contributed to the prediction of cluster assignment most accurately (84% in out-of-sample data).

The Consequences of General Medication Beliefs Measured by the Beliefs about Medicine Questionnaire on Medication Adherence: A Systematic Review

(1) Background: Medication adherence is a key determinant of patient health outcomes in chronic illnesses. However, adherence to long-term therapy remains poor. General beliefs about medicine are considered factors influencing medication adherence. It is essential to address the gap in the literature regarding understanding the impact of general beliefs about medicine on medication adherence to promote adherence in chronic illnesses. (2) Methods: PubMed, CINHAL, and EMBASE databases were searched. Studies were included if they examined medication beliefs using the Beliefs about Medicine Questionnaire in one of four chronic illnesses: hypertension, diabetes, chronic obstructive pulmonary disease, and/or asthma. (3) Results: From 1799 articles obtained by the search, only 11 met the inclusion criteria. Hypertension and diabetes represented 91% of included studies, while asthma represented 9%. Higher medication adherence was associated with negative general medication beliefs; 65% of the included studies found a negative association between harm beliefs and adherence, while 30% of studies found a negative association with overuse beliefs. (4) Conclusions: This review evaluated the impact of harm and overuse beliefs about medicines on medication adherence, highlighting the gap in literature regarding the impact of harm and overuse beliefs on adherence. Further research is needed to fully identify the association between general beliefs and medication adherence in people with different cultural backgrounds, and to explore these beliefs in patients diagnosed with chronic illnesses, particularly asthma and chronic obstructive pulmonary disease (COPD). Healthcare providers need to be aware of the impact of patients’ cultural backgrounds on general medication beliefs and adherence.

The impact of personal and cultural beliefs on medication adherence of patients with chronic illnesses: a systematic review

BACKGROUND

Patients' adherence to therapeutic regimes may be influenced by subjective beliefs about chronic conditions. One of the challenges for health professionals in enhancing adherence is taking patients' understanding into account when giving health advice and/or providing medical treatment.

PURPOSE

This review aimed to evaluate the consequent effects of personal and cultural beliefs on medication adherence, in patients with chronic conditions such as hypertension, diabetes mellitus, chronic obstructive pulmonary disease and asthma.

METHOD

A systematic review methodology was used. PubMed, CINAHL, EMBASE and PsychINFO, databases were searched for relevant articles. The main terms analyzed were illness perceptions, health beliefs, cultural beliefs, chronic conditions and medication adherence.

RESULTS

From 2,646 articles, 127 were retained for further assessment, and finally 25 met the inclusion criteria. A cross-sectional questionnaire survey research design was conducted in all included articles. Of these most (n=22) targeted hypertension or diabetes mellitus. A number of personal and cultural based factors were identified as being associated with adherence to medication regimes - 40% of articles (n=10) examined perception of illness, 20% (n=5) health literacy, 16% (n=4) cultural beliefs, 12% (n=3) self-efficacy, 16% (n=4) spiritual and religious beliefs, as well as 20% (n=5) illness knowledge. Statistically significant associations between medication adherence and these personal and cultural factors were found in 80% (n=20) of the included studies. However, the direction of associations varied between studies depending on the factor that was examined.

CONCLUSION

This review has evaluated the impact of personal and cultural factors on medication adherence and highlighted the gaps in literature regarding adherence. Further research is required to fully identify the associations between religious beliefs, control beliefs and illness knowledge and medication adherence.

Proportion of Japanese outpatients filling prescriptions for long-term medication regimens

Aim: Our study aimed to clarify how long outpatients with chronic diseases such as hypertension continuously fill prescriptions for the same medications as those prescribed initially and how many medications they take over the long term. Methods: Medication records from April 1, 2016 to March 31, 2017 with total days between initial and final dispensation date ≥330 days and total days of medication supplies ≥180 days were extracted from an electronic database in a Japanese community pharmacy chain. The continuity of refilling medications over 1 year (ie, medication fill adherence) was measured using the medication possession ratio (MPR). Results: A total of 34,549 outpatients received long-term medications under the above conditions (4.4% of all patients in the database). Mean age was 66.0±17.4 years; 63.1% were ≥65 years. The mean number of medications prescribed per patient was 3.2±2.3. More than one-fifth of patients (22.6%) were taking ≥5 medications. The mean MPR for patients overall was 93.6±11.2%; 87.2% of patients had an MPR ≥80% but <110%. Amlodipine besylate, an antihypertensive, was the most commonly prescribed drug (n=5,537 patients). Conclusion: Outpatients that received long-term medications with no change in prescription had an MPR >90% for around 3 medications. It can be reasonably assumed that these patients could receive a longer-term medication supply with the partial fills based on a physician's instruction ("Bunkatu Chozai" in Japanese). This longer-term supply would be similar to a basic prescription refill, but would require a physician's signature allowing for partial refills rather than a new prescription for each refill.

Role of a Community Pharmacy Service in Care of Bronchial Asthma Patients in Lithuania

Bronchial asthma is one of the most common chronic respiratory diseases, and its care is often complex. In this research, we tested the proposal that participation of pharmacists in the management of bronchial asthma can improve patient outcomes. A two-stage study was constructed consisting of a training element and a service element, using the Asthma Control Test and a structured questionnaire about the patients' disease condition (based on the results of a qualitative study). The study was conducted in 21 pharmacies in Lithuania and involved 338 asthmatic patients (age 18–88 years). It was found that before the pharmacy service was provided, the average number of mistakes patients made in administration of asthma medications was 2.03; this number decreased to 1.12 after the service was provided (p < 0.05). Disease control paralleled the improvement in number of mistakes: 26.1% of patients who previously exerted no control over the disease symptoms began to exert sufficient control over their asthma symptoms (Asthma Control Test >20) after the service was provided (p < 0.05). The reduced number of mistakes probably can be attributed to the positive effects of the provided services. By reducing the number of patient mistakes, pharmacists may improve the outcomes of asthmatic patients.

Traditional Therapies for Severe Asthma

Severe asthma is a complex and heterogeneous disease. The European Respiratory Society and American Thoracic Society guidelines define severe asthma for patients 6 years or older as "asthma which requires treatment with high-dose inhaled corticosteroids…plus a second controller or systemic corticosteroids to prevent it from becoming 'uncontrolled' or which remains 'uncontrolled' despite this therapy." This article reviews available traditional therapies, data behind their uses in severe asthma, and varying recommendations. As various asthma endotypes and phenotypes are better understood and characterized, targeted therapies should help improve disease outcomes, efficacy, and cost-effectiveness.

Modelling the effect of beliefs about asthma medication and treatment intrusiveness on adherence and preference for once-daily vs. twice-daily medication

People with asthma who do not adhere to their maintenance medication may experience poorer asthma control and need more healthcare support than those who adhere. People (N = 1010) aged 18–55 years with self-reported asthma, taking one or more asthma maintenance medication(s), from five European countries, participated in a survey using validated scales (Medication Adherence Report Scale [MARS], Asthma Control Test™ [ACT], Beliefs about Medicine Questionnaire [BMQ] and the Asthma Treatment Intrusiveness Questionnaire [ATIQ]). We performed a post hoc evaluation of adherence to maintenance medication, asthma control, beliefs about medication, preferences for once-daily vs. twice-daily asthma maintenance medication and treatment intrusiveness, using structural equation modelling to investigate the relationships between these factors. Most participants reported potential problems with asthma control (ACT < 19: 76.8% [n = 776]), low adherence (median MARS = 3.40) and preferred once-daily medication (73.5% [n = 742/1010]). Non-adherence was associated with worse asthma control (r = 0.262 [P < 0.001]) and a expressed preference for once-daily medication over a "twice daily medication that works slightly better" (test statistic [T] = 2.970 [P = 0.003]). Participants reporting non-adherence/preferring once-daily medication had negative beliefs about their treatment (BMQ necessity-concerns differential: r = 0.437 [P < 0.001]/T = 6.886 [P < 0.001]) and found medication intrusive (ATIQ: r = −0.422 [P < 0.001]/T = 2.689[P = 0.007]). Structural equation modelling showed complex relationships between variables, including: (1) high concerns about treatment associated with increased perceived treatment intrusiveness and reduced adherence, which influenced asthma control; (2) high concerns about treatment and healthcare seeking behaviour, which were predictive of preferring twice-daily asthma medication. Concerns about medication and perceived treatment intrusiveness were predictive of poor adherence, and were associated with preference for once-daily asthma medication. Confirm the utility of the PAPA model and NCF in explaining nonadherence linked to poor asthma control.

Encouraging adherence to maintenance medication for asthma requires a dual approach that considers patient perceptions as well as practicalities. While doctors may prescribe patients with appropriate medication to control asthma, many patients do not adhere to their maintenance regime. The reasons for this are complex, revolving around patient beliefs about long-term medication. Robert Horne at University College London, UK, and co-workers modelled data collected from interviews with 1010 adult patients from five European countries. Over a quarter of patients reported non-adherence and this was linked to concerns about ICS and perceived treatment intensiveness. Patients' beliefs about ICS and the concept of medication 'intrusiveness' were key factors in non-adherence. Understanding individual patient goals, eliciting patient concerns and addressing practical barriers should help encourage adherence.

Long-Term Inhaled Corticosteroid Adherence in Asthma Patients with Short-Term Adherence

BACKGROUND

Although the use of inhaled corticosteroids (ICS) in asthma is known to be overall erratic, the long-term use of ICS by patients selected during an episode of regular use is poorly documented.

OBJECTIVE

In a cohort of patients with asthma regularly acquiring ICS therapy over several months, we verified whether these patients remained treated in the following 12 months. The correlates of regular ICS use over this period were investigated.

METHODS

A historical cohort of patients with asthma was identified from the Echantillon généraliste de bénéficiaires national French health care reimbursement data (2007-2012). Patients (6-40 years) were selected during a regular ICS use episode, with 3 or more ICS refills within 120 days. Continuous multiple-interval measures of medication availability (CMA) were computed for the 12 months after the third dispensation, and the factors associated with a CMA value of 80% or more (adherent patients) were identified.

RESULTS

Among 5096 patients (42.1% children/teenagers, 48.8% females), only 24.0% had a CMA value of 80% or more (mean CMA = 54.4%) over the 12 months following the ICS selection period. Achieving a CMA value of 80% or more was primarily associated with being a child/teenager (P = .002), having more severe or less controlled asthma (P = .007), more previous dispensing of short-acting beta agonists (P < .0001), and receiving devices with 200 unit doses (P < .0001). Adherent patients had more frequent general practitioner visits (P < .0001), more distinct prescribers of respiratory therapy (P = .0002), and more frequent switches of ICS (P < .0001).

CONCLUSIONS

Most patients with asthma selected during an episode of regular ICS use did not maintain therapy over the following months. Adherence should be repeatedly monitored, and the reasons for discontinuation should be investigated, at prescriber and patient levels.

Enhancing Respiratory Medication Adherence: The Role of Health Care Professionals and Cost-Effectiveness Considerations

Adherence to medication comprises a multiphased temporal process involving (1) initiation of prescribed therapy, (2) implementation as prescribed, and (3) subsequent persistence. Medication adherence remains suboptimal in most patients with long-term respiratory conditions such as asthma and chronic obstructive pulmonary disease (COPD). Interventions have been shown to effectively improve treatment initiation, implementation, and persistence when delivered at the health care professional level or the system level, but demonstration of the cost-effectiveness of these interventions is necessary to ensure their widespread use. This review summarizes how health care professionals can intervene to improve medication adherence in patients with asthma and COPD, provides some examples of effective primary care interventions, and illustrates some of the challenges to optimal implementation arising from cost-effectiveness modeling. Improving adherence is shown to be an economically viable treatment option for patients with asthma and COPD, but there are differences in the health economics pertaining to each condition and setting that can affect whether an intervention is considered cost-effective. Targeting adherence interventions at patients with the greatest to gain, and tailoring them to individual patient needs, may help to optimize cost-effectiveness ratios and improve the probability of positive reimbursement decisions, systemwide implementation, and resultant health benefits.

Impact of an Electronic Monitoring Intervention to Improve Adherence to Inhaled Medication in Patients with Asthma and Chronic Obstructive Pulmonary Disease: Study Protocol for a Randomized Controlled Trial

Background

Despite progress in pharmacological and non-pharmacological treatment in recent years, the burden of disease among patients with asthma and chronic obstructive pulmonary disease (COPD) is high and patients are frequently hospitalized due to exacerbations. Reasons for uncontrolled diseases are manifold, but are often associated with poor inhalation technique and non-adherence to the prescribed treatment plan. This causes substantial mortality, morbidity, and costs to the healthcare system. In this respect, the study of causes for non-adherence and the development of measures to increase and maintain treatment adherence in chronic diseases is of major clinical importance.

Objective

The primary objective of this study is to investigate the impact of using specific, validated electronic devices on adherence to inhaled medication in patients with chronic obstructive lung diseases such as asthma and COPD. Furthermore, it aims to assess the impact of a reminder and close supervision of the course of disease and quality of life.

Methods

In this ongoing prospective, single-blind, randomized controlled study, adherence to inhaled medication is analyzed over a 6-month period in at least 154 in- and outpatients with asthma or COPD who have experienced at least 1 exacerbation during the last year. Adherence is measured using electronic data capture devices, which save the date and time of each inhalative device actuation and transfer these data daily via a wireless connection to a Web-based database. Patients are randomly assigned to either the intervention or the control group. The clinical intervention consists of an automated and personal reminder. The intervention group receives an audio reminder and support calls in case medication has not been taken as prescribed or if rescue medication is used more frequently than pre-specified in the study protocol. During the study, participants are assessed every 2 months in the form of clinical visits.

Results

Recruitment started in January 2014. To date, a total of 169 patients have been recruited. Follow-up assessments are still ongoing. The study will be concluded in the first quarter of 2017. Data analysis will take place during 2017.

Conclusions

Few studies have investigated medication adherence in patients with chronic obstructive lung diseases. With this prospective study design and the use of state-of-the-art devices for measuring adherence, we expect scientifically relevant and clinically meaningful results that will have a substantial and positive impact on the provision of healthcare in chronically ill patients suffering from asthma or COPD.

Trial Registration

ClinicalTrials.gov: NCT02386722; https://clinicaltrials.gov/ct2/show/NCT02386722 (Archived by WebCite at http://www.webcitation.org/6oJq1fel0)

Factors predicting self-reported medication low adherence in a large sample of adults in the US general population: a cross-sectional study

OBJECTIVES

The study objective was to determine the level and correlates of self-reported medication low adherence in the US general population.

SETTING

A 30 min cross-sectional online survey was conducted with a national sample of adults.

PARTICIPANTS

9202 adults (aged 18+) who had filled at least three or more prescriptions at a community pharmacy in the past 12 months.

PRIMARY AND SECONDARY OUTCOME MEASURES

Self-reported medication adherence was measured with the 8-item Morisky Medication Adherence Scale.

RESULTS

Low adherence was reported by 42.0%, 29.4% had medium adherence and 28.6% had high adherence. Low adherence was significantly associated with: lower age, being of Hispanic origin or African-American, having difficulty with healthcare, medication or transportation costs, needing the support of others to access primary care, health limiting activity, using multiple providers, infrequent visits to primary care providers and visiting an emergency department >3 times in last 12 months.

CONCLUSIONS

A very high level of low medication adherence is seen in the general population, particularly for ethnic minorities, those who use multiple healthcare providers and those who experience barriers to access for regular primary care. As clinical, patient education and counselling, and healthcare policy initiatives are directed to tracking the problem of low medication adherence, these should be priority populations for research and interventions.

Patient Characteristics and Individualization of Biologic Therapy

Progress in the understanding of disease processes has provided additional therapeutic targets, best exemplified by the increasing role of biologics in the clinical armamentarium. This article provides a focused review of current treatment paradigms and pathophysiology for asthma, atopic dermatitis, urticaria, as well as C1 inhibitor deficiency. It elucidates the populations in which biologics were studied for the aforementioned disease states, emphasizing characteristics to consider when selecting therapy. It is important to correctly estimate patient outcome before starting therapy based on cost analysis. Treatment decisions need to be guided by appropriate patient stratification based on each individual's underlying phenotype.

Spotlight on fluticasone furoate/vilanterol trifenatate for the once-daily treatment of asthma: design, development and place in therapy

The use of inhaled corticosteroids (ICSs) plays a key role in the treatment of asthmatic patients, and international guidelines have designated ICSs as an early maintenance therapy in controlling asthma symptoms. When asthmatic patients remain symptomatic on ICSs, one common option is to add a long-acting beta₂ agonist (LABA) to the maintenance treatment. Fixed combination inhalers that contain both an ICS and a LABA have been popular for both chronic obstructive pulmonary disease (COPD) and asthma. Historically, these inhalers have been dosed twice daily. However, currently, there is a once-daily combination therapy with the ICS fluticasone furoate (FF) and the LABA vilanterol trifenatate (VI) with indications for use in both COPD and asthma. This dry powder inhaler (DPI) comes in two doses of FF (100 or 200 μg) both combined with VI (25 μg). This article reviews the clinical trial data for FF, VI and FF/VI combination inhalers and documents the efficacy and safety of once-daily inhaled maintenance therapy by DPI in asthmatic patients.

Inhaled Corticosteroid Adherence Patterns in a Longitudinal Asthma Cohort

BACKGROUND

Electronic prescribing records can enable exploration of medication adherence, but analysis decisions may influence estimates and require alignment to new consensus-based definitions.

OBJECTIVE

To compare different computations of inhaled corticosteroid (ICS) implementation in a primary care asthma population initiating ICS therapy when assessed within episodes of persistent use, and examine longitudinal variation in implementation.

METHODS

A historical cohort study was conducted on UK's Optimum Patient Care Research Database. Eligible patients had physician-diagnosed asthma, initiated ICS therapy, and had 3 or more years of continuous registration. ICS treatment episodes were constructed on the basis of 3 definitions, permitting 30-, 90-, and 182-day gaps between prescriptions. Implementation was estimated using 2 continuous medication availability (CMA I and II) definitions to explore effects of carryover of previous prescriptions in 4 observation windows: 6, 8, 12, and 24 months. Impact of methodology was assessed by descriptive statistics, linear mixed models, and measures of agreement.

RESULTS

A total of 13,922 eligible patients (mean age, 39.9 years; 48.7% men) were identified. For CMA I, permitting a 90-day gap, mean ICS implementation for the 2-year period was 89.3% (±16.0%; range, 14.4%-100%). Sensitivity analyses with 30- and 182-day gaps resulted in increased (97.0% ± 7.2%) and decreased (81.1% ± 21.6%) estimates. CMA II produced estimates with varying concordance (0.69-0.87). Substantial variance was found between and within patients (intraclass coefficient, 0.30-0.36).

CONCLUSIONS

Different analysis choices resulted in substantial variation in implementation estimates, highlighting the need for transparent and clinically relevant methododology. Distinguishing between (non)persistence and implementation is important in clinical practice, and may require different interventions in routine consultations.

Adherence to Glaucoma Medications Over 12 Months in Two US Community Pharmacy Chains

This study determined the degree of adherence to medications for glaucoma among patients refilling prescriptions in community pharmacies. Methods: Data abstracted from the dispensing records for 3615 adult patients (18 years or older, predominantly over 45) receiving glaucoma medications from two retail pharmacy chains (64 stores in total) were analyzed. From a 24-month historic data capture period, the 12-month levels of adherence were determined using standard metrics, the proportion of days covered (PDC) and the medication possession ratio (MPR). The overall 12-month mean PDC was only 57%, and the mean MPR was 71%. Using a criterion by which 80% coverage was considered satisfactory adherence, only 30% had satisfactory overall 12-month PDC coverage, and only 37% had satisfactory overall 12-month MPR coverage. Refill adherence increased with age and was highest in the 65-and-older age group (p < 0.001). Differential adherence was found across medication classes, with the highest satisfactory coverage seen for those taking alpha2-adrenergic agonists (PDC = 36.0%; MPR = 47.6%) down to those taking direct cholinergic agonists (PDC = 25.0%; MPR = 31.2%) and combination products (PDC = 22.7%; MPR = 31.0%). Adherence to glaucoma medications in the community setting, as measured by pharmacy refill data, is very poor and represents a critical target for intervention. Community pharmacists are well positioned to monitor and reinforce adherence in this population.

Evaluation of asthma medication adherence rates and strategies to improve adherence in the underserved population at a Federally Qualified Health Center

BACKGROUND

Adherence with asthma medications is less than optimal, measuring approximately 30-50%. Several factors have been shown to contribute to medication non-adherence including low-socioeconomic status, low literacy, medication cost, access to care, and language barriers. Community Health Clinic Ole has attempted to reduce medication adherence barriers associated with cost, access to care, and language by 1) allowing medications to be obtained from the clinic at a reduced cost via the 340B drug pricing program and patient assistance programs, and 2) providing one-on-one consultations from bilingual Spanish-speaking clinicians. Limited evidence is available regarding chronic disease-state medication adherence among Spanish-speaking individuals presenting to a Federally Qualified Health Center (FQHC).

OBJECTIVE

The purpose of this study is to assess asthma medication adherence and determine predictors of non-adherence in the underserved population at an FQHC.

METHODS

Adult patients with a diagnosis of persistent asthma receiving medication refills from clinic between October 1, 2011 and October 31, 2012 were identified (N = 121). Individuals with intermittent or seasonal asthma only, exercise-induced asthma only, or mixed asthma/COPD; individuals who have not picked up at least one fill of inhaled corticosteroid in the past one-year; and individuals without active prescriptions for asthma controller medications were excluded. Medication adherence was assessed by using the medication possession ratio (MPR) for asthma controller medications (e.g. inhaled corticosteroids, long-acting beta-2 agonists, leukotriene modifiers, and theophylline). Patients were categorized into two adherence groups: medium-high (MPR ≥ 0.5) and low (MPR < 0.5).

RESULTS

Approximately one-third of individuals were identified with medium-high adherence to asthma medications, of which only 8.3% of individuals were found to be fully adherent (MPR ≥ 0.8). The majority of individuals (66.1%) were identified with low adherence, despite efforts to reduce medication adherence barriers associated with drug cost, access to care, and language. Patients with low adherence were younger (39.3 vs. 45.4 yo; P < 0.012), had fewer medication refills (2.1 vs. 5.3; P < 0.001), had fewer primary care provider (PCP) visits (3.4 vs. 5.0; P < 0.05), lower baseline Asthma Control Test (ACT) scores (13.1 vs. 17.3; P < 0.001), and lower asthma medication ratios (AMR) (0.7 vs. 0.9; P < 0.001) than patients with medium-high adherence. No significant differences in MPR rates were found between Hispanics and non-Hispanics. The average MPR in both groups was 0.55.

CONCLUSION

Our findings demonstrate that asthma medication adherence remains poor among all underserved patients despite improved access to care via reduced medication pricing and the provision of Spanish-speaking medication consultations at refill pick-ups. Poor adherence rates remained common among both the Non-Hispanic and Hispanic, younger, and lower-socioeconomic patients in our study. Future studies may wish to explore whether providing a service that encompasses healthcare team support, optimal medication counseling, and utilization of patient-centered communication strategies improves asthma medication adherence in the Hispanic population.

The effects of direct-to-consumer advertising on medication use among Medicaid children with asthma

Asthma medication adherence is low, particularly among Medicaid enrollees. There has been much debate on the impact of direct-to-consumer advertising (DTCA) on health care use, but the impact on medication use among children with asthma has been unexamined. The study sample included 180,584 children between the ages of 5 and 18 with an asthma diagnosis from a combined dataset of Medicaid Analytic eXtract and national advertising data. We found that DTCA expenditure during the study period was significantly associated with an increase in asthma medication use. However, the effectiveness declined after a certain level.

Community pharmacy: an untapped patient data resource

As community pharmacy services become more patient centered, they will be increasingly reliant on access to good quality patient information. This review describes how the information that is currently available in community pharmacies can be used to enhance service delivery and patient care. With integration of community pharmacy and medical practice records on the horizon, the opportunities this will provide are also considered. The community pharmacy held patient medication record, which is the central information repository and has been used to identify non-adherence, prompts the pharmacist to clinically review prescriptions, identify patients for additional services, and identify those patients at greater risk of adverse drug events. While active recording of patient consultations for treatment over the counter may improve the quality of consultations and information held, the lost benefits of anonymity afforded by community pharmacies need to be considered. Recording of pharmacy staff activities enables the workload to be monitored, remuneration to be justified, critical incidents to be learned from, but is not routine practice. Centralization of records between community pharmacies enables practices to be compared and consistent problems to be identified. By integrating pharmacy and medical practice records, patient behavior with respect to medicines can be more closely monitored and should prevent duplication of effort. When using patient information stored in a community pharmacy, it is, however, important to consider the reason why the information was recorded in the first instance and whether it is appropriate to use it for a different purpose without additional patient consent. Currently, community pharmacies have access to large amounts of information, which, if stored and used appropriately, can significantly enhance the quality of provided services and patient care. Integrating the records increases opportunities to enhance patient care yet further. While community pharmacies have significant amounts of information available to them, this is frequently untapped.

The combination of fluticasone furoate and vilanterol trifenatate in the management of asthma: clinical trial evidence and experience

The treatment of persistent asthma has been aided by the recent approval of new medications. The combined inhaled corticosteroid (ICS)/long-acting β2 agonist (LABA) powder inhaler fluticasone furoate (FF)/vilanterol trifenatate (VI) is one of these new agents, which was recently approved as a maintenance therapy for persistent asthma. This once-daily ICS/LABA inhaler has previously been approved and used in chronic obstructive pulmonary disease as a maintenance therapy. Both FF and VI individually have been shown to have efficacy in the treatment of persistent asthma; the combination of FF/VI at the dose of 100/25 μg daily improves trough peak expiratory flows and forced expiratory volume in 1 s. It also reduces the frequency of asthma exacerbations in patients with persistent asthma. The once-daily dosing is well tolerated, with limited clinically significant adverse events; the once-daily inhaled dosing regimen should also improve medication adherence. The data supporting the use of the FF/VI inhaler in persistent asthma are reviewed. The dry powder inhaler of FF/VI (100/25 μg) is an effective and well tolerated once-daily maintenance treatment for patients with persistent asthma.