A real-world analysis of pharmacotherapy adherence and the factors influencing it in Serbia: a nationwide, population-based, cross-sectional study

Introduction

Monitoring the pharmacotherapy adherence in society is crucial for identifying occurance and causes of potential inadequate use of drugs and inform providers about the need for better customer counceling. It is necessary component of the strategic planning of the quality of healthcare services. This population- based study aimed to assess the medication intake adherence in the Republic of Serbia and the individual factors and health system variables influencing its pattern.

Methods

We applied a cross-sectional approach to study medication intake adherence using a secondary analysis of the latest 2019 Serbian National Health Survey data. The statistical modeling of the pharmacotherapy adherence incorporated sociodemographic data, self-reported disease, and lifestyle behavior.

Results

In 2019, in the representative sample of 12,066 adults in Serbia, requiring prescribed medicine, 49.8% did comply with the prescribed drugs, and 50.2% do not. Participants who adhered to prescribed medication were significantly (p < 0.001) older (62.4 ± 14 years), predominantly female (55.3%), had secondary education (48.5%), resided in southern and eastern parts of Serbia (55.5%), and belonged to the lowest income quintile (21.4%). The participants most often take prescribed drugs for hypertension (64.1%) and lower back pain (30.5%), while around 20% take medication for coronary disease, diabetes mellitus, and high blood cholesterol. About 85-92% of participants with financial or general difficulties using prescribed medication.

Conclusion

There is poor medication intake adherence to prescribed medication in Serbia. Gender, age, and region determine the adherence. Also, health-related and healthcare system-related factors impact the use of prescribed medication. Study findings can inform planning the counceling interventions in the target groups where improving medication adherence is necessary, as well as to enhance training of healthcare providers about pharmacotherapy adherence.

Are diet diaries of value in recording dietary intake of sugars? A retrospective analysis of completion rates and information quality

Objectives Current guidance recommends that dental practitioners should routinely give dietary advice to patients, with diet diaries as a tool to help diet assessment. We explored patients' compliance with diet-diaries usage in a paediatric clinic within a teaching hospital setting, where remuneration is not an issue. Objectives were to investigate associated factors affecting diet diaries return rate and the information obtained from returned diaries.Methods A retrospective study of 200 randomly selected clinical records of children aged 5-11 years who had received diet analysis and advice as part of a preventive dental care programme at a dental teaching hospital between 2010 and 2013. Clinical records, with a preventive care pro forma, were included in the study. Data on social and family history, DMFT-dmft, oral hygiene practices, dental attendance and dietary habits were obtained and compared with information given in completed diet-diaries. A deductive content analysis of returned diet-diaries was undertaken using a pre-developed coding scheme.Results Of 174 complete records included in this study, diet diaries were returned in 60 (34.5%) of them. Diet diaries were more likely to be returned by those children who reported that they regularly brushed their teeth (P <0.05), and those who came from smaller families (P <0.05). Content analysis of diet diaries enabled the identification of harmful types of foods and drinks in 100% of diaries. General dietary issues, frequency and between-meals intake of sugars were also all captured in the majority of diaries (95.0%, N = 56). Information on sugar amount (53.0%, N = 32), prolonged-contact with teeth (57.0%, N = 34) and near bedtime intakes (17.0%, N = 28) was reported in fewer diaries.Conclusions The return rate of diet-diaries in this setting was low, and associated with patients' demographic and oral health characteristics. Returned diet-diaries showed a varied range of missing important dietary information, such as sugar amount, which appears to compromise their validity as a diet assessment tool. Development of a more reliable and acceptable dietary assessment tool for use in the dental setting is needed.

Determination of Unclaimed Prescriptions at an Outpatient Department, Songklanagarind Hospital

Unclaimed prescriptions are an initial indication of noncompliance. Although the patients receive the best treatment, they may fail to take their medicines. As a result, the illness may not be relieved and this can lead to hospitalization or use of emergency services. This study was conducted to determine the characteristics and reasons for unclaimed prescriptions in a 680-bed and tertiary care center from July to October 1997. Patients' data were collected from medical records and from questionnaires that asked for the reasons prescriptions were not claimed. During the four-month period, 695 unclaimed prescriptions were identified, accounting for approximately 0.67% of all prescriptions filled. Results showed that patients least likely to claim a prescription included women, those who visited the hospital during official hours, those who had chronic disease, and those who went to see internal medicine physicians. Three most common diseases were those involving respiratory system (8.6%), musculoskeletal system (6.3%), and genitourinary system (6.0%). More than half (56.5%) were treated with the essential drugs. Neuromuscular agent was the most frequent drug class of unclaimed prescriptions, followed by respiratory agent, dermatological agent, and vitamins and minerals. Of the 695 patients, 152 patients responded to the questionnaires. Sixty-one patients indicated that they had received their medications later on and, therefore, were excluded from the analysis. Thus, 61 questionnaires were analyzed. The most important reason patients did not claim their prescriptions was cost (22.0%). The next most frequently mentioned reasons were forgetfulness (12.1%), business (11.0%), and lack of communication (8.8%). These patients need to be counseled about the importance of taking their medicines. In addition, health care providers should develop strategies to improve patient compliance with their medications.

Multiple Episodes of Phenytoin Toxicity in an Elderly Patient

Objective:

To describe a case involving multiple episodes of phenytoin toxicity leading to hospitalization over a period of 13 months in an elderly man and to review the risk factors contributing to drug toxicity in this individual.

Case Summary:

A 70-year-old African-American man presented four times with phenytoin toxicity manifested as ataxia and bilateral nystagmus, leading to multiple hospitalizations over 13 months. Each time the phenytoin concentration was dangerously high, and each time the symptoms of toxicity resolved without serious consequences when phenytoin therapy was temporarily stopped. Each toxicity episode was characterized by a variety of risk factors.

Discussion:

The risk factors contributing to the drug toxicity in this elderly individual are discussed.

Conclusions:

This case illustrates that age is not an independent risk factor for adverse drug reactions and that appropriate and comprehensive geriatric pharmaceutical care approaches are necessary to prevent and/or reduce the incidence of these reactions.

Zidovudine Compliance as Measured by Different Methods in an HIV Ambulatory Clinic

Objective:

To measure and compare medication compliance by patient reports, pill counts, physician assessments, and electronic monitoring with the Medication Event Monitoring System (MEMS) in patients infected with HIV.

Methods:

Five patients monitored in a Veterans Affairs Medical Center HIV clinic were dispensed zidovudine for 3 months in MEMS vials. Zidovudine was refilled every month, at which time MEMS data were retrieved and pill counts were performed. Medication compliance surveys requesting the number of missed doses were also administered to patients and their physicians every month for 3 months.

Results:

Compliance assessments were as follows: patient report 80–100%, physician assessment less than 30–100%, pill counts 50–100%, and MEMS 9–100%. MEMS identified one patient's misunderstanding of zidovudine dosing. Three patients removed zidovudine from MEMS vials and placed the medication in a smaller vial for easy transport, thereby decreasing the usefulness of MEMS data.

Conclusions:

A combination of compliance assessment tools produces a more accurate representation of zidovudine dosing and facilitates identification of patient dosing errors. Use of multiple compliance tools, including MEMS data, during patient counseling may be an effective strategy for enhancing medication compliance.

Improving Medication Compliance: A Practical Intervention

Objective:

To examine the effect of a device specifically designed to improve patient medication compliance. This device, the Counter Cap (CC), is a prescription vial closure that mechanically indicates when the bottle was last opened, presumably to take a dose of medication. The primary objective was to assess the effect of the CC on patient compliance as measured by refill behavior.

Method:

An experimental pretest-posttest control group design was used to study the effect of the CC on patient compliance. A systematic sampling technique was used to assign subjects to the experimental and control groups. Patient compliance was assessed through prescription refill behaviors measured over a six-month period (three months pre-CC and three months post-CC).

Results:

A full six months of prescription refill data were analyzed for 186 of 337 patients from 21 pharmacies. Patients in the experimental group (n = 88) demonstrated significantly improved (F = 4.44, p = 0.0366) medication compliance and less variability in the number of days of departure from the ideal compliance rate (F = 6.89, p = 0.009) over the control group (n = 98) as measured by refill behavior.

Conclusions:

The CC proved to be an inexpensive means to improve medication compliance as defined by this investigation.

Topical Review: Theoretical Frameworks in Pediatric Adherence-Promotion Interventions: Research Findings and Methodological Implications

OBJECTIVE

To summarize the guiding theoretical frameworks included in pediatric adherence-promotion interventions and characterize targeted domains using the theoretical domains framework (TDF), a standardized system developed by adult behavior change researchers.

METHODS

A systematic review of PubMed, PsycINFO, and CINAHL databases identified 47 articles describing pediatric adherence-promotion interventions. Data extraction was completed independently by two authors. Targeted intervention domains were classified using the TDF.

RESULTS

The majority of interventions did not cite a guiding theoretical framework or cited multiple theories with overlapping domains. The TDF was a reliable categorization system and suggested that pediatric adherence-promotion interventions most commonly target knowledge, skills, and social influences.

CONCLUSIONS

Pediatric adherence-promotion interventions draw from a variety of theories and lack a consistent language for describing targeted domains. The adapted TDF proposed here is one method of reducing variability in intervention development and reporting and may facilitate efforts to identify the processes that improve adherence.

Medication adherence: a complex behavior of medication and illness beliefs

Medication nonadherence is a public health issue costing an estimated US$290 billion in the USA. The paper discusses the key facts known about medication nonadherence based on past research including predictors, measurements and interventions; and the recent research developments in medication nonadherence. Recent research has shown the need to approach medication adherence as a complex behavior of a patient’s beliefs regarding illnesses and medications; and how it varies across each medication for each patient. The paper concludes with the call to develop tailored interventions that match with the reasons for nonadherence for each medication.

Pharmacist counseling to cardiac patients in Israel prior to discharge from hospital contribute to increasing patient's medication adherence closing gaps and improving outcomes

BACKGROUND

Medication non adherence is a global epidemic perplexing phenomenon that is eminent, but not insurmountable. Our first objective was to explore whether providing pharmacist's counseling to cardiac patients prior to discharge can increase patient's medication adherence, and our second objective was to assess whether better medication adherence leads to reduction of hospital readmissions.

METHODS

Observational study was conducted among diagnosed cardiac patients using an intervention strategy at discharge from two hospitals in Israel; The Nazareth and the Haemek hospital. 74 patients were recruited between January 2010 and January 2011. Two separate groups were selected; intervention group: 33 patients who prior to discharge received nurse, pharmacist interventions, and control group: 41 patients who had received the nurse and hospital discharge counseling only.

RESULTS

Regression analysis for examining the first objective reflected significant effect when having a pharmacist interventions, which explains the increasing 11.6% of the variance in medication adherence, [F change (1,73) = 9.43, p < 0.003]. Stepwise regression analysis for examining the second objective demonstrated that the relation between medication adherence and readmissions was insignificant [F (1,73) = 9.43, n.s].

CONCLUSIONS

While physicians and nurses can have an impact on improving adherence, pharmacists have demonstrated the ability to inform, problem-solve and provide performance support directly to patients.

Determinants of different types of medication non-adherence in cholesterol lowering and asthma maintenance medications: a theoretical approach

OBJECTIVE

To quantify and compare the determinants of different types of medication non-adherence in cholesterol lowering and asthma maintenance medications using a theoretical approach.

METHODS

Study design was online cross sectional survey. A conceptual framework was developed using Andersen's Behavioral Model and Leventhal's Common Sense Model to understand the determinants of medication non-adherence. Regression analyses were used to test the models for predicting non-adherence.

RESULTS

The models based on Andersen's Behavioral Model and Leventhal's Common Sense Model were significant. While predisposing factors such as treatment convenience and beliefs in medications were significant in cholesterol lowering medications, need factors such as illness perceptions and disease severity were significant in asthma maintenance medications. Among the enabling factors, self efficacy was a significant predictor in both cholesterol lowering and asthma maintenance medications.

CONCLUSION

Different determinants explained different types of non-adherence and suggest the need to consider different types of non-adherence for different medications as well as different determinants for each type of non-adherence.

PRACTICE IMPLICATIONS

Identifying determinants of different types of non-adherence can help health care professionals develop targeted interventions which can be more successful than the current model of single and generalized interventions to reduce non-adherence.

Beliefs about medications: a questionnaire survey of people with rheumatoid arthritis

OBJECTIVES

To investigate beliefs about medications held by people with rheumatoid arthritis (RA), what factors are related to these specific medication beliefs, and whether these beliefs influence adherence.

METHODS

The design was a cross-sectional postal questionnaire survey of people with RA. The Beliefs about Medicines Questionnaire was used to assess beliefs about the necessity of medication and concerns about it. Questionnaires were mailed to 600 out-patients with RA.

RESULTS

The response rate was 57.3%. Most (74.3%) respondents agreed or strongly agreed that their arthritis medications are necessary for their health. However, 47.4% were concerned about potential adverse consequences. The overall necessity score (mean 19.2, s.d. 3.13) was higher than the concerns score (mean 15.84, s.d. 3.53; P<0.001). Greater disability was associated with higher necessity scores (r = 0.36; P<0.001). Greater helplessness correlated with higher concerns scores (r = 0.49; P<0.001). There was no association between RA knowledge and beliefs about medications (necessity scale, r = 0.02, P = 0.66; concerns scale, r=-0.08, P = 0.14). Concerns scores for non-adherent participants (mean 17.88, s.d. 3.29) were higher than for the adherent group (mean 15.64, s.d. 3.51; P = 0.002).

CONCLUSIONS

Most people with RA have positive beliefs about the necessity of their medication. However, levels of concern are high and associate with helplessness and non-adherence. The Beliefs about Medicines Questionnaire may identify people at risk of poor adherence and provide a focus for patients to discuss their beliefs, providing opportunities to improve adherence.

Patient adherence to treatment: three decades of research. A comprehensive review

Low compliance to prescribed medical interventions is an ever present and complex problem, especially for patients with a chronic illness. With increasing numbers of medications shown to do more good than harm when taken as prescibed, low compliance is a major problem in health care. Relevant studies were retrieved through comprehensive searches of different database systems to enable a thorough assessment of the major issues in compliance to prescribed medical interventions. The term compliance is the main term used in this review because the majority of papers reviewed used this term. Three decades have passed since the first workshop on compliance research. It is timely to pause and to reflect on the accumulated knowledge. The enormous amount of quantitative research undertaken is of variable methodological quality, with no gold standard for the measurement of compliance and it is often not clear which type of non-compliance is being studied. Many authors do not even feel the need to define adherence. Often absent in the research on compliance is the patient, although the concordance model points at the importance of the patient's agreement and harmony in the doctor-patient relationship. The backbone of the concordance model is the patient as a decision maker and a cornerstone is professional empathy. Recently, some qualitative research has identified important issues such as the quality of the doctor-patient relationship and patient health beliefs in this context. Because non-compliance remains a major health problem, more high quality studies are needed to assess these aspects and systematic reviews/meta-analyses are required to study the effects of compliance in enhancing the effects of interventions.

Using focus groups to identify barriers to drug use in patients with congestive heart failure

STUDY OBJECTIVE

To explore barriers to adherence to drug therapy identified by patients with congestive heart failure (CHF).

SETTING

University-associated heart failure clinic and a family practice clinic.

PATIENTS

Twenty-six patients with CHF.

INTERVENTION

Four focus group sessions.

MEASUREMENTS AND MAIN RESULTS

Participants were asked to describe how their lives changed as a result of developing CHF and the challenges they face when taking drugs for the condition. In the second half of each session, participants were asked for their opinions regarding various teaching and memory aids for improving adherence with therapy. They recognized the value of these aids and often created their own when health care professionals did not supply them. Transcripts were reviewed and comments grouped to identify patient-perceived barriers to adherence. The disease placed significant limitations on lifestyle. Furosemide had dramatic effects on daily activities, and some patients altered the dosing schedule to accommodate their plans. Influences on adherence were generalized into five themes: confidence in health care providers; their own knowledge regarding the disease and drugs used to treat it; previous experience with drugs; support from family and friends; and ease of communication with health care professionals.

CONCLUSION

Focus groups are an effective and efficient method to explore patients opinions of barriers to drug therapy adherence. Such information can have a direct impact on management of patients with CHF. Information gathered in this study will be used to construct a survey to measure barriers to drug adherence and design interventions to improve adherence.

The role and contribution of leukotrienes in asthma

LEARNING OBJECTIVES

Reading this article will reinforce the reader's knowledge of the biochemistry and pharmacology of leukotrienes (LTs), including the enzymes and cells involved in their synthesis, the receptors that mediate their biologic effects, and the evidence that cysteinyl leukotrienes (CysLT) may play an important role in asthma. The 5-lipoxygenase inhibitors, 5-lipoxygenase-activating protein antagonists, and CysLT receptor antagonists are three classes of LTs modulators now in clinical use. The effects of these agents in clinical models of asthma induced by allergens, exercise, and aspirin and in multicenter asthma trials are reviewed.

DATA SOURCES

Key papers published in peer-reviewed journals.

STUDY SELECTION

Key papers published in peer-reviewed journals.

CONCLUSIONS

The pharmacology of these new medications and experience in clinical trials suggest that they may play a therapeutic role in the treatment of asthma.

Meeting Patient Needs in Asthma Education

Preventable drug-related morbidity and mortality in asthma patients is related to inappropriate behavior by both patients (noncompliance) and health care professionals (prescribing and monitoring). Compliance is the crucial factor for success of a therapeutic regimen. Impacting factors have been identified as skills in administration techniques, interactions between patients and providers, and patient expectations. Beneficial effects on the cost of care and quality of life are gained from increasing level of care available to patients. Intensive education including development of self-monitoring skills, early treatment of exacerbations, and access to regular outpatient and Emergency Room care have been shown to be effective.

Patient decision making. The missing ingredient in compliance research

Medical noncompliance has been identified as a major public health problem that imposes a considerable financial burden upon modern health care systems. There is a large research record focusing on the understanding, measurement, and resolution of noncompliance, but it is consistently found that between one third and one half of patients fail to comply with medical advice and prescriptions. Critically absent from this research record has been the patient's role in medical decision making. For patients, particularly those with chronic illnesses, compliance is not an issue: they make their own reasoned decisions about treatments based on their own beliefs, personal circumstances, and the information available to them. The traditional concept of compliance is thus outmoded in modern health care systems, where chronic illness and questioning patients predominate.