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

Gender-Related Factors in Medication Adherence for Metabolic and Cardiovascular Health

This review explores the impact of gender on medication adherence in the context of metabolic and cardiovascular diseases. Optimal adherence to medication is crucial for achieving treatment goals and preventing adverse outcomes in chronic diseases. The review examines specific conditions such as type 2 diabetes, hypercholesterolemia, arterial hypertension, cardiovascular diseases, and heart failure. In type 2 diabetes, female sex, younger age, new drug prescription, non-white ethnicity, low education level, and low income were identified as predictors of non-adherence. Depressive disorders were also found to influence adherence. In hypercholesterolemia, women exhibited poorer adherence to statin therapy compared to men, with statin-related side effects and patient perception being significant factors. Adherence to anti-hypertensive therapy showed conflicting results, with studies reporting both higher and lower adherence in women. Limited evidence suggests that women may have poorer adherence after acute myocardial infarction and stroke. Regarding heart failure, adherence studies have shown inconsistent findings. The reasons for gender differences in medication adherence are multifactorial and include sociodemographic, disease-related, treatment-related, and psychological factors. This review emphasizes the need for further research to better understand these differences and develop gender-customized interventions that can improve medication adherence and reduce the burden of metabolic and cardiovascular diseases.

Adherence and persistence to pharmacotherapy in patients with heart failure: a nationwide cohort study, 2014-2020

AIMS

We aimed to study initiation, adherence, and long-term persistence to beta-blockers (BB), renin-angiotensin system inhibitors (RASi), and mineralocorticoid receptor antagonists (MRA) in a nationwide cohort of patients with heart failure (HF).

METHODS

Patients aged 18-80 years in Norway with a first diagnosis of HF from 2014 until 2020 that survived ≥30 days were identified from the Norwegian Patient Registry and linked to the Norwegian Prescription Database. We collected information about BB, RASi [angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARB), and angiotensin receptor-neprilysin inhibitors (ARNI)], and MRA. Dual HF therapy was defined as taking at least two out of three drug classes, whereas triple HF therapy was defined as taking all three. Initiation (time to initiation) and persistence (time to discontinuation using a grace period of 30 days) of HF drugs was calculated by the Kaplan-Meier method, followed to outcome of interest, death, or December 2020. One-year adherence was measured as proportion of days covered (PDC) using a cut-off at 80%. For adherence and persistence measurements, we allowed for maximum 60 days of stockpiling and switching within drug groups. We performed sensitivity analyses to test the robustness of our findings.

RESULTS

Out of 54 899 patients included in the cohort, 75%, 69%, and 21% initiated a BB, RASi, and MRA, respectively, whereas 13% did not receive any. Dual and triple HF therapy was prescribed to 61% and 16%, respectively. The proportion of adherent patients during the first year following initiation was 83%, 81%, 84%, and 61% for BB, RASi, ARNI, and MRA, whereas 42% and 5% were adherent to dual and triple HF therapy, respectively. From 2 to 5 years following initiation, persistence decreased from 58% to 38%, 57% to 37%, and 31% to 15% for BB, RASi, and MRA, respectively. Within the RASi group, persistence was higher for ARNI than for ACEI and ARB. There were no major changes in either initiation or adherence of the drug classes from 2014 to 2019, except for an increase in initiation and adherence of MRA.

CONCLUSIONS

We found low adherence to dual and triple HF therapies in this nationwide cohort study of newly diagnosed HF patients. Efforts are needed to increase adherence and persistence to HF therapies into clinical practice, emphasizing maintenance of multiple drug therapies in patients with such an indication.

Determinants of left ventricular function improvement for cardiac resynchronization therapy candidates

AIMS

A waiting period of more than 3 months is recommended for patients before undergoing cardiac resynchronization therapy (CRT). However, due to an anticipated high mortality rate, early implementation of CRT might be beneficial for some patients. We aimed to evaluate the rate and the probability of left ventricular (LV) function improvement and their predictors in patients with heart failure (HF) with indications for CRT.

METHODS AND RESULTS

From March 2011 to February 2014, a total of 5625 hospitalized patients for acute HF were consecutively enrolled in 10 tertiary hospitals. Among them, we analysed 1792 patients (mean age 63.96 ± 15.42 years, female 63.1%) with left ventricular ejection fraction (LVEF) ≤ 35% at the baseline echocardiography and divided them into three groups: 144 with left bundle branch block (LBBB), 136 with wide QRS complexes without LBBB, and 1512 not having these findings (control). We compared and analysed these three groups for improvement of LV function at follow-up echocardiography. In patients who met CRT indications (patients with LBBB or wide QRS complexes without LBBB), logistic regression was performed to identify risk factors for no improvement of LV. No improvement of LV was defined as LVEF ≤ 35% at follow-up echocardiography or the composite adverse outcomes: death, heart transplantation, extracorporeal membrane oxygenation, or use of a ventricular assist device before follow-up echocardiography. A classification tree was established using the binary recursive partitioning method to predict the outcome of patients who met CRT indications. In a median follow-up of 11 months, LVEF improvement was observed in 24.3%, 15.4%, and 40.5% of patients with LBBB, wide QRS complexes without LBBB, and control, respectively. Patients meeting CRT indications had higher 3 month mortality rates than the control (24.6% vs. 17.7%, P = 0.002). Multivariable logistic regression analysis revealed that large LV end-systolic dimension [odds ratio (OR) 1.10, 95% confidence interval (CI) 1.05-1.15, P < 0.001], low LVEF (OR 0.92, 95% CI 0.87-0.98, P = 0.006), diabetes requiring insulin (OR 6.49, 95% CI 2.53-19.33, P < 0.001), and suboptimal medical therapy (OR 6.85, 95% CI 3.21-15.87, P < 0.001) were significant factors predictive of no improvement. A decision tree analysis was consistent with these results.

CONCLUSIONS

Patients with CRT indications had higher mortality during their follow-up compared with control. LV function improvement was rare in this population, especially when they had some risk factors. These results suggest that the uniform waiting period before CRT implantation could be reconsidered and individualized.

Treatment prescription, adherence, and persistence after the first hospitalization for heart failure: A population-based retrospective study on 100785 patients

BACKGROUND

This study evaluates, in a real-world setting, to what extent the recommended therapies by international guidelines, are prescribed after a first hospitalization for heart failure (HF), and to analyse adherence and persistence, and the effect of treatment adherence on mortality and re-hospitalization.

METHODS

From the Lombardy healthcare administrative database, we analysed patients discharged after their incident HF, from 2000 to 2012. Adherence was defined as the proportion of days covered (PDC) ≥80% adjusted for hospitalizations and persistence as the absence of discontinuation of therapy for >30 days. A logit model was used to determine the effect of patients' adherence on mortality and readmissions.

RESULTS

Of 100422 HF patients (52% males, age 75 ± 12 years), 86846 (87%) had a prescription for angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACE/ARBs), 64135 (64%) for beta-blockers (BB), and 36893 (37%) for mineralocorticoid receptor antagonists (MRAs), as mono-, bi- or tri-therapy. In patients on monotherapy, PDC was 78 ± 22% for ACE/ARBs, 69 ± 29% for BB and 54 ± 29% for MRAs; in those on bi-therapy, PDC was 63 ± 31% for ACEI/ARBs+BB, 41 ± 29% for ACEI/ARBs+MRAs, and 40 ± 26% for MRAs+BB; for patients on tri-therapy, PDC was 42 ± 28%. Medication persistence was present in 47% of patients treated with ACEI/ARBs, in 35% of patients treated with BB and in 14% of patients treated with MRAs. Re-hospitalizations and in mortality were significantly reduced in adherent patients (p < 0.000).

CONCLUSIONS

Polypharmacy is associated with an increased rate of non-adherence and non-persistence in incident HF. Non-adherence is associated with an increased risk of mortality and re-hospitalizations.

Optimal Usage of Sacubitril/Valsartan for the Treatment of Heart Failure: The Importance of Optimizing Heart Failure Care in Canada

BACKGROUND

Heart failure (HF) with reduced ejection fraction represents approximately 50% of the 600,000 Canadians currently living with HF and over 90,000 new cases diagnosed each year. The angiotensin receptor neprilysin inhibitor, sacubitril/valsartan, demonstrated superior efficacy in reducing cardiovascular death and HF hospitalization over standard of care therapy.

METHODS

The potential magnitude of benefit in Canada with respect to preventing or postponing deaths and reducing hospitalizations resulting from its optimal implementation in patients with HF with an ejection fraction <40% was estimated based on published sources.

RESULTS

Of the potentially eligible 225,562 patients, this would amount to the prevention of 4699 cardiovascular deaths and first HF hospitalizations, 3698 thirty-day HF readmissions, and 2820 deaths due to all-cause mortality. The number of patients receiving sacubitril/valsartan nationally in 2018 was 27,267. This represents approximately 12% of the calculated eligible population for this therapy in Canada.

CONCLUSIONS

The findings from this analysis suggest that a substantial number of deaths, hospitalizations, and HF readmissions could potentially be avoided by optimal usage of sacubitril/valsartan therapy in Canada. This emphasizes the importance of rapidly and appropriately implementing evidence-based medications into routine clinical practice, to achieve the best possible outcomes for our patients with HF and to reduce the high burden and cost of HF in Canada.

Long-Term Adherence to Renin-Angiotensin System Inhibitors and β-Blockers After Heart Failure Hospitalization in Senior Patients

AIMS

We investigated long-term adherence to renin-angiotensin system inhibitors (RASIs) and β-blockers, and associated predictors, in senior patients after hospitalization for heart failure (HF).

METHODS

A population-based data set identified 4488 patients who survived 60 days following their index hospitalization for HF in Western Australia from 2003 to 2008 with a 3-year follow-up. Their person-linked Pharmaceutical Benefits Scheme records identified medications dispensed during follow-up. Drug discontinuation was defined as the first break ≥90 days following the previous supply. Medication adherence was calculated using the proportion of days covered (PDC), with PDC ≥ 80% defined as being adherent. Multivariable logistic regression models were used to identify predictors of PDC < 80%.

RESULTS

In the cohort (57% male, mean age: 76.6 years), 77.4% were dispensed a RASI and 52.7% a β-blocker within 60 days postdischarge. Over the 3-year follow-up, 28% and 42% of patients discontinued RASI and β-blockers, respectively. Only 64.6% and 47.5% of RASI and β-blocker users, respectively, were adherent to their treatment over 3 years, with adherence decreasing over time (trend P < .0001 for RASI and trend P = .02 for β-blockers). Older age, increasing Charlson comorbidity score, chronic kidney disease, and chronic obstructive pulmonary disease were independent predictors of PDC < 80% for both drug groups.

CONCLUSION

Among seniors hospitalized for HF, discontinuation gaps were common for RASI and β-blockers postdischarge, and long-term adherence to these medications was suboptimal. Where appropriate, strategies to improve long-term medication adherence are indicated in HF patients, particularly in elderly patients with comorbidities.

Comparison of Different Strategies to Measure Medication Adherence via Claims Data in Patients With Chronic Heart Failure

Medication adherence correlates with morbidity and mortality in patients with chronic heart failure (CHF), but is difficult to assess. We conducted a retrospective methodological cohort study in 3,808 CHF patients, calculating adherence as proportion of days covered (PDC) utilizing claims data from 2010 to 2015. We aimed to compare different parameters’ influence on the PDC of elderly CHF patients exemplifying a complex chronic disease. Investigated parameters were the assumed prescribed daily dose (PDD), stockpiling, and periods of hospital stay. Thereby, we investigated a new approach using the PDD assigned to different percentiles. The different dose assumptions had the biggest influence on the PDC, with variations from 41.9% to 83.7%. Stockpiling and hospital stays increased the values slightly. These results queries that a reliable PDC can be calculated with an assumed PDD. Hence, results based on an assumed PDD have to be interpreted carefully and should be presented with sensitivity analyses to show the PDC's possible range.

Adherence to the evidence-based heart failure drug treatment: Are there sex-specific differences among new users?

BACKGROUND

The evidence-based heart failure (HF) drug treatment is made of a β-blocker and an angiotensin-converting enzyme inhibitor or an angiotensin II receptor blocker, or hydralazine + isosorbide dinitrate. Little is known about sex-based difference in adherence to the evidence-based HF drug treatment.

OBJECTIVES

To assess among new users of the evidence-based HF drug treatment, the association between sex and 1) persistence with the treatment 1 year after its initiation, 2) implementation of the treatment among those who persisted, and 3) overall adherence to treatment in the year following its initiation.

METHODS

A cohort study was conducted among new users of this treatment using Quebec medico-administrative data. Patients still on the evidence-based HF drug treatment one year after initiation were considered persistent. Among persistent users, those with ≥88% of days covered by the treatment were deemed to have adequately implemented it. Persistent patients who have adequately implemented the treatment were considered adherent. To measure the association between, on one hand sex, and on the other persistence, implementation and adherence, adjusted proportion ratios (APR) with their 95% confidence intervals (CI) were calculated.

RESULTS

Among 13,453 women, 72.1% were persistent, 72.2% adequately implemented the treatment, and 52.8% were adherent. Among the 14,614 men, these proportions were 73.6%, 67.9% and 50.1%, respectively. Men were less likely than women to be adherent to their treatment (APR: 0.96, 95% CI: 0.94-0.99).

CONCLUSION

Among individuals initiating an evidence-based multi-drug treatment for HF, men are less likely than women to be adherent to this treatment.

Impact of a Multidisciplinary Heart Failure Postdischarge Management Clinic on Medication Adherence

PURPOSE

Disease management programs have been associated with improved adherence to heart failure (HF) medications. However, there remain limited data on the benefit of a comprehensive multidisciplinary HF postdischarge management (PDM) clinic that promptly follows HF-related hospitalization on evidence-based HF medication adherence.

OBJECTIVE

The aim of this study was to evaluate the effects of an HF-PDM clinic on adherence to evidence-based HF medication therapy.

METHODS

In this retrospective cohort study, we identified patients discharged from the Veterans Affairs Greater Los Angeles Healthcare System between 2009 and 2012 with a primary diagnosis of HF. Data from patients who attended the HF-PDM clinic immediately following HF-related hospitalization between 2010 and 2012 were compared with those from historical controls, who did not attend the HF-PDM clinic, from 2009. The main outcome was adherence to evidence-based HF medications during the 90 days after discharge. Adherence was defined as the proportion of days covered at 90 days after discharge (PDC-90) of ≥0.80. The percentages of patients adherent to each medication were compared between the 2 groups using the χ² test. A logistic regression model adjusted for potential confounding variables was constructed to evaluate the percentages of patients adherent to evidence-based HF medications.

FINDINGS

A total of 277 patients (144 clinic, 133 control) were included in the study. Both univariate and multivariate analyses showed that the clinic was associated with improved medication adherence to angiotensin-converting enzyme inhibitors, a twice-daily β-blocker, and aldosterone antagonists compared with controls. The most significant increases were in adherence to angiotensin-converting enzyme inhibitors, with mean PDC-90 values of 0.84 (control) versus 0.93 (clinic) (P = 0.008) and 90-day adherence rates of 69% (control) versus 87% (clinic) (P = 0.005).

IMPLICATIONS

Care in the multidisciplinary HF-PDM clinic was associated with significant increases in 90-day adherence to evidence-based HF medications in patients who were recently discharged after an HF-related hospitalization.

Does the association between adherence to statin medications and mortality depend on measurement approach? A retrospective cohort study

BACKGROUND

The aim of this study was to examine the relationship between mortality and statin adherence using two different approaches to adherence measurement (summary versus repeated-measures).

METHODS

A retrospective cohort study was conducted using administrative data from Saskatchewan, Canada between 1994 and 2008. Eligible individuals received a prescription for a statin following hospitalization for acute coronary syndrome (ACS). Adherence was measured using proportion of days covered (PDC) expressed either as: 1) a fixed summary measure, or 2) as a repeatedly measured covariate. Multivariable Cox-proportional hazards models were used to estimate the association between adherence and mortality.

RESULTS

Among 9,051 individuals, optimal adherence (≥80%) modeled with a fixed summary measure was not associated with mortality benefits (adjusted HR 0.97, 95% CI 0.86 to 1.09, p = 0.60). In contrast, repeated-measures approach resulted in a significant 25% reduction in the risk of death (adjusted HR 0.75, 95% CI 0.67 to 0.85, p < 0.01).

CONCLUSIONS

Unlike the summary measure, the repeated measures approach produces a significant reduction of all-cause mortality with optimal adherence. This effect may be a result of the repeated measures approach being more sensitive, or more prone to survival bias. Our findings clearly demonstrate the need to undertake (and report) multiple approaches when assessing the benefits of medication adherence.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

Medication Initiation Burden Required to Comply With Heart Failure Guideline Recommendations and Hospital Quality Measures

BACKGROUND

Guidelines for heart failure (HF) recommend prescription of guideline-directed medical therapy before hospital discharge; some of these therapies are included in publicly reported performance measures. The burden of new medications for individual patients has not been described.

METHODS AND RESULTS

We used Get With The Guidelines-HF registry data from 2008 to 2013 to characterize prescribing, indications, and contraindications for angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, β-blockers, aldosterone antagonists, hydralazine/isosorbide dinitrate, and anticoagulants. The difference between a patient's medication regimen at hospital admission and that recommended by HF quality measures at discharge was calculated. Among 158 922 patients from 271 hospitals with a primary discharge diagnosis of HF, initiation of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers was indicated in 18.1% of all patients (55.5% of those eligible at discharge were not receiving angiotensin-converting enzyme inhibitors or angiotensin receptor blockers at admission), β-blockers in 20.3% (50.5% of eligible), aldosterone antagonists in 24.1% (87.4% of eligible), hydralazine/isosorbide dinitrate in 8.6% (93.1% of eligible), and anticoagulants in 18.0% (58.0% of eligible). Cumulatively, 0.4% of patients were eligible for 5 new medication groups, 4.1% for 4 new medication groups, 9.4% for 3 new medication groups, 10.1% for 2 new medication groups, and 22.7% for 1 new medication group; 15.0% were not eligible for new medications because of adequate prescribing at admission; and 38.4% were not eligible for any medications recommended by HF quality measures. Compared with newly indicated medications (mean, 1.45 ± 1.23), actual new prescriptions were lower (mean, 1.16 ± 1.00).

CONCLUSIONS

A quarter of patients hospitalized with HF need to start >1 medication to meet HF quality measures. Systems for addressing medication initiation and managing polypharmacy are central to HF transitional care.

Medication Adherence Based on Part D Claims for Patients With Heart Failure After Hospitalization (from the Atherosclerosis Risk in Communities Study)

Medication nonadherence is a common precipitant of heart failure (HF) hospitalization and is associated with poor outcomes. Recent analyses of national data focus on long-term medication adherence. Little is known about adherence of patients with HF immediately after hospitalization. Hospitalized patients with HF were identified from the Atherosclerosis Risk in Communities study. Atherosclerosis Risk in Communities data were linked to Medicare inpatient and part D claims from 2006 to 2009. Inclusion criteria were a chart-adjudicated diagnosis of acute decompensated or chronic HF; documentation of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB), β blocker (BB), or diuretic prescription at discharge; and Medicare part D coverage. Proportion of ambulatory days covered was calculated for up to twelve 30-day periods after discharge. Adherence was defined as ≥80% proportion of ambulatory days covered. We identified 402 participants with Medicare part D: mean age 75, 30% men, and 41% black. Adherence at 1, 3, and 12 months was 70%, 61%, and 53% for ACEI/ARB; 76%, 66%, and 62% for BB; and 75%, 68%, and 59% for diuretic. Adherence to any single drug class was positively correlated with being adherent to other classes. Adherence varied by geographic site/race for ACEI/ARB and BB but not diuretics. In conclusion, despite having part D coverage, medication adherence after discharge for all 3 medication classes decreases over 2 to 4 months after discharge, followed by a plateau over the subsequent year. Interventions should focus on early and sustained adherence.

Cardiovascular medication utilization and adherence among heart failure patients in rural and urban areas: a retrospective cohort study

BACKGROUND

Rural residence is a negative prognostic factor for heart failure (HF). The objective was to explore rural and urban differences in the utilization, adherence, and persistence with medications, and mortality among incident HF patients.

METHODS

Using administrative databases from Alberta (Canada), subjects > 65 years old with a first hospitalization for HF between 1999 and 2008 who survived ≥ 90 days after discharge were identified. Pharmacy claims for renin-angiotensin system (RAS) agents, β-blockers (BBs), digoxin, or spironolactone were identified. The association between rural and urban residence and medication utilization, adherence (optimal adherence defined as ≥ 80% adherence over 1 year), persistence, and 1-year mortality was assessed.

RESULTS

The cohort included 10,430 patients, with a mean age of 80.2 (SD, 7.7) years, 47% were male, and 25% were rural residents. Rural residents were less likely to receive RAS agents (74% vs 79%, adjusted odds ratio [aOR], 0.78; 95% confidence interval [CI], 0.69-0.89) or BBs (44% vs 54%; aOR, 0.83; 95% CI, 0.73-0.93) than urban residents, but had similar use of other medications. Although < 69% of patients who received RAS agents and 53% who received BBs had optimal adherence, few differences in adherence or persistence were detected among patients in rural vs urban areas. The 1-year mortality rate was significantly lower for patients who demonstrated optimal adherence to RAS agents or BBs (aOR, 0.78; 95% CI, 0.65-0.94) with no significant differences in the first 6 months between patients residing in rural vs urban areas.

CONCLUSIONS

Rural residents with HF were less likely to receive RAS agents or BBs, but few differences in adherence were noted compared with their urban counterparts. Suboptimal adherence with evidence-based HF therapy was associated with increased risk of mortality.

Adjunctive therapy and management of the transition of care in patients with heart failure

Heart failure is a costly and difficult disease to treat. However, new metrics make it an imperative to keep these patients out of the hospital. Implementing and maintaining patients on successful treatment plans is difficult. A multitude of factors make transitioning care to the outpatient setting difficult. A careful and well-orchestrated team of cardiologists, general practitioners, nurses, and ancillary support staff can make an important difference to patient care. A strong body of literature supports the use of pharmacologic therapy, and evidence-based therapies can improve mortality and quality of life, and reduce hospital admissions. Adjunctive therapies can be equally important.

Does hospitalization influence patients' medication adherence and community pharmacists' interventions?

BACKGROUND

Medication adherence reduces disease morbidity. Data regarding changes in a patient's adherence before and after hospitalization and how this hospitalization influences a pharmacist's interventions are scarce.

OBJECTIVE

To assess changes in adherence to cardiovascular and respiratory medications in the year preceding and following a hospitalization; explore patients' perceptions about medication adherence and the pharmacist's role; and describe pharmacists' interventions regarding medication adherence.

METHODS

This cohort study included patients hospitalized for acute coronary syndrome, acute worsening of heart failure, or acute COPD exacerbations. Adherence to cardiovascular and respiratory medications was measured by calculating the proportion of days covered (PDC) from prescription refills. Patient interviews were completed to explore their perceptions about medication adherence and the role of the pharmacist. Community pharmacists were invited to complete an online survey and to participate in focus groups to discuss interventions to improve medication adherence.

RESULTS

Medication adherence was assessed for 61 patients; the mean PDC was 69.8% 12 months before hospitalization and 72.4% 12 months following hospitalization. Patients reported that they felt the need to take their medications to prevent worsening of their disease. They were satisfied with current pharmaceutical services. A total of 136 questionnaires completed by pharmacists were analyzed and 9 participants attended the focus groups. Most pharmacists reported monitoring prescription renewals to assess adherence, with no significant influence from the hospitalization itself. The patient's interest was reported to be an important facilitator, whereas a lack of time and face-to-face interaction with patients who had their medication delivered to their home was reported a main barrier to interventions. This study was limited by a small sample size.

CONCLUSIONS

Patient medication adherence did not significantly change following hospitalization. Hospitalization does not appear to significantly influence patient and pharmacist behavior towards medication adherence.

Proportion and risk indicators of nonadherence to antihypertensive therapy: a meta-analysis

PURPOSE

The World Health Organization (WHO) concluded that poor adherence to treatment is the most important cause of uncontrolled high blood pressure, with approximately 75% of patients not achieving optimum blood pressure control. The WHO estimates that between 20% and 80% of patients receiving treatment for hypertension are adherent. As such, the first objective of our study was to quantify the proportion of nonadherence to antihypertensive therapy in real-world observational study settings. The second objective was to provide estimates of independent risk indicators associated with nonadherence to antihypertensive therapy.

MATERIALS AND METHODS

We performed a systematic literature review and meta-analysis of all studies published between database inception and December 31, 2011 that reviewed adherence, and risk indicators associated with nonadherence, to antihypertensive medications.

RESULTS

In the end, 26 studies met our inclusion and exclusion criteria and passed our methodological quality evaluation. Of the 26 studies, 48.5% (95% confidence interval 47.7%-49.2%) of patients were adherent to antihypertensive medications at 1 year of follow-up. The associations between 114 variables and nonadherence to antihypertensive medications were reviewed. After meta-analysis, nine variables were associated with nonadherence to antihypertensive medications: diuretics in comparison to angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) and calcium channel blockers (CCBs), ACE inhibitors in comparison to ARBs, CCBs in comparison to ARBs, those with depression or using antidepressants, not having diabetes, lower income status, and minority cultural status.

CONCLUSION

This study clarifies the extent of adherence along with determining nine independent risk indicators associated with nonadherence to antihypertensive medications.

Impact of drug plans on adherence to and the cost of antihypertensive medications among patients covered by a universal drug insurance program

BACKGROUND

This study aimed to assess the impact of the type of drug plan on adherence to antihypertensive medication treatment as well as the cost of these medications within universal drug insurance programs.

METHODS

To compare adherence to antihypertensive medication treatment and the cost of antihypertensive medications between adults with public and private drug insurance in the province of Québec, Canada, we reconstructed a matched retrospective cohort by linking data recorded in 3 administrative databases between March 2008 and May 2010. The cohort included 186 privately and 1747 publicly insured patients aged 18-64 years who were treated with 1 or 2 antihypertensive medications. Adherence measured with the proportion of days covered (PDC) over 1 year and the cost of antihypertensive medications were evaluated for new and prevalent users separately.

RESULTS

More than 70% of patients were 50-64 years old and 90% of the publicly and 72% of the privately insured patients were using only 1 antihypertensive medication. The mean PDC among new users of 1 antihypertensive medication was 58.8% for privately insured patients and 65.0% for publicly insured patients, but the difference was not statistically significant. However, privately insured patients treated with 2 antihypertensive medications were more likely to be adherent (PDC-P, 15.0%; 95% confidence interval, 7.0-24.0). Privately insured patients (CAD$41.52) had to pay significantly more for their antihypertensive medications than did publicly insured patients (CAD$32.21).

CONCLUSIONS

The cost of antihypertensive medications was higher for patients with private drug insurance, although adherence was similar in both groups. The results may reflect regulation of dispensing fees for publicly insured patients.

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

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

Heart failure in North America

Heart failure is a major health problem that affects patients and healthcare systems worldwide. Within the continent of North America, differences in economic development, genetic susceptibility, cultural practices, and trends in risk factors and treatment all contribute to both inter-continental and within-continent differences in heart failure. The United States and Canada represent industrialized countries with similar culture, geography, and advanced economies and infrastructure. During the epidemiologic transition from rural to industrial in countries such as the United States and Canada, nutritional deficiencies and infectious diseases made way for degenerative diseases such as cardiovascular diseases, cancer, overweight/obesity, and diabetes. This in turn has resulted in an increase in heart failure incidence in these countries, especially as overall life expectancy increases. Mexico, on the other hand, has a less developed economy and infrastructure, and has a wide distribution in the level of urbanization as it becomes more industrialized. Mexico is under a period of epidemiologic transition and the etiology and incidence of heart failure is rapidly changing. Ethnic differences within the populations of the United States and Canada highlight the changing demographics of each country as well as potential disparities in heart failure care. Heart failure with preserved ejection fraction makes up approximately half of all hospital admissions throughout North America; however, important differences in demographics and etiology exist between countries. Similarly, acute heart failure etiology, severity, and management differ between countries in North America. The overall economic burden of heart failure continues to be large and growing worldwide, with each country managing this burden differently. Understanding the inter-and within-continental differences may help improve understanding of the heart failure epidemic, and may aid healthcare systems in delivering better heart failure prevention and treatment.

Patient complexity and risk factor control among multimorbid patients with type 2 diabetes: results from the R2D2C2 study

BACKGROUND

Among patients with type 2 diabetes, it is not known whether risk factor control is better or worse for those who also have heart disease, depression, multiple other comorbidities, and associated management challenges.

OBJECTIVE

To examine the relationship between this complex constellation of multimorbidities, adherence to treatment and risk factor control among patients with type 2 diabetes, independent of regimen intensity.

RESEARCH DESIGN

Observational cross-sectional study.

SUBJECTS

A total of 1314 patients with diabetes from the Reducing Racial Disparities in Diabetes Coached Care (R2D2C2) Study.

MEASURES

A composite cardiometabolic risk factor profile was the dependent variable. Independent variables included a composite measure of patient complexity, patient-reported adherence to treatment, history of coronary heart disease (CHD), and intensity of medication regimen.

RESULTS

A higher proportion of the most complex patient-reported problems with adherence compared with the least complex patients (83.5% vs. 43.3%, P<0.001). Compared with those without a history of CHD, fewer patients with CHD-reported problems with medication adherence (59.3% vs. 69.3%, P<0.01) and had better risk factor control, independent of complexity and regimen intensity. Better risk factor control was independently associated with less patient complexity (P=0.003) and to history of CHD (P=0.01).

CONCLUSIONS

The presence of a complex illness profile was associated with poorer control of risk factors. Those with CHD were more adherent to treatment and had better risk factor control. The occurrence of CHD may present an opportunity for physicians to emphasize risk factor management. Diabetes patients with a complex illness profile may be at highest risk for cardiovascular events and in greatest need of prevention of cardiac disease.

TRIAL REGISTRATION

Clinicaltrial.gov identifier: NCT01123239.

The association between market availability and adherence to antihypertensive medications: an observational study

BACKGROUND

High adherence to angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) reported in observational studies has frequently been attributed to improved tolerability. However, these agents are also relatively new to the market compared to other antihypertensive medications. We aimed to determine if an association exists between adherence and market availability of a specific antihypertensive agent.

METHODS

This retrospective cohort study used administrative data from Saskatchewan, Canada. Subjects were ≥40 years of age and received a new antihypertensive medication between 1994 and 2002. The primary outcome was the proportion of subjects achieving optimal adherence (≥80%) at 1 year, stratified by antihypertensive medication class and the year of availability. Adherence was measured using the cumulative mean gap ratio.

RESULTS

A total of 36,214 subjects met the inclusion criteria. Optimal adherence was observed in 4987 of 8623 (57.8%) subjects receiving ACEIs and 1013 of 1600 (63.3%) subjects receiving ARBs, but adherence appeared inconsistent when examined within each antihypertensive class. A pattern of increasing mean adherence was observed according to availability in the ACEI subgroup (Spearman r = 0.82; P = 0.007) but not the ARB subgroup (Spearman r = 0.41; P = 0.49). However, the association between availability and optimal adherence converged when ARB and ACEI users were combined (Spearman r = 0.85, P < 0.001).

CONCLUSIONS

Optimal adherence with ACEIs and ARBs compared to other antihypertensive agents may be associated with their relative availability. To what extent optimal adherence is also associated with improved tolerability, as currently believed, remains to be determined.

Non-adherence in type 2 diabetes: practical considerations for interpreting the literature

The rising prevalence of type 2 diabetes poses a serious threat to human health and the viability of many health care systems around the world. Although several prescription medications can play a vital role in controlling symptoms and preventing complications, non-adherence to these therapies is highly prevalent and has been linked to increases in morbidity, mortality, and health care costs. Although a vast array of significant adherence predictors has been identified, the ability to explain or predict non-adherence with known risk-factors remains poor. Further, the definitions, outcomes, and various measures used in the non-adherence literature can be misleading for the unfamiliar reviewer. In this narrative review, a practical overview of important considerations for interpreting adherence endpoints and measures is discussed. Also, an organizational framework is proposed to consider published adherence interventions. This framework may allow for a unique appreciation into areas of limited knowledge and thus highlights targets for future research.

Nonadherence to statin therapy: discontinuation after a single fill

INTRODUCTION

Adherence to statin medications is known to be suboptimal. What is less known is the rate of discontinuation immediately after therapy has been initiated. The primary objective of this study was to determine what proportion of nonadherence in the first year of statin therapy was due to discontinuation after a single fill.

METHODS

We identified new statin users within low-risk (hypertension [HTN]), medium-risk (coronary heart disease [CHD]), and high-risk (heart failure [HF]) cohorts during a 9-year period. All data came from administrative health care databases.

RESULTS

The cohorts included 9445 HTN, 1141 CHD, and 778 HF patients. At 1 year, the proportions of patients with less than 80% adherence to statin medications were 47.9% (HTN), 38.3% (CHD), and 50.0% (HF). Among all patients classified as nonadherent at 1 year, 18.0% of HTN, 16.3% of CHD, and 28.2% of HF patients had discontinued statin medications after only 1 dispensation. Within 3 months of starting statin therapy, 29.7%, 40.3%, and 47.5% of all nonadherent HTN, CHD, and HF patients, respectively, had discontinued the new statin medication. After regression analysis, the only independent covariate that was consistently associated with discontinuation after a single fill was receiving fewer medical follow-up visits.

CONCLUSIONS

Immediate discontinuation after a single fill contributes disproportionately to statin nonadherence. This suggests an important time to prevent nonadherence is within the first month of treatment initiation.

First-fill medication discontinuations and nonadherence to antihypertensive therapy: an observational study

BACKGROUND

Medication nonadherence is a barrier to successfully managing hypertension, but little is known about the contribution that immediate discontinuations have on antihypertensive (AHT) nonadherence. The purpose of this study was to determine the proportion of new AHT users who discontinue after a single dispensation, and to examine potential predictors of these discontinuations.

METHODS

This retrospective cohort study utilizing linked administrative data from Saskatchewan, Canada. Subjects were ≥40 years of age and received a new AHT between 1994-2002. The primary end point was the proportion of subjects who discontinued their AHT after the first dispensation (first-fill discontinuation). The proportion of nonadherence attributed to first-fill discontinuations was then calculated. Multivariate regression identified factors associated with first-fill discontinuations.

RESULTS

52,039 subjects were included in the analyses. Mean age was 59.4 (s.d. 12.5) years, and 42% were male. Overall, 25,812/52,039 (50%) subjects were nonadherent at 1 year; first-fill discontinuations accounted for 39.1% (10,081/25,812) of this nonadherence. Approximately 20% (10,081/52,039) of all subjects discontinued all AHT therapy after the first fill. A higher chronic disease score (adjusted odds ratio (OR) 1.09, 95% confidence interval (CI) 1.08-1.11) and antidepressant medication usage during the observation year (adjusted OR 1.17, 95% CI 1.09-1.26) was associated with increased risk for first-fill discontinuations. Older age, starting AHT therapy after 1994, frequent physician visits, or use of a statin, acetylsalicylic acid, warfarin or antihyperglycemic during the observation year was associated with a lower risk for first-fill discontinuations.

CONCLUSION

A substantial proportion of nonadherence to AHT medications is due to discontinuations after only a single dispensation.

Long-term persistence with the immunomodulatory drugs for multiple sclerosis: a retrospective database study

BACKGROUND

Immunomodulatory drugs (IMDs) for multiple sclerosis (MS) have been available in Canada since 1995 and are currently the most commonly prescribed treatment for MS. However, relatively little is known about the long-term persistence to these drugs.

OBJECTIVE

The purpose of this study was to describe patterns of, and factors associated with, long-term persistence to the first-line IMDs in an MS population in British Columbia, Canada.

METHODS

Study data were collected from the British Columbia MS database. Adults from British Columbia with definite MS who were prescribed a first-line IMD (interferon beta-1b, interferon beta-1a [subcutaneous and intramuscular], and glatiramer acetate) from January 1, 1995, through December 31, 2008, were eligible for the study. Time to discontinuation of use of all first-line IMDs (ie, switching among IMD therapies was allowed) and the initially prescribed IMD was assessed using Kaplan-Meier survival analysis and multivariate Cox regression.

RESULTS

A total of 1896 patients were included. Mean (SD) age was 40.2 (9.5) years, and 75.1% were female. Median time to discontinuation of all first-line IMD therapies was 6.3 years (95% CI, 5.8-6.7 years). Patients with a longer disease duration and higher level of disability were at higher risk for discontinuing use of the IMDs. Age, sex, and the initial IMD were not associated with discontinuation. Persistence appeared to have decreased over time (P = 0.01 for trend). Median time to discontinued use of, or switching from, the initially prescribed IMD was 2.9 years (95% CI, 2.5-3.2 years).

CONCLUSIONS

Approximately half of the MS patients discontinued use of their IMD within 6 years. It is unknown whether this persistence is adequate because uncertainties remain regarding the optimal level of persistence to the IMDs. Further investigation is needed to examine why some individuals are more at risk for discontinuation of IMD therapy and why, in contrast to other chronic diseases, persistence to IMDs in patients with MS has not improved over time.

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.

Poor prognosis in chronic heart failure patients with reduced ejection fraction in China

Most Chinese cardiologists are challenged by the high mortality rate of heart failure (HF) in patients with reduced ejection fraction in China. This study was designed as a single-center, retrospective study. All consecutive HF patients with left ventricular ejection fraction (LVEF) ≤ 45% from January 1, 2007, to December 31, 2009, were enrolled. The primary outcome was all-cause mortality. The secondary outcome was all-cause mortality or the first cardiovascular readmission event. A total of 187 patients comprised the study population, classified into two groups: LVEF ≤ 35% (n=83) and LVEF 36% to 45% (n=104). The median follow-up was 18 months (2-41 months). All-cause mortality was 27% among patients with LVEF ≤ 35%, as compared with 14% among those with LVEF 36% to 45% (P=.025). All-cause mortality or first cardiovascular readmission rates were 53% and 32% among patients with LVEF ≤ 35% and 36% to 45% (P=.003), respectively. The predictors of all-cause mortality were advanced age and New York Heart Association functional class, chronic kidney disease, oral β-blockers, and statins at discharge. The prognosis of chronic HF patients with LVEF ≤ 45% was poor in China, especially for patients with LVEF ≤ 35%. Cardiologists should provide further efforts to improve the prognosis of HF in Chinese patients.

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

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

Increased use of acid-suppressing drugs before the occurrence of ischemic events: a potential source of confounding in recent observational studies

STUDY OBJECTIVE

To determine if the use of acid-suppressing drugs is increased before the occurrence of ischemic events.

DESIGN

Population-based, nested case-control analysis.

DATA SOURCE

Administrative databases in Saskatchewan, Canada.

PATIENTS

Cases were 1612 patients (aged ≥ 40 yrs) who started a first-ever antihypertensive drug between January 1, 1994, and December 31, 2003, and were hospitalized for a first ischemic heart event of either myocardial infarction (1002 patients) or unstable angina (610 patients); five control patients were matched to each case patient by age, sex, and year of first antihypertensive prescription (8060 controls).

MEASUREMENTS AND MAIN RESULTS

Within the case and control groups, we calculated exposure to acid-suppressing therapy, defined as proton pump inhibitors (PPIs) or histamine(2)-receptor antagonists (H(2)RAs), within 90 days leading up to the event. Exposure to acid-suppressing therapy was higher among cases than controls (15.3% [246/1612] vs 10.4% [837/8060], adjusted odds ratio [AOR] 1.26, 95% confidence interval [CI] 1.06-1.49, p<0.009). Exposure to each acid suppressant was similarly higher among cases than controls: H(2)RA users (11.7% [188/1612] vs 8.4% [678/8060], AOR 1.21, 95% CI 1.00-1.46, p<0.048) and PPI users (4.0% [64/1612] vs 2.2% [179/8060], AOR 1.32, 95% CI 0.95-1.84, p=0.094). Use of other drugs was also significantly increased during this period.

CONCLUSIONS

Use of acid-suppressing drugs increased before the occurrence of ischemic events regardless of the type (PPI or H(2)RA) or whether other drugs, such as clopidogrel, were concurrently administered. In addition, significant increases in overall drug use were observed during this time frame, suggesting that many patients exhibit warning signs before an acute hospitalization. Thus, PPI use before the occurrence of ischemic events may simply be a marker of unmeasured and uncontrolled confounding in observational studies that have implicated a PPI-clopidogrel interaction as a cause of recurrent ischemic events.

A pragmatic cluster randomized trial evaluating the impact of a community pharmacy intervention on statin adherence: rationale and design of the Community Pharmacy Assisting in Total Cardiovascular Health (CPATCH) study

BACKGROUND

Traditional randomized controlled trials are considered the gold standard for evaluating the efficacy of a treatment. However, in adherence research, limitations to this study design exist, especially when evaluating real-world applicability of an intervention. Although adherence interventions by community pharmacists have been tested, problems with internal and external validity have limited the usefulness of these studies, and further well-designed and well-conducted research is needed. We aimed to determine the real-world effectiveness of a community pharmacy adherence intervention using a robust study design. This novel design integrates cluster randomization and an outcome evaluation of medication adherence using a population-based administrative data source in the province of Saskatchewan, Canada.

METHODS/DESIGN

Community pharmacies from across the province of Saskatchewan, Canada were randomized to deliver an adherence intervention to their patients or usual care. Intervention pharmacies were trained to employ a practical adherence strategy targeted at new users of statin medications. While randomization and implementation of the intervention occurred at the community pharmacy level, the outcome analysis will occur at the level of the individual subjects. The primary outcome is the mean statin adherence among all eligible new users of statin medications. Secondary outcomes include the proportion of new statin users who exhibit adherence>or=80%, and persistence with statin use.

DISCUSSION

This novel study design was developed to combine the rigor of a randomized trial with a pragmatic approach to implementing and capturing the results in a real-world fashion. We believe this approach can serve as an example for future study designs evaluating practice-based adherence interventions.

TRIAL REGISTRATION

ClinicalTrials.gov no. NCT00971412.