All that glisters is not gold: a comparison of electronic monitoring versus filled prescriptions--an observational study

Relationship between electronically monitored adherence to direct oral anticoagulants and ischemic or hemorrhagic events after an initial ischemic stroke-A case control study

BACKGROUND

Patients with atrial fibrillation (AF) have a high risk for recurrent clinical events after an ischemic stroke. Direct oral anticoagulants (DOAC) are prescribed for secondary prevention. Adherence to DOAC is crucial mainly because of their short elimination half-life. Non-adherence to DOAC can negatively impact patients' outcomes. The relationship between (non-)adherence and recurrent clinical events is unknown in AF patients after initial stroke. We investigated adherence to DOAC in stroke survivors with AF who were included in the MAAESTRO study at the University Hospital Basel, Switzerland, between 2008 and 2022.

METHODS

This study is a secondary analysis of data from MAAESTRO with a matched nested case-control design and 1:2 ratio. DOAC intake was measured with a small electronic device (Time4MedTM). We defined two arbitrary intervals of 17 days and 95 days as the longest time spans with electronic monitoring data per patient to maximize the number of participants with adequate amount of observation time available for analysis. Taking and timing adherence were calculated retrospectively i.e., prior to the recurrent event for cases. Trendline analysis of adherence over 95 days was calculated. Linear regression analysis was performed after adjusting for the co-variables age and daily pill burden. Sensitivity analysis was performed with controls for intervals in the reverse direction (prospectively).

RESULTS

We analyzed 11 cases and 22 matched controls (mean age: 75.9 ± 9.2 years vs. 73.1 ± 8.4 years; n.s.) with similar stroke characteristics (NIHSS, mRS, MoCA) and 36.4% women in each group. Mean adherence values were high and similar between cases and controls (95 days taking: 87.0 ± 18.9% (cases) vs. 90.8 ± 9.8% (controls), n.s.; similar values for timing adherence). Six hemorrhagic and five ischemic events had occurred. Compared to controls, a significantly higher 95 days taking adherence was observed for hemorrhagic events (96.0 ± 5.0% (cases) vs. 88.1 ± 11.5% (controls); p<0.01) and a significantly lower 95 days taking adherence was observed for ischemic events (75.7 ± 24.8% (cases) vs. 94.2 ± 6.2% (controls), p = 0.024). Values for timing adherence were similar. A non-significant downward linear trend of adherence was observed over 95 days independently of the clinical events. The sensitivity analysis showed that the direction of the interval had negligible impact on the 95 days adherence.

CONCLUSION

Because recurrent ischemic events after an AF-related stroke were associated with low adherence to DOAC <76%, adherence enhancing interventions seem crucial in anticoagulated AF-patients. However, AF-patients with high adherence might benefit from a regular re-assessment of the bleeding risk as hemorrhagic complications were associated with adherence to DOAC >96%.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03344146.

Intra-Individual Variability in Self-Reported Use of Non-Steroidal Anti-Inflammatory and Analgesic Medicines Depending on Mode of Data Collection - Observations from the Population Study of Women in Gothenburg, Sweden

Background

Self-report by questionnaire is one of the main methods to collect data on drug utilization. There are several modes of data collection by questionnaire, differing in the way of delivering the questionnaire to respondents and in the administration of the questions, both influencing the recall and participation rates. The aim of this study was to compare different modes of data collection for self-reported use of non-steroidal anti-inflammatory (NSAIDs) and analgesic medicines.

Methods

Data on 573 women (38 or 50 years) were retrieved from the Population Study of Women in Gothenburg. Data on medicine use were collected using two different modes: (1) a self-administered questionnaire with closed-ended medicine-specific questions; and (2) an interviewer-administered questionnaire with open-ended questions. Cohen’s kappa statistics were applied to assess the agreement of the two modes.

Results

The proportion of participants that reported use of NSAIDs and analgesics was higher with the self-administered questionnaire compared with the interviewer-administered questionnaire (69.3% vs 58.5%, p <0.001). The overall agreement between the two modes of data collection was fair (Ⱪ=0.27), ranging from none for antimigraine preparations to fair (Ⱪ=0.36) for NSAIDs. A higher proportion of the participants aged 38 years reported use of NSAIDs and analgesics compared with the 50-year olds. In the regression model using data from the self-administered questionnaire, all four categories of bodily pain were significant predictors for use of NSAIDs and analgesics. The most severe reported bodily pain was the only significant predictor in the model using data from the interviewer-administered questionnaire.

Conclusion

This study showed that use of a self-administered questionnaire with closed-ended medicine-specific questions identified more users of NSAIDs and analgesic medicines compared with an interviewer-administered questionnaire with open-ended questions. Reported use according to the self-administered questionnaire was also more strongly associated with experienced pain.

A Systems-Level Approach to Improving Medication Adherence in Hypertensive Latinos: a Randomized Control Trial

BACKGROUND

Despite numerous interventions targeting medication adherence in patients with uncontrolled hypertension, practice-based trials in Latino patients are scant.

OBJECTIVE

To evaluate the effect of a systems-level adherence intervention, delivered by medical assistants (MAs), versus a comparison condition on medication adherence and blood pressure (BP) in 119 hypertensive Latino patients who were initially non-adherent to their antihypertensive medications.

STUDY DESIGN

Randomized control trial.

PARTICIPANTS

Patients (50% women; mean age, 61 years) were recruited from April 2013 to August 2015 in a community-based practice in New York.

INTERVENTION

Systems-level approach that included an office system component built into the electronic health record and a provider support component consisting of nine MA-delivered health coaching sessions for improving medication adherence. The comparison group received the standard health coaching procedures followed at the clinic.

MAIN OUTCOME MEASURES

The primary outcome was rate of medication adherence measured by an electronic monitoring device (EMD) across 6 months. The secondary outcomes were self-reported medication adherence measured by the eight-item Morisky Medication Adherence Scale (MMAS-8) and BP reduction from baseline to 6 months.

KEY RESULTS

Adherence as measure by EMD worsened for both groups (p = 0.04) with no between-group difference (- 9.6% intervention and - 6.6% control, p = 0.66). While systolic BP improved in both groups, the difference between groups was not significant (- 6 mmHg in intervention vs. - 2.7 mmHg in control, p = 0.34). In contrast, the intervention group had a greater improvement in self-reported adherence (mean change 1.98 vs. 1.26, p = 0.03) when measured using the MMAS-8.

CONCLUSIONS

Among Latinos with poorly controlled BP who were non-adherent to their antihypertensive medications, a systems-level intervention did not improve adherence as measured by EMD nor blood pressure. However, many patients reported challenges to using the EMD. Improvements in self-reported adherence suggest that this measure captures different aspects of adherence behavior than EMD.

CLINICAL TRIAL REGISTRATION

NCT03560596.

Patients' Online Information-Seeking Behavior Throughout Treatment: The Impact on Medication Beliefs and Medication Adherence

Research on the longitudinal impact of using the internet as an information source on patients' beliefs and medication adherence is scarce. Chronic patients (N = 107) from six hospitals were surveyed to longitudinally explore their online information seeking behavior throughout treatment (i.e., before the consultation about their newly prescribed medication in the initiation phase and after six months in the implementation phase) and how this affects their medication beliefs (concerns and necessity) and medication adherence after three weeks (T1) and six months (T2). Most patients (79%) used the internet. Patients who used the internet before the consultation reported to have more concerns about their medication at T1 and T2 compared to those who did not. Moreover, patients who used the internet throughout treatment valued their concerns higher than the necessity after six months (T2). Patients who used the internet after the consultation reported to be more non-adherent after three weeks (T1) compared to those who did not. Because of the longitudinal nature of this study, we were able to pinpoint in which treatment phase patients' online information seeking behavior is particular relevant in affecting patients' beliefs and medication adherence.

Distinct Profiles on Subjective and Objective Adherence Measures in Patients Prescribed Antidepressants

Objective

A recurrent observation is that associations between self-reported and objective medication adherence measures are often weak to moderate. Our aim was therefore to identify patients with different profiles on self-reported and objective adherence measures.

Study Design and Setting

This was an observational study of 221 community pharmacy patients who were dispensed antidepressants. Adherence profiles were estimated with Latent Profile Analysis (LPA) using data on self-reported adherence (Medication Adherence Rating Scale) complemented with data on medication beliefs (perceived necessity and concerns measured with the Beliefs about Medicines Questionnaire) and data from objective adherence measures (electronic monitoring of medication taking and the Medication Possession Ratio calculated from pharmacy dispensing data).

Results

‘Goodness-of-fit’ statistics indicated the presence of three classes: “concordantly high adherent” (83%, high adherence on all measures), “concordantly suboptimal adherent” (11%, low adherence on all measures), and “discordant” (6%, high self-reported adherence but lower adherence on objective measures).

Conclusion

Most patients had concordant outcomes on self-reported and objective measures of adherence. A small discordant class had high self-reported but low objective adherence. LPA will enable sensitivity analyses in future studies, for example excluding patients from the discordant class.

What does the literature say about using electronic pillboxes for older adults? A systematic literature review

Purpose: The purpose of this study is to answer two research questions: (1) What is the clinical evidence for the reported outcomes in studies on electronic pillboxes for older adults? and (2) What is the technology readiness level (TRL) of the electronic pillboxes used, or intended to be used, for older adults?Methods: The scholarly literature was systematically searched and analyzed. Articles were included if they reported results about electronic pillboxes that were used or intended to be used for older adults' medication.Results: Clinical studies used commercially well-established electronic pillboxes with a high TRL. New electronic pillboxes in development had a low TRL. The discovered outcome was mainly adherence to medication. The overall mean adherence to medication regimens for all the studies using an electronic pillbox was higher than the gold standard of a good adherence level cut-off point (mean adherence 88.8%>80%). However, we found a large variation in this variable (SD = 10.7). With regard to an older adult population's adherence to medication regimens, for the outcome variable of those who had undergone a kidney transplant, the clinical evidence that electronic pillboxes have a positive impact was strong (1b); for those with a chronic hepatitis C medical condition, the clinical evidence was medium (3), and for those with arterial hypertension and multiple chronic (diabetes and hypertension) medical conditions, the clinical evidence was weak (5).Conclusion: More research is needed in this area using designs that provide greater validity.Implications for RehabilitationElectronic pillboxes with multiple reminders such as the "voice of a friend" or relative, which implies that electronic pillboxes which adopt "a social role" are advisable.An unequal level of clinical evidence that electronic pillboxes have a positive impact on the adherence outcome variable was found.For new electronic pillboxes still in development that specifically take into account older adults' needs, the TRL is still low; as a result, they could not be tested in real settings.

Barriers and facilitators of adjuvant hormone therapy adherence and persistence in women with breast cancer: a systematic review

PURPOSE

Nonadherence to hormone therapy in breast cancer survivors is common and associated with increased risk of mortality. Consistent predictors of nonadherence and nonpersistence are yet to be identified, and little research has examined psychosocial factors that may be amenable to change through intervention. This review aimed to identify predictors of nonadherence and nonpersistence to hormone therapy in breast cancer survivors in order to inform development of an intervention to increase adherence rates.

METHODS

Studies published up to April 2016 were identified through MEDLINE, Embase, Web of Science, PsycINFO, CINAHL and gray literature. Studies published in English measuring associations between adherence or persistence and any predictor variables were included. Eligible studies were assessed for methodological quality, data were extracted and a narrative synthesis was conducted.

RESULTS

Sixty-one eligible articles were identified. Most studies focused on clinical and demographic factors with inconsistent results. Some evidence suggested that receiving specialist care and social support were related to increased persistence, younger age and increased number of hospitalizations were associated with nonadherence, and good patient-physician relationship and self-efficacy for taking medication were associated with better adherence. A small amount of evidence suggested that medication beliefs were associated with adherence, but more high-quality research is needed to confirm this.

CONCLUSION

Some psychosocial variables were associated with better adherence and persistence, but the results are currently tentative. Future high-quality research should be carried out to identify psychosocial determinants of nonadherence or nonpersistence that are modifiable through intervention.

A Multifaceted Nurse- and Web-Based Intervention for Improving Adherence to Treatment in Patients With Cardiovascular Disease: Rationale and Design of the MIRROR Trial

Background

Poor adherence to medication is one of the limitations in the treatment of cardiovascular diseases, thereby increasing the risk of premature death, hospital admissions, and related costs. There is a need for simple and easy-to-implement interventions that are based on patients’ perspectives, beliefs, and perceptions of their illness and medication.

Objective

The objective is to test the effectivity of this intervention to improve medication adherence in patients with established cardiovascular disease, that is, in secondary prevention.

Methods

In this study the effect of a personalized visualization of cardiovascular risk levels through a website aiming at supporting self management in combination with a group consultation and communication intervention by a nurse on adherence to treatment in 600 patients with manifest cardiovascular diseases will be assessed. The health belief model was chosen as main theoretical model for the intervention.

Results

Primary outcome is adherence to treatment calculated by refill data. Secondary outcomes include the Beliefs about Medication Questionnaire and the Modified Morisky Scale. Patients are followed for one year. Results are expected by 2015.

Conclusions

This study assesses adherence to treatment in a high-risk cardiovascular population by applying an intervention that addresses patients’ capacity and practical barriers as well as patients’ beliefs and perceptions of their illness and medication.

ClinicalTrial

ClinicalTrials.gov NCT01449695; https://clinicaltrials.gov/ct2/show/NCT01449695 (Archived by WebCite at http://www.webcitation.org/6kCzkIKH3)

A mobile application improves therapy-adherence rates in elderly patients undergoing rehabilitation: A crossover design study comparing documentation via iPad with paper-based control

Medication adherence is crucial for success in the management of patients with chronic conditions. This study analyzes whether a mobile application on a tablet aimed at supporting drug intake and vital sign parameter documentation affects adherence in elderly patients.Patients with coronary heart disease and no prior knowledge of tablet computers were recruited. They received a personal introduction to the mobile application Medication Plan, installed on an Apple iPad. The study was conducted using a crossover design with 3 sequences: initial phase, interventional phase (28 days of using the app system), and comparative phase (28 days of using a paper diary). Users experienced the interventional and comparative phases alternately.A total of 24 patients (12 males; mean age 73.8 years) were enrolled in the study. The mean for subjectively assessed adherence (A14-scale; 5-point Likert scale, from "never" to "very often" which results in a score from 0 to 56) before the study was 50.0 (SD = 3.44). After both interventions there was a significant increase, which was more pronounced after the interventional phase (54.0; SD = 2.01) than after the comparative phase (52.6; SD = 2.49) (for all pairs after both interventions, P <0.001). Neither medical conditions nor the number of drug intake (amount and frequency of drug taking) per day affected subjective adherence. Logging data showed a significantly stronger adherence for the medication app than the paper system for both blood pressure recordings (P <0.001) and medication intake (P = 0.033). The majority of participants (n = 22) stated that they would like to use the medication app in their daily lives and would not need further assistance with the app.A mobile app for medication adherence increased objectively and subjectively measured adherence in elderly users undergoing rehabilitation. The findings have promising clinical implications: digital tools can assist chronic disease patients achieve adherence to medication and to blood pressure measurement. Although this requires initial offline training, it can reduce complications and clinical overload because of nonadherence.

The feasibility of determining the effectiveness and cost-effectiveness of medication organisation devices compared with usual care for older people in a community setting: systematic review, stakeholder focus groups and feasibility randomised controlled trial

BACKGROUND

Medication organisation devices (MODs) provide compartments for a patient's medication to be organised into the days of the week and the recommended times the medication should be taken.

AIM

To define the optimal trial design for testing the clinical effectiveness and cost-effectiveness of MODs.

DESIGN

The feasibility study comprised a systematic review and focus groups to inform a randomised controlled trial (RCT) design. The resulting features were tested on a small scale, using a 2 × 2 factorial design to compare MODs with usual packaging and to compare weekly with monthly supply. The study design was then evaluated.

SETTING

Potential participants were identified by medical practices.

PARTICIPANTS

Aged over 75 years, prescribed at least three solid oral dosage form medications, unintentionally non-adherent and self-medicating. Participants were excluded if deemed by their health-care team to be unsuitable.

INTERVENTIONS

One of three MODs widely used in routine clinical practice supplied either weekly or monthly.

OBJECTIVES

To identify the most effective method of participant recruitment, to estimate the prevalence of intentional and unintentional non-adherence in an older population, to provide a point estimate of the effect size of MODs relative to usual care and to determine the feasibility and acceptability of trial participation.

METHODS

The systematic review included MOD studies of any design reporting medication adherence, health and social outcomes, resource utilisation or dispensing or administration errors. Focus groups with patients, carers and health-care professionals supplemented the systematic review to inform the RCT design. The resulting design was implemented and then evaluated through questionnaires and group discussions with participants and health-care professionals involved in trial delivery.

RESULTS

Studies on MODs are largely of poor quality. The relationship between adherence and health outcomes is unclear. Of the limited studies reporting health outcomes, some reported a positive relationship while some reported increased hospitalisations associated with MODs. The pre-trial focus groups endorsed the planned study design, but suggested a minimum recruitment age of 50-60 years. A total of 35.4% of patients completing the baseline questionnaire were excluded because they already used a MOD. Active recruitment yielded a higher consent rate, but passive recruitment was more cost-effective. The prevalence of intentional non-adherence was 24.7% [n = 71, 95% confidence interval (CI) 19.7% to 29.6%] of participants. Of the remaining 76 participants, 46.1% (95% CI 34.8% to 57.3%) were unintentionally non-adherent. There was no indication of a difference in adherence between the study arms. Participants reported a high level of satisfaction with the design. Five adverse/serious adverse events were identified in the MOD study arms and none was identified in the control arms. There was no discernible difference in health economic outcomes between the four study arms; the mean intervention cost was £20 per month greater for MOD monthly relative to usual supply monthly.

CONCLUSIONS

MOD provision to unintentionally non-adherent older people may cause medication-related adverse events. The primary outcome for a definitive MOD trial should be health outcomes. Such a trial should recruit patients by postal invitation and recruit younger patients.

FUTURE WORK

A study examining the association between MOD initiation and adverse effects is necessary and a strategy to safely introduce MODs should be explored. A definitive study testing the clinical effectiveness and cost-effectiveness of MODs is also required.

STUDY REGISTRATION

Current Controlled Trials ISRCTN 30626972 and UKCRN 12739.

FUNDING

This project was funded by National Institute for Health Research (NIHR) Health Technology Assessment Programme and will be published in full in Health Technology Assessment; Vol. 20, No. 50. See the NIHR Journals Library website for further project information.

A scoping review of studies comparing the medication event monitoring system (MEMS) with alternative methods for measuring medication adherence

Different methods are available for measuring medication adherence. In this paper, we conducted a scoping review to identify and summarize evidence of all studies comparing the Medication Event Monitoring System (MEMS) with alternative methods for measuring medication adherence. A literature search was performed using the open database www.iAdherence.org that includes all original studies reporting findings from the MEMS. Papers comparing methods for measuring adherence to solid oral formulations were included. Data was extracted using a standardized extraction table. A total of 117 articles fulfilled the inclusion criteria, including 251 comparisons. Most frequent comparisons were against self-report (n = 119) and pill count (n = 59). Similar outcome measures were used in 210 comparisons (84%), among which 78 used dichotomous variables (adherent or not) and 132 used continuous measures (adherence expressed as percentage). Furthermore, 32% of all comparisons did not estimate adherence over the same coverage period and 44% of all comparisons did not use a statistical method or used a suboptimal one. Only eighty-seven (35%) comparisons had similar coverage periods, similar outcome measures and optimal statistical methods. Compared to MEMS, median adherence was grossly overestimated by 17% using self-report, by 8% using pill count and by 6% using rating. In conclusion, among all comparisons of MEMS versus alternative methods for measuring adherence, only a few used adequate comparisons in terms of outcome measures, coverage periods and statistical method. Researchers should therefore use stronger methodological frameworks when comparing measurement methods and be aware that non-electronic measures could lead to overestimation of medication adherence.

Adherence to antiepileptic drugs in children with epilepsy in a Scottish population cohort

AIM

To measure the adherence to antiepileptic drugs (AED) in a population cohort of children with epilepsy and to study the relationship between adherence and a series of clinical variables.

METHOD

A population-based study of children (<16y) with epilepsy on AED treatment from the Tayside region of Scotland during two epochs of 12 months each. A clinical database was constructed using hospital records and linked to a community dispensing pharmacy database to calculate an Adherence Index. The principal outcome measure was the measurement of population-based adherence to AEDs. Secondary outcome measures were the association of adherence with the clinical characteristics of the population.

RESULTS

The median age of study group was 10 years and the median duration of epilepsy was 4 years. Only 30.9% of the total 320 children adhered to recommended AED treatment (Adherence Index >90%) across a year of treatment. Twenty-five percent of children had an Adherence Index of less than 50%. Adherence declined with increasing age. There was no significant correlation between adherence and other clinical characteristics studied (sex, duration of epilepsy, other comorbid health problems, other regular medications, and seizure frequency).

INTERPRETATION

Our data shows adherence to AED treatment is poor in children with epilepsy.

Usefulness of inducible ventricular tachycardia to predict long-term adverse outcomes in arrhythmogenic right ventricular cardiomyopathy

The role of the electrophysiologic (EP) study for risk stratification in patients with arrhythmogenic right ventricular cardiomyopathy is controversial. We investigated the role of inducible sustained monomorphic ventricular tachycardia (SMVT) for the prediction of an adverse outcome (AO), defined as the occurrence of cardiac death, heart transplantation, sudden cardiac death, ventricular fibrillation, ventricular tachycardia with hemodynamic compromise or syncope. Of 62 patients who fulfilled the 2010 Arrhythmogenic Right Ventricular Cardiomyopathy Task Force criteria and underwent an EP study, 30 (48%) experienced an adverse outcome during a median follow-up of 9.8 years. SMVT was inducible in 34 patients (55%), 22 (65%) of whom had an adverse outcome. In contrast, in 28 patients without inducible SMVT, 8 (29%) had an adverse outcome. Kaplan-Meier analysis showed an event-free survival benefit for patients without inducible SMVT (log-rank p = 0.008) with a cumulative survival free of an adverse outcome of 72% (95% confidence interval [CI] 56% to 92%) in the group without inducible SMVT compared to 26% (95% CI 14% to 50%) in the other group after 10 years. The inducibility of SMVT during the EP study (hazard ratio [HR] 2.99, 95% CI 1.23 to 7.27), nonadherence (HR 2.74, 95% CI 1.3 to 5.77), and heart failure New York Heart Association functional class II and III (HR 2.25, 95% CI 1.04 to 4.87) were associated with an adverse outcome on univariate Cox regression analysis. The inducibility of SMVT (HR 2.52, 95% CI 1.03 to 6.16, p = 0.043) and nonadherence (HR 2.34, 95% CI 1.1 to 4.99, p = 0.028) remained as significant predictors on multivariate analysis. This long-term observational data suggest that SMVT inducibility during EP study might predict an adverse outcome in patients with arrhythmogenic right ventricular cardiomyopathy, advocating a role for EP study in risk stratification.

The roles of past behavior and health beliefs in predicting medication adherence to a statin regimen

PURPOSE

Current medication-adherence predictive tools are based on patient medication-taking beliefs, but studying past behavior may now be a more explanatory and accessible method. This study will evaluate if past medication-refill behavior for a statin regimen is more predictive of medication adherence than patient medication-taking health beliefs.

PATIENTS AND METHODS

This prospective longitudinal study was implemented in a national managed care plan in the United States. A group of 1433 statin patients were identified and followed for 6 months. Medication-taking health beliefs, collected from self-reported mail questionnaires, and past medication-refill behavior, using proportion of days covered (PDC), were collected prior to 6-month follow-up. Outcomes were measured using categorical PDC variable (of adherence, PDC ≥ 85%, versus nonadherence, PDC < 85%), with model fit estimated using receiver operator characteristic analysis.

RESULTS

The area under the receiver operator characteristic curve for past behavior (A(z) = 0.78) was significantly greater (P < 0.05) than for patient health beliefs (A(z) = 0.69), indicating that past prescription-refill behavior is a better predictor of medication adherence than prospective health beliefs. Among health beliefs, the factor most related to medication adherence was behavioral intent (odds ratio, 5.12; 95% confidence interval, 1.84 to 15.06). The factor most strongly related to behavioral intent was impact of regimen on daily routine (odds ratio, 3.3; 95% confidence interval, 1.41 to 7.74).

CONCLUSION

Electronic medical records and community health-information networks may make past prescription-refill rates more accessible and assist physicians with managing medication-regimen adherence. Health beliefs, however, may still play an important role in influencing medication-taking behaviors.

Effects of eHealth interventions on medication adherence: a systematic review of the literature

BACKGROUND

Since medication nonadherence is considered to be an important health risk, numerous interventions to improve adherence have been developed. During the past decade, the use of Internet-based interventions to improve medication adherence has increased rapidly. Internet interventions have the potential advantage of tailoring the interventions to the needs and situation of the patient.

OBJECTIVE

The main aim of this systematic review was to investigate which tailored Internet interventions are effective in improving medication adherence.

METHODS

We undertook comprehensive literature searches in PubMed, PsycINFO, EMBASE, CINAHL, and Communication Abstracts, following the guidelines of the Cochrane Collaboration. The methodological quality of the randomized controlled trials and clinical controlled trials and methods for measuring adherence were independently reviewed by two researchers.

RESULTS

A total of 13 studies met the inclusion criteria. All included Internet interventions clearly used moderately or highly sophisticated computer-tailored methods. Data synthesis revealed that there is evidence for the effectiveness of Internet interventions in improving medication adherence: 5 studies (3 high-quality studies and 2 low-quality studies) showed a significant effect on adherence; 6 other studies (4 high-quality studies and 2 low-quality studies) reported a moderate effect on adherence; and 2 studies (1 high-quality study and 1 low-quality study) showed no effect on patients' adherence. However, most studies used self-reported measurements to assess adherence, which is generally perceived as a low-quality measurement. In addition, we did not find a clear relationship between the quality of the studies or the level of sophistication of message tailoring and the effectiveness of the intervention. This might be explained by the great difference in study designs and the way of measuring adherence, which makes results difficult to compare. There was also large variation in the measured interval between baseline and follow-up measurements.

CONCLUSION

This review shows promising results on the effectiveness of Internet interventions to enhance patients' adherence to prescribed long-term medications. Although there is evidence according to the data synthesis, the results must be interpreted with caution due to low-quality adherence measurements. Future studies using high-quality measurements to assess medication adherence are recommended to establish more robust evidence for the effectiveness of eHealth interventions on medication adherence.

Cultural adaptation of a compliance questionnaire for patients with rheumatoid arthritis to a Korean version

BACKGROUND/AIMS

The Compliance Questionnaire-Rheumatology (CQR) is a validated scale to evaluate patient compliance for anti-rheumatic medications. We developed a Korean version of the CQR (KCQR) and confirmed its reliability and validity.

METHODS

We prepared the KCQR by translating and back-translating the original CQR with modifications to adapt it to Korean culture. Fifty Korean patients with rheumatoid arthritis (RA) were enrolled in this study. The test-retest reliability of the KCQR was evaluated at a 2-week interval using the intraclass correlation coefficient (ICC). The validity of the KCQR was assessed by identifying associations between KCQR scores and patient compliance, measured using pharmacy refill data.

RESULTS

The reliability of the KCQR was adequate, with an ICC of 0.71 for test-retest reliability. With respect to validity, the summed score of the weighted KCQR showed a significant correlation with pharmacy refill data (r² = 0.57) on multiple regression analysis.

CONCLUSIONS

Our results indicate that the KCQR is a reliable, valid instrument to evaluate compliance of Korean patients for RA medications.

The Allocation of Treatment Responsibility scale: a novel tool for assessing patient and caregiver management of pediatric medical treatment regimens

The purpose of the current study is to report preliminary psychometric properties of the ATR scale, a brief measure of the distribution of treatment tasks across the family members of children with a kidney transplant. Pediatric patients with renal transplants (ages 7-18 yr) and their caregivers completed the ATR and measures of adherence and family functioning. Internal consistency for the ATR (total score and subscales) was strong (range α = 0.75-0.93). Validity for the ATR was supported by significant correlations between the ATR caregiver total score of patient responsibility and patient age, as well as the ATR caregiver total score of patient responsibility and adherence. The ATR scale is a promising new tool for assessing the distribution of medical regimen tasks between patients and their caregivers. The availability of a standardized measure of ATR could assist in monitoring patient preparation for transition and identifying factors contributing to non-adherence.

Understanding prescription adherence: pharmacy claims data from the Contraceptive CHOICE Project

BACKGROUND

We examined prescription adherence rates by contraceptive method among women who used oral contraceptive pills (OCP), transdermal patch or vaginal ring.

STUDY DESIGN

Women in the St. Louis area were provided their choice of OCP, patch or ring at no cost and followed for 18 months. Time between monthly refills was obtained from pharmacy data and analyzed as a marker of adherence. Risk factors for initial nonadherence were estimated using Cox proportional hazards; predictors for repeated nonadherence were analyzed using Poisson regression with robust error variance.

RESULTS

Overall, 619 participants filled 6435 contraceptive prescriptions with a median of 10 refills per participant. Only 30% of women (n = 187) obtained all refills on time. In the time-to-failure analysis, use of vaginal ring and increased parity were predictors of early nonadherence (p < .05). In the multivariable analysis, use of the vaginal ring and history of abortion were risk factors for repeated nonadherence (p < .01).

CONCLUSIONS

Even with financial barriers removed, pharmacy data show that many women inconsistently refill their contraception and may be at risk for unintended pregnancy.

Multicenter cluster-randomized trial of a multifactorial intervention to improve antihypertensive medication adherence and blood pressure control among patients at high cardiovascular risk (the COM99 study)

BACKGROUND

Medication nonadherence is common and results in preventable disease complications. This study assessed the effectiveness of a multifactorial intervention to improve both medication adherence and blood pressure control and to reduce cardiovascular events.

METHODS AND RESULTS

In this multicenter, cluster-randomized trial, physicians from hospital-based hypertension clinics and primary care centers across Spain were randomized to receive and provide the intervention to their high-risk patients. Eligible patients were ≥ 50 years of age, had uncontrolled hypertension, and had an estimated 10-year cardiovascular risk greater than 30%. Physicians randomized to the intervention group counted patients' pills, designated a family member to support adherence behavior, and provided educational information to patients. The primary outcome was blood pressure control at 6 months. Secondary outcomes included both medication adherence and a composite end point of all-cause mortality and cardiovascular-related hospitalizations. Seventy-nine physicians and 877 patients participated in the trial. The mean duration of follow-up was 39 months. Intervention patients were less likely to have an uncontrolled systolic blood pressure (odds ratio 0.62, 95% confidence interval 0.50 to 0.78) and were more likely to be adherent (odds ratio 1.91, 95% confidence interval 1.19 to 3.05) than control group patients at 6 months. After 5 years, 16% of the patients in the intervention group and 19% in the control group met the composite end point (hazard ratio 0.97, 95% confidence interval 0.67 to 1.39).

CONCLUSIONS

A multifactorial intervention to improve adherence to antihypertensive medication was effective in improving both adherence and blood pressure control, but it did not appear to improve long-term cardiovascular events.

Risk factors promoting hypertensive crises: evidence from a longitudinal study

BACKGROUND

Current knowledge about risk factors promoting hypertensive crisis originates from retrospective data. Therefore, potential risk factors of hypertensive crisis were assessed in a prospective longitudinal study.

METHODS

Eighty-nine patients of the medical outpatient unit at the University Hospital of Bern (Bern, Switzerland) with previously diagnosed hypertension participated in this study. At baseline, 33 potential risk factors were assessed. All patients were followed-up for the outcome of hypertensive crisis. Cox regression models were used to detect relationships between risk factors and hypertensive crisis (defined as acute rise of systolic blood pressure (BP) > or =200 mm Hg and/or diastolic BP > or =120 mm Hg).

RESULTS

The mean duration of follow-up was 1.6 +/- 0.3 years (range 1.0-2.4 years). Four patients (4.5%) were lost to follow-up. Thirteen patients (15.3%) experienced hypertensive crisis during follow-up. Several potential risk factors were significantly associated with hypertensive crisis: female sex, higher grades of obesity, the presence of a hypertensive or coronary heart disease, the presence of a somatoform disorder, a higher number of antihypertensive drugs, and nonadherence to medication. As measured by the hazard ratio, nonadherence was the most important factor associated with hypertensive crisis (hazard ratio 5.88, 95% confidence interval 1.59-21.77, P < 0.01).

CONCLUSIONS

This study identified several potential risk factors of hypertensive crisis. Results of this study are consistent with the hypothesis that improvement of medical adherence in antihypertensive therapy would help to prevent hypertensive crises. However, larger studies are needed to assess potential confounding, other risk factors and the possibility of interaction between predictors.

Improving adherence to medication in stroke survivors (IAMSS): a randomised controlled trial: study protocol

Background

Adherence to therapies is a primary determinant of treatment success, yet the World Health Organisation estimate that only 50% of patients who suffer from chronic diseases adhere to treatment recommendations. In a previous project, we found that 30% of stroke patients reported sub-optimal medication adherence, and this was associated with younger age, greater cognitive impairment, lower perceptions of medication benefits and higher specific concerns about medication. We now wish to pilot a brief intervention aimed at (a) helping patients establish a better medication-taking routine, and (b) eliciting and modifying any erroneous beliefs regarding their medication and their stroke.

Methods/Design

Thirty patients will be allocated to a brief intervention (2 sessions) and 30 to treatment as usual. The primary outcome will be adherence measured over 3 months using Medication Event Monitoring System (MEMS) pill containers which electronically record openings. Secondary outcomes will include self reported adherence and blood pressure.

Discussion

This study shall also assess uptake/attrition, feasibility, ease of understanding and acceptability of this complex intervention.

Trial Registration

Current Controlled Trials ISRCTN38274953

Comparison of two self-rating instruments for medication adherence assessment in hypertension revealed insufficient psychometric properties

OBJECTIVE

In cases of insufficiently controlled blood pressure, it is important for practitioners to distinguish between "nonadherence" and "nonresponse" to antihypertensive drug treatment. A reliable and valid adherence measurement based on the patient's self-report may be helpful in daily practice.

STUDY DESIGN AND SETTING

In a primary care sample with 353 hypertensive patients, we applied two self-rating instruments to assess medication adherence (the "Hill-Bone Compliance to High Blood Pressure Therapy Scale" and Morisky's "Self-Reported Measure of Medication Adherence") and compared their psychometric properties.

RESULTS

Both scales showed low acceptability and insufficiency to moderate internal consistency (Cronbach's alpha=0.25 and 0.73, respectively). Their convergent validity as indexed by kappa=0.39 could be judged as "fair" at best. Testing the power to predict blood pressure >140/90mmHg, both scales showed an accuracy of 57% and 62%, respectively. The positive likelihood, that is, the increase in likelihood of high blood pressure in cases of nonadherence was 1.00 and 1.32, respectively.

CONCLUSION

The use of both scales cannot be recommended. They showed considerable floor effects, and their ability to identify medication adherence was inconsistent for nearly every third patient. The power of both scales to predict uncontrolled blood pressure was essentially a chance. The underlying conceptual framework of medication adherence therefore needs to be rethought.

Adherence with topical glaucoma medication monitored electronically the Travatan Dosing Aid study

PURPOSE

To assess patient adherence and behaviors with topical once-daily therapy for glaucoma.

DESIGN

Prospective, observational cohort study.

PARTICIPANTS

One hundred ninety-six patients with glaucoma who were being treated with a prostaglandin analog in 1 or both eyes at the Scheie or Wilmer Eye Institutes between August 2006 and June 2007.

METHODS

Detailed medical history was obtained from each patient. All subjects used the Travatan Dosing Aid (DA; Alcon, Fort Worth, TX) to administer travoprost as prescribed. Devices were collected at 3 months and the data of drop usage was downloaded using software provided with the dosing aid. Data were analyzed for the 8-week period starting 2 weeks after the enrollment visit and ending 2 weeks before the 3-month visit.

MAIN OUTCOME MEASURES

Assessment of adherence and patterns of drop usage as indicated by the DA.

RESULTS

A total of 282 subjects consented to be in the study and 86 (30%) withdrew before study completion or had device errors, leaving 196 subjects (70%) with evaluable data at 3 months. The overall mean (+/-standard deviation) adherence rate was 0.71 (+/-0.24), ranging from 0.02 to 0.97. One hundred nine of these patients (55.6%) took greater than 75% of the expected doses. Those with adherence of less than 50% of expected doses showed substantially increased dose taking immediately after the office visit and just before the return visit at 3 months (P = 0.03). The mean adherence rate estimates of the physician and patient self-report were 0.77 and 0.95, respectively. The agreement between the physician assessment and DA-recorded adherence rate showed poor correlation for individual cases (intraclass correlation coefficient, 0.09; 95% confidence interval, 0.00-0.19).

CONCLUSIONS

Nearly 45% of patients using an electronic monitoring device who knew they were being monitored and were provided free medication used their drops less than 75% of the time. Patients reported far higher medication use than their actual behavior. The ability of the physician to identify which persons are poorly adherent from their self-report or from other subjective clues is poor.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Patients' perceptions of electronic monitoring devices affect medication adherence in hypertensive African Americans

BACKGROUND

Electronic monitoring devices (EMDs) are regarded as the gold standard for assessing medication adherence in clinical research. However, little is known about the effect of patients' acceptance of EMDs on medication adherence in African Americans with hypertension who are followed in primary care practices

OBJECTIVE

To assess patients' perceptions of EMDs, their acceptance of EMDs, and the relationship of these perceptions to medication adherence in African Americans with hypertension who are followed in community-based practices.

METHODS

Patients were recruited from a larger randomized controlled trial assessing the effect of motivational interviewing on medication adherence and blood pressure in hypertensive African American patients followed in 2 New York City primary care practices. Medication adherence was assessed with a Medication Event Monitoring System (MEMS) during a 12-month monitoring period. At the 12-month follow-up, patients' perceptions of the MEMS were assessed with a 17-item questionnaire. ANOVA was used to compare patients' responses (agree, neither, disagree) with the MEMS adherence over the monitoring period. Tukey's post hoc tests were used to determine whether there were significant differences among the 3 groups.

RESULTS

Participants were predominantly women, low-income, unemployed, had a high school education, and were a mean age of 53 years. Approximately two-thirds of the participants stated that the MEMS helped them remember to take their medications, 93% reported that the MEMS was easy to open, 85% did not find it stressful, and 75% liked the MEMS and used it everyday. One-third of patients preferred using a pillbox and 25% did not like traveling with the MEMS. Patients who stated that they used the MEMS every day, felt comfortable using it in front of others, and remembered to put refills in the MEMS had significantly better adherence over the study period than did those who disagreed (p </= 0.05).

CONCLUSIONS

African American patients treated for hypertension in community-based practices held positive perceptions about a MEMS. Perceptions about the practicality of a MEMS may yield important information about actual medication-taking behavior.

Comparison of individual perceptions of medication costs and benefits between intentional and unintentional medication non-adherence among Japanese patients

OBJECTIVE

To identify Japanese patients' perceptions of the costs and benefits of their medications by administering a questionnaire validated in Western patients and to compare the association between the perception levels and non-adherence to medication in the two non-adherent patient types, intentional, and unintentional.

METHODS

Japanese patients with chronic diseases were given a questionnaire and interviewed, and the validity and reliability of the scales generated were assessed. Logistic regression was used to analyse the association between individual perception levels and non-adherence to the medication regimen.

RESULTS

From 151 responses, two kinds of scales were generated following a report of Western patients; the necessity scale showed satisfactory reliability (Cronbach's alpha 0.79) but the concerns scale did not. Individual levels of perception of the necessity of medications were associated with unintentional non-adherence (the higher the level, the lower the odds ratio 1.0, 0.56, 0.40, and 0.15), while they were not associated with intentional non-adherence.

CONCLUSION

Japanese patients' perceptions of the benefits of medications, but not the costs were similar to those of Western patients, and these perceptions were likely to be different between intentionally and unintentionally non-adherent patients.

PRACTICE IMPLICATIONS

Strategies to improve non-adherence should be designed according to the non-adherent type.

Beliefs about medicines predict refill adherence to inhaled corticosteroids

OBJECTIVE

Despite the importance of the chronic use of inhaled corticosteroids (ICS) in maintaining asthma control, reported adherence varies between 40% and 60%. The Beliefs about Medicines Questionnaire (BMQ) has been shown to correlate with self-reported adherence. The aim of this study is to investigate whether beliefs about ICS (necessity and concerns), as measured by the BMQ, relate to adherence objectively measured by prescription-refill records.

METHODS

In a cross-sectional study of patients aged 18-45 years who filled at least two ICS prescriptions in 11 community pharmacies in The Netherlands, perceptions of ICS were assessed using the BMQ. Additionally, self-reported adherence was assessed using the Medication Adherence Report Scale. ICS prescription-refill adherence rates for a 12-month period prior to the survey were obtained from automated pharmacy dispensing records. Four attitudinal groups were defined using the necessity and concerns constructs. Statistical tests were used to examine associations between ICS adherence (assessed by subjective self-report and objective pharmacy records), specific beliefs about and attitudes towards ICS, and more general beliefs about pharmaceuticals.

RESULTS

Questionnaires were returned by 238 patients (51.1%). Both self-reported adherence (r=.38) and adherence by pharmacy records (rho=0.32) correlated with ICS necessity beliefs and concerns. Patients defined as skeptical, indifferent, ambivalent, or accepting, on the basis of these constructs, differed with respect to both their attitudes towards medicines in general and their adherence to medication.

CONCLUSIONS

Patients' beliefs about ICS correlate not only with adherence by self-report but also with a more objective measure of medication adherence calculated by pharmacy dispensing records. The necessity-concerns constructs offer a potentially useful framework to help clinicians elicit key treatment beliefs influencing adherence to ICS.

Patient risk profiles and practice variation in nonadherence to antidepressants, antihypertensives and oral hypoglycemics

BACKGROUND

Many patients experience difficulties in following treatment recommendations. This study's objective is to identify nonadherence risk profiles regarding medication (antidepressants, antihypertensives, and oral hypoglycemics) from a combination of patients' socio-demographic characteristics, morbidity presented within general practice and medication characteristics. An additional objective is to explore differences in nonadherence among patients from different general practices.

METHODS

Data were obtained by linkage of a Dutch general practice registration database to a dispensing registration database from the year 2001. Subjects included in the analyses were users of antidepressants (n = 4,877), antihypertensives (n = 14,219), or oral hypoglycemics (n = 2,428) and their GPs. Outcome variables were: 1) early dropout i.e., a maximum of two prescriptions and 2) refill nonadherence (in patients with 3+ prescriptions); refill adherence < 80% was considered as nonadherence. Multilevel modeling was used for analyses.

RESULTS

Both early dropout and refill nonadherence were highest for antidepressants, followed by antihypertensives. Risk factors appeared medication specific and included: 1) non-western immigrants being more vulnerable for nonadherence to antihypertensives and antidepressants; 2) type of medication influencing nonadherence in both antihypertensives and antidepressants, 3) GP consultations contributing positively to adherence to antihypertensives and 4) somatic co-morbidity influencing adherence to antidepressants negatively. There was a considerable range between general practices in the proportion of patients who were nonadherent.

CONCLUSION

No clear risk profiles for nonadherence could be constructed. Characteristics that are correlated with nonadherence vary across different types of medication. Moreover, both patient and prescriber influence adherence. Especially non-western immigrants need more attention with regard to nonadherence, for example by better monitoring or communication. Since it is not clear which prescriber characteristics influence adherence levels of their patients, there is need for further research into the role of the prescriber.

Compliance with therapy in hypertensive patients

OBJECTIVE

This study investigated pharmacological compliance in hypertensive patients recruited during a 24-month period at the Hypertension Clinic of the S. Maria Nuova Hospital.

METHODS

The compliance profile scale was developed in order to classify compliance as sufficient, or poor. Compliance was evaluated according to patients' (1) global cardiovascular risk (hypertensive) and (2) complexity of prescribed treatment at enrolment (drug, number of pills).

RESULTS

A total of 367 patients were recruited; 82 were excluded owing to changes in therapeutic schedule or medication necessitated by other medical or surgical disease. Compliance was evaluated in 285 patients, 66% were male; the mean age was 72 +/- 12 years. Compliance was evaluated at a series of follow-ups at 3-month intervals and at 36 months of observation. Compliance at 36 months was good or sufficient in 56% of patients, but differed according to hypertensive and drug status. Compliance was better in patients with a higher level vs. lower level of hypertension severity. Specifically, compliance was better in hypertensives with co-morbidity (76%) than in hypertensives without co-morbidity (37%) or hypertensives with risk factors (65%). Moreover, compliance was better in patients with a more complex therapeutic regimen (drug 1 through 3: 47, 59 and 66%).

CONCLUSIONS

These data demonstrate a relationship between disease severity and compliance, independent of the prescribed therapeutic regimen. This suggests that the most important factor for therapy adherence is disease awareness and severity, and patients with a higher level of disease are more likely to be compliant.