Racial differences in long-term adherence to oral antidiabetic drug therapy: a longitudinal cohort study

Clinical efficacy and cost-effectiveness of metformin in different patient populations: A narrative review of real-world evidence

Over the past two decades, diabetes pharmacopoeia has flourished, with new drugs that, on top of their glucose-lowering efficacy, have been shown to protect the heart and the kidney. Despite these new opportunities, metformin retains a pivotal role among glucose-lowering agents. As one of the few available insulin sensitizers, metformin is an effective, safe, and overall well-tolerated drug backed by over 60 years of clinical experience, including evidence for potential benefits beyond glucose reduction across different ages, sexes, genetic backgrounds, geographical areas, and stages of disease. Although there is some discussion of whether metformin offers the most effective front-line option in newly diagnosed type 2 diabetes (T2D), it remains a natural companion to all other glucose-lowering agents. Furthermore, metformin comes at a very low cost and, as such, it has extremely high cost-effectiveness, particularly given the serious economic burden associated with diabetes complications. This financial advantage is particularly relevant in resource-constrained healthcare systems, where the affordability of metformin may be instrumental in implementing an effective treatment in an evergrowing number of individuals. We present here compelling real-world evidence in support of the clinical efficacy and cost-effectiveness of metformin across different patient populations, highlighting areas where more population-based studies are needed to further incorporate and consolidate its use in the pharmacological management of T2D.

Depression and Medication Beliefs in African Americans with Diabetes

Medication non-adherence impacts health significantly in African Americans with diabetes. We performed a retrospective data analysis on 56 patients who presented to the emergency departments of two hospitals in Philadelphia, PA, USA. Demographic data, medical history, and point-of-care hemoglobin A1c were collected at baseline. Using Spearman rank correlations, we examined whether depressive symptoms measured with the Patient Health Questionnaire-9 (PHQ-9) were associated with diabetes health beliefs, which were assessed with the Diabetes Health Belief Scale (DHBS). PHQ-9 scores were significantly correlated with DHBS's Perceived Side Effects scores [r(56) = 0.474, p < 0.01] and Perceived Barriers scores [r(56) = 0.337, p < 0.05]. These findings suggest that negative health beliefs may play a role in the relationship between depression and low medication adherence. Treatment of diabetes in middle-aged and older African American individuals should address both depression and negative health beliefs on side effects and perceived barriers.

Using the integrated theory of health behavior change to assess factors affecting diabetes medication adherence among black adults during COVID-19: an explanatory sequential mixed methods design

OBJECTIVES

(1) Evaluate changes in medication adherence and the role of psychosocial and interpersonal factors on adherence. (2) Explain the changes in medication adherence based on patient perceptions of adherence behaviors.

DESIGN

We used an explanatory sequential mixed methods design for surveys at baseline and 1-year follow-up, followed by interviews. The Integrated Theory of Health Behavior Change guided the design of a questionnaire including self-reported measures of medication adherence, psychosocial factors such as illness and medication beliefs, self-efficacy, and depressive symptoms, interpersonal factors including social support and patient-provider communication, and socio-demographic and clinical factors. A convenience sample (n = 228) of adult patients with type 2 diabetes who self-identified as Black/African American completed the mail/telephone surveys. Nine semi-structured interviews were conducted with respondents of both surveys who had changes in medication adherence. Descriptive, mean differential, bivariate correlational analyses, and content analysis was conducted. Data integration merged quantitative and qualitative results as a joint display.

RESULTS

Response rates for the baseline and follow-up survey were 28% and 47% respectively. Medication adherence scores were significantly correlated with illness perceptions (r = .30) and depression (r = .25) at baseline, and self-efficacy (r = -.51) and depression (r = .37) at follow-up. Qualitative themes included patient perceptions of adherence behaviors, impact of the COVID-19 pandemic, health literacy and self-efficacy. Mixed methods integration showed contrasting perceptions of the same themes including adherence behaviors, medication beliefs, social support, and patient-provider communication among participants whose medication adherence increased and decreased overtime.

CONCLUSION

Self-efficacy, diabetes beliefs, and depressive symptoms were key psychosocial factors that affected medication adherence among Blacks/African Americans. Contrasting perceptions of beliefs in medicines, social support, provider relationships and communication among increased and decreased adherence participant groups explained the changes in adherence, which can be used to adapt existing interventions.

Not obtaining a medication the first time it is prescribed: primary non-adherence to cardiovascular pharmacotherapy

Primary medication non-adherence describes the situation when a first prescription for a new medication is never filled. Primary non-adherence is an important, yet understudied aspect of reduced effectiveness of pharmacotherapy. This review summarizes the frequency, impact, reasons, predictors, and interventions regarding primary non-adherence to cardiovascular/cardiometabolic drugs. The current literature reveals a high prevalence of primary non-adherence. The individual risk of primary non-adherence is determined on multiple factors, e.g., primary non-adherence of lipid-lowering drugs is higher compared to antihypertensive medications. However, the overall rate of primary non-adherence is > 10%. Additionally, this review identifies specific areas for research to better understand why patients forgo evidence-based beneficial pharmacotherapy and to explore targeted interventions. At the same time, measures to reduce primary non-adherence-once proven to be effective-may represent an important new opportunity to reduce cardiovascular diseases.

Racial and Ethnic Differences in Medication Initiation Among Adults Newly Diagnosed with Type 2 Diabetes

OBJECTIVE

Given persistent racial/ethnic differences in type 2 diabetes outcomes and the lasting benefits conferred by early glycemic control, we examined racial/ethnic differences in diabetes medication initiation during the year following diagnosis.

METHODS

Among adults newly diagnosed with type 2 diabetes (2005-2016), we examined how glucose-lowering medication initiation differed by race/ethnicity during the year following diagnosis. We specified modified Poisson regression models to estimate the association between race/ethnicity and medication initiation in the entire cohort and within subpopulations defined by HbA1c, BMI, age at diagnosis, comorbidity, and neighborhood deprivation index (a census tract-level socioeconomic indicator).

RESULTS

Among the 77,199 newly diagnosed individuals, 47% started a diabetes medication within 12 months of diagnosis. The prevalence of medication initiation ranged from 32% among Chinese individuals to 58% among individuals of Other/Unknown races/ethnicities. Compared to White individuals, medication initiation was less likely among Chinese (relative risk: 0.78 (95% confidence interval 0.72, 0.84)) and Japanese (0.82 (0.75, 0.90)) individuals, but was more likely among Hispanic/Latinx (1.27 (1.24, 1.30)), African American (1.14 (1.11, 1.17)), other Asian (1.13 (1.08, 1.18)), South Asian (1.10 (1.04, 1.17)), Other/Unknown (1.31 (1.24, 1.39)), American Indian or Alaska Native (1.11 (1.04, 1.18)), and Native Hawaiian/Pacific Islander (1.28 (1.19, 1.37)) individuals. Racial/ethnic differences dissipated among individuals with higher HbA1c values.

CONCLUSIONS

Initiation of glucose-lowering treatment during the year following type 2 diabetes diagnosis differed markedly by race/ethnicity, particularly for those with lower HbA1c values. Future research should examine how patient preferences, provider implicit bias, and shared decision-making contribute to these early treatment differences.

Effects of Part D Star Ratings on racial and ethnic disparities in health care costs

Background

Racial/ethnic minorities are less likely than non-Hispanic White (White) patients to be included in the Medicare Part D Star Ratings measure assessment due to the restrictive inclusion criteria for the measures.

Objective

This paper examined the effects of racial/ethnic disparities in the measure assessment in Part D Star Ratings on disparities in healthcare costs among patients with Alzheimer's disease and related dementias (ADRD).

Methods

This cross-sectional study analyzed 2017 Medicare data. Proportions of Beneficiaries with ADRD were categorized into the included and excluded groups based on the inclusion criteria for the calculation of medication adherence measures in Star Ratings. Outcomes included costs for medications, physician visits, emergency room (ER) visits, and total costs. A generalized linear model was employed to compare costs across racial/ethnic groups. To explore the differential disparities in healthcare costs between the 2 groups, interaction terms between dummy variables for being excluded from the measure calculation and racial/ethnic minorities were included in the models.

Results

The patterns of racial/ethnic disparities in healthcare costs found in this study were generally consistent with expectations, with some exceptions. For example, compared with White patients, in the hyperlipidemia cohort, the physician visit cost for Black patients among the included group was 31% lower (cost ratio or CR = 0.69, 95% CI = 0.67-0.72); in the hypertension cohort, the hospitalization cost for Blacks among the excluded group was 15% higher (CR = 1.15, 95% CI = 1.12-1.19). More importantly, exclusion from measurement assessments was associated with differential cost disparities. For example, compared with individuals included in the measure assessment for hypertension, the Black-White disparities in costs for hospitalization and total healthcare were 30% higher (CR = 1.30, 95% CI = 1.26-1.34), and 10% higher (CR = 1.10; 95% CI = 1.08-1.12), respectively, among the excluded group.

Conclusions

Medicare Part D Star Ratings may be associated with aggravated racial/ethnic disparities in healthcare costs in the Medicare Part D population.

Are Frail Older People from Racial/Ethnic Minorities at Double Jeopardy of Putting off Healthcare during the Pandemic?

Given the differential impacts of COVID-19 on racial and ethnic groups, it is unclear how racial/ethnic status and frailty combine to influence pandemic-related healthcare disruptions. This study aimed to test the double jeopardy hypothesis: racial/ethnic minority older adults suffer a double disadvantage in access to health care during the pandemic due to the interactive effects of frailty and race. This study uses the linked National Health and Aging Trends Study (NHATS) and COVID-19 public use data files. A multivariate logistic regression model was performed. Overall, approximately two out of five (41%) older adults reported postponing care due to the pandemic. The likelihood of putting off care increased slightly by frailty status. We found no significant difference between Whites and non-Whites in putting off care. However, the simple comparison masked significant variation across frailty status. Robust non-White older people were less likely to put off care than robust Whites (robust non-Whites: 29% vs. robust Whites: 39%); in contrast, frail non-White older people were more likely to put off care (frail non-Whites: 55% vs. frail Whites: 42%). Being frail and non-White creates double jeopardy, which has a negative impact on access to healthcare. Timely access to care is essential for frail older people, particularly non-Whites, because of their complex health conditions accentuated by health and social disparities.

Ethnic disparities in medication adherence? A systematic review examining the association between ethnicity and antidiabetic medication adherence

OBJECTIVES

Adherence to prescribed medication is an essential component of diabetes management to obtain optimal outcomes. Understanding the relationship between medication adherence and ethnicity is key to optimising treatment for all people with different chronic illnesses, including those with diabetes. The aim of this review is to examine whether the adherence to antidiabetic medications differed by ethnicity among people with diabetes.

METHODS

A systematic review was conducted of studies reporting adherence to antidiabetic medication amongst people from different ethnic groups. MEDLINE, Embase, CINAHL, and PsycINFO were searched from their inception to June 2022 for quantitative studies with a specific focus on studies assessing adherence to antidiabetic medications (PROSPERO: CRD42021278392). The Joanna Briggs Institute critical appraisal checklist and a second checklist designed for studies using retrospective databases were used to assess study quality. A narrative synthesis approach was used to summarize the results based on the medication adherence measures.

RESULTS

Of 17,410 citations screened, 41 studies that included observational retrospective database research and cross-sectional studies were selected, each of which involved diverse ethnic groups from different settings. This review identified a difference in the adherence to antidiabetic medications by ethnicity in 38 studies, despite adjustment for several confounding variables that may otherwise explain these differences.

CONCLUSION

This review revealed that adherence to antidiabetic medication differed by ethnicity. Further research is needed to explore the ethnicity-related factors that may provide an explanation for these disparities.

Racial disparity in cardiovascular morbidity and mortality associated with obstructive sleep apnea: The sleep heart health study

BACKGROUND

African Americans (AA) have higher prevalence of cardiovascular diseases (CVD) and obstructive sleep apnea (OSA) compared to Whites. Previous research demonstrated increased risk of cardiovascular complications from OSA but there is paucity of data about any interaction of race on this effect. Sleep Heart Health Study (SHHS) is a multi-center cohort study that was done to determine the cardiovascular consequences of OSA. Using this data, we assessed the racial disparity of various CVD incidence and mortality between Whites and AA associated with OSA.

METHODS

We analyzed data from 5692 participants. Logistic regressions were done to compare the incidence of all CVD and stroke between White and AA. Cumulative death risk from all causes over 13 years were assessed by Cox's proportional hazard model. All models were adjusted for age, BMI, gender, education, hypertension, diabetes, smoking, total sleep time and OSA.

RESULTS

Compared to Whites, AA had higher adjusted odds of developing any CVD (OR = 1.6, 95% CI = 1.19-2.15) and stroke (OR = 1.71, 95 CI = 1.13-2.61). OSA remains an independent risk factor for CVD (OR = 1.15, 96% CI = 1.01-1.47) and stroke (OR = 1.36, 95% CI = 1.04-2.16) after adjusting for race and other covariates. The cumulative adjusted mortality risk was 1.24 times higher in AA than White (95% CI = 1.02-1.51) during this follow up period. Subjects with OSA in highest AHI quartile had 1.35 times (95% CI = 1.13-1.63) higher mortality compared to lowest quartile.

CONCLUSION

AA race and untreated OSA are independent predictors for new onset CVD, stroke and higher all-cause mortality, after adjusting for cardiovascular risk factors.

Sacubitril/valsartan use patterns among older adults with heart failure in clinical practice: a population-based cohort study of >25 000 Medicare beneficiaries

AIMS

Sacubitril/valsartan is strongly supported in guidelines for the management of heart failure, but suboptimal adherence and treatment non-persistence may limit the population-level benefit that this therapy might otherwise offer.

METHODS AND RESULTS

We identified a cohort of Medicare beneficiaries (2014-2017) initiating sacubitril/valsartan after ≥6 months of continuous enrolment. We assessed adherence as the proportion of days covered (PDC) and proportion of patients non-persistent (having no prescription available) at 180 days after initiation. We fit a multivariable negative binomial model with a count of adherent days to evaluate independent factors associated with of sacubitril/valsartan adherence. Among 27 063 new sacubitril/valsartan users, most (n = 17 663, 65%) were prescribed low-dose at 24 mg/26 mg and most (n = 19 984, 74%) were switched from prior angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEi/ARB) rather than being RASi treatment naïve. Median 180-day PDC was 86% (25th-75th percentiles 58-98%). Black patients, those with high comorbid disease burden (≥8 comorbidities), and patients with recent hospitalization within 30 days had fewer adherent days, while those treated with preceding ACEi/ARB had more adherent days. Thirty-four percent of patients did not have an active sacubitril/valsartan prescription at day 180. Among these, few had preceding dose down-titrations (6% among patients on 49 mg/51 mg and 9% among patients on 97 mg/103 mg) and 68% did not have a subsequent ACEi/ARB prescription. Among patients who remained persistent, dose up-titrations occurred in 29% of patients who started on 24 mg/26 mg and 27% of patients on 49 mg/51 mg.

CONCLUSIONS

Overall adherence to sacubitril/valsartan among Medicare beneficiaries is acceptable, but is lower in Black patients, those with higher comorbidities or those who started therapy after recent hospitalization. While broad implementation of guideline-directed medical therapy is a key priority, additional focused efforts to improve adherence early after hospitalization and among at-risk patients are needed in parallel.

Association of formulary restrictions and initiation of an SGLT2i or GLP1-RA among Medicare beneficiaries with type 2 diabetes

BACKGROUND

Use of SGLT2 inhibitors (SGLT2i) and GLP-1 receptor agonists (GLP1-RA) among older adults with type 2 diabetes (T2D) has been limited.

OBJECTIVE

To examine factors associated with initiation of an SGLT2i or GLP-1RA among Medicare beneficiaries with T2D in the early years after their market approval, with a particular focus on formulary restrictions (e.g. prior authorization, step therapy requirements, higher co-pays).

METHODS

A retrospective cohort study using data from a 5% random sample of Medicare beneficiaries with T2D followed from 1/1/2015-12/31/16. Formulary restrictiveness was defined as: (1) the number of target drugs (i.e. SGLT2is or GLP1-RAs) included in tiers 1-3 of a beneficiary's formulary (greater number of drugs in tiers 1-3 being less restrictive) and (2) the number of drugs without prior authorization or step therapy (requirement to try less expensive drugs prior to "stepping up" to more expensive therapies). We used multivariable logistic regression models to estimate the association between measures of formulary restrictiveness and initiation of a target drug, controlling for patient demographics, diabetes duration, clinical comorbidities, and provider specialty.

RESULTS

Among 112,985 beneficiaries with T2D, 5,619 (5%) initiated an SGLT2i or GLP1-RA. After adjusting for baseline characteristics, patients enrolled in formularies with ≥ 2 target drugs available in tiers 1-3 had 17% higher odds of initiating an SGLT2i or GLP1-RA (aOR 1.17, 95% CI 1.05-1.31) compared to patients enrolled in formularies with 0 drugs available in tiers 1-3. There was no significant association between the number of drugs without prior authorization or step therapy requirements and initiation of a target drug (aOR 0.96, 95% CI, 0.85-1.09). Age 75 years or older (vs < 65, aOR 0.23, 95% CI 0.21-0.26) and black race (vs white, aOR 0.65, 95% CI 0.59-0.71) were associated with lower odds of initiating a target drug.

CONCLUSIONS

Having a greater number of target drugs available on less expensive formulary tiers is associated with increased odds of initiating an SGLT2i or GLP-1RA among Medicare beneficiaries with T2D.

Improved survival with post-diagnostic metformin and statin use in a racially diverse cohort of US Veterans with advanced prostate cancer

OBJECTIVE

To examine the association between post-diagnostic metformin or statin use with all-cause and prostate cancer (PCa)-specific mortality in men with advanced prostate cancer.

METHODS

Our study consisted of 4572 men (Black = 1352, White = 3192, Other Race = 28) diagnosed with advanced cancer (T4/M1/N1) between 1999 and 2013 in the Veteran Health Administration. The association between post-diagnostic (1) metformin and (2) statin use with all-cause and PCa-specific mortality was examined using multivariable, time-varying Cox Proportional Hazard Models. In a secondary analysis, models were stratified by race.

RESULTS

Post-diagnostic metformin use was associated with a reduced risk of all-cause (Hazard Ratio (HR) 0.84, 95% Confidence Interval (CI): 0.73, 0.96) and PCa-specific death (HR: 0.76, 95% CI: 0.63, 0.91). In stratified analyses, the inverse association between post-diagnostic metformin use and both all-cause PCa-specific mortality was limited to White men. Post-diagnostic statin use was associated with a reduced risk of all-cause (HR: 0.75, 95% CI: 0.68, 0.83) and PCa-specific mortality (HR: 0.72; 95% CI: 0.64, 0.81). In stratified analyses, similar inverse associations were observed for post-diagnostic statin use and all-cause and PCa-specific mortality in both Black and White men.

CONCLUSION

Post diagnostic metformin and statin use may prevent progression to lethal prostate cancer in men with advanced prostate cancer.

Identifying Racial, Ethnic, and Socioeconomic Inequities in the Use of Novel P2Y12 Inhibitors After Percutaneous Coronary Intervention

BACKGROUND

Novel P2Y12 inhibitors prasugrel and ticagrelor were approved for patients with acute coronary syndrome (ACS) in 2009 and 2011, respectively. We assessed the association of racial, ethnic, and socioeconomic factors with initiation of and adherence to novel P2Y12 inhibitors in a commercially insured population.

METHODS

We performed a retrospective cohort analysis of adults undergoing percutaneous coronary intervention with placement of a drug-eluting stent, stratified by ACS status, between January 2008 and December 2016 using Clinformatics Data Mart (OptumInsight). We estimated multivariable logistic regression models to identify factors associated with the initiation of clopidogrel vs novel P2Y12 inhibitors as well as subsequent 6-month medication adherence, assessed via pharmacy records.

RESULTS

A total of 55,664 patients were included in the analysis. Hispanic ethnicity was independently associated with the initiation of clopidogrel compared with novel P2Y12 inhibitors among ACS patients (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.04-1.36; P<.01). ACS patients with an annual median household income of over $100,000 were less likely to be started on clopidogrel when compared with those who earned less than $40,000 (OR, 0.67; 95% CI, 0.61-0.75; P<.01). Black race, Hispanic ethnicity, and lower household income were each associated with significantly reduced odds of P2Y12 inhibitor adherence.

CONCLUSION

Hispanic ethnicity and lower household income were associated with novel P2Y12 inhibitor initiation, and non-White race and ethnicity were associated with lower P2Y12 inhibitor adherence over 6-month follow-up. These findings highlight continued inequity of care, even in an insured population, and point to a need for new strategies to close these gaps.

The Potential For Bias In Machine Learning And Opportunities For Health Insurers To Address It

As the use of machine learning algorithms in health care continues to expand, there are growing concerns about equity, fairness, and bias in the ways in which machine learning models are developed and used in clinical and business decisions. We present a guide to the data ecosystem used by health insurers to highlight where bias can arise along machine learning pipelines. We suggest mechanisms for identifying and dealing with bias and discuss challenges and opportunities to increase fairness through analytics in the health insurance industry.

Visual/anatomical outcome of diabetic macular edema patients lost to follow-up for more than 1 year

To investigate the visual/anatomical outcome of diabetic macular edema (DME) patients lost to follow-up (LTFU) for more than 1 year during intravitreal anti-VEGF treatment. A retrospective review of 182 treatment-naïve DME patients was performed. Among them, we identified patients LTFU for more than 1 year during anti-VEGF treatment. Visual acuity and anatomic outcomes at the first visit, last visit before being LTFU, return visit, and after re-treatment were analyzed and compared with those of DME patients with regular follow-up. Patients who had continuous follow-up visits were assigned to the control group. Sixty patients (33%) with DME were LTFU for more than 1 year during anti-VEGF treatment. Multivariate analysis revealed that the ratio of male (p = 0.004), diabetes mellitus (DM) duration less than 5 years (p = 0.015), and poor early anatomic response (p = 0.012) were higher compared to the control group. Eighteen patients returned to the clinic and received re-treatment. After re-treatment with anti-VEGF, central subfield thickness (CST) was significantly improved to the CST of before LTFU. However, visual acuity did not recover to the level before LTFU (0.63 ± 0.26 vs. 0.45 ± 0.28, p = 0.003). About thirty percent of DME patients were LTFU for more than 1 year. Permanent visual loss was observed in these LTFU patients. Patients with a high risk of LTFU such as male, early DM, and poor response after initial injections should be treated more aggressively to improve the visual outcomes.

A Randomized Encouragement Trial to Increase Mail Order Pharmacy Use and Medication Adherence in Patients with Diabetes

BACKGROUND

Mail order pharmacy (MOP) use has been linked to improved medication adherence and health outcomes among patients with diabetes. However, no large-scale intervention studies have assessed the effect of encouraging MOP use on medication adherence.

OBJECTIVE

To assess an intervention to encourage MOP services to increase its use and medication adherence.

DESIGN

Randomized encouragement trial.

PATIENTS

63,012 diabetes patients from three health care systems: Kaiser Permanente Northern California (KPNC), Kaiser Permanente Hawaii (KPHI), and Harvard Pilgrim Health Care (HPHC) who were poorly adherent to at least one class of cardiometabolic medications and had not used MOP in the prior 12 months.

INTERVENTION

Patients were randomized to receive either usual care (control arm) or outreach encouraging MOP use consisting of a mailed letter, secure email message, and automated telephone call outlining the potential benefits of MOP use (intervention arm). HPHC intervention patients received the letter only.

MEASUREMENTS

We compared the percentages of patients that began using MOP and that became adherent to cardiometabolic medication classes during a 12-month follow-up period. We also conducted a race/ethnicity-stratified analysis.

RESULTS

During follow-up, 10.6% of intervention patients began using MOP vs. 9.3% of controls (p < 0.01); the percent of cardiometabolic medication delivered via mail was 42.1% vs. 39.8% (p < 0.01). Metformin adherence improved in the intervention arm relative to control at the two KP sites (52% vs. 49%, p < 0.01). Stratified analyses suggested a significant positive effect of the intervention in White (RR: 1.12, 95% CI: 1.03, 1.22) and Asian (RR: 1.30, 95% CI: 1.17, 1.45) patients.

CONCLUSION

This pragmatic trial showed that simple outreach to encourage MOP modestly increased its use and improved adherence measured by refills to a key class of diabetes medications in some settings. Given its minimal cost, clinicians and health systems should consider outreach interventions to actively promote MOP use among diabetes patients.

TRIAL REGISTRATION

ClinicalTrials.gov registration number: NCT02621476.

Racial disparities in medication use: imperatives for managed care pharmacy

The COVID-19 pandemic and the social unrest pervading U.S. cities in response to the killings of George Floyd and other Black citizens at the hands of police are historically significant. These events exemplify dismaying truths about race and equality in the United States. Racial health disparities are an inexcusable lesion on the U.S. health care system. Many health disparities involve medications, including antidepressants, anticoagulants, diabetes medications, drugs for dementia, and statins, to name a few. Managed care pharmacy has a role in perpetuating racial disparities in medication use. For example, pharmacy benefit designs are increasingly shifting costs of expensive medications to patients, creating affordability crises for lower income workers, who are disproportionally persons of color. In addition, the quest to maximize rebates serves to inflate list prices paid by the uninsured, among which Black and Hispanic people are overrepresented. While medication cost is a foremost barrier for many patients, other factors also propagate racial disparities in medication use. Even when cost sharing is minimal or zero, medication adherence rates have been documented to be lower among Blacks as compared with Whites. Deeper understandings are needed about how racial disparities in medication use are influenced by factors such as culture, provider bias, and patient trust in medical advice. Managed care pharmacy can address racial disparities in medication use in several ways. First, it should be acknowledged that racial disparities in medication use are pervasive and must be resolved urgently. We must not believe that entrenched health system, societal, and political structures are impermeable to change. Second, the voices of community members and their advocates must be amplified. Coverage policies, program designs, and quality initiatives should be developed in consultation with those directly affected by racial disparities. Third, the industry should commit to dramatically reducing patient cost sharing for essential medication therapies. Federal and state efforts to limit annual out-of-pocket pharmacy spending should be supported, even though increased premiums may be an undesirable (yet more equitable) consequence. Finally, information about race should be incorporated into all internal and external reporting and quality improvement activities. DISCLOSURES: No funding was received for the development of this manuscript. Kogut is partially supported by Institutional Development Award Numbers U54GM115677 and P20GM125507 from the National Institute of General Medical Sciences of the National Institutes of Health, which funds Advance Clinical and Translational Research (Advance-CTR), and the RI Lifespan Center of Biomedical Research Excellence (COBRE) on Opioids and Overdose, respectively. The content is solely the responsibility of the author and does not necessarily represent the official views of the National Institutes of Health.

An Effectiveness Evaluation of a Primary Care-Embedded Clinical Pharmacist-Led Intervention Among Blacks with Diabetes

BACKGROUND

Black individuals with type 2 diabetes suffer disproportionate morbidity and mortality relative to whites with type 2 diabetes, irrespective of health insurance coverage.

OBJECTIVE

Examine the impact of a primary care-embedded clinical pharmacist-led intervention (UCMyRx) on cardiovascular risk factor control among blacks with type 2 diabetes in a large healthcare system.

DESIGN

We used data extracted from the electronic health records (EHR) system and a difference-in-differences study design with a propensity-matched comparison group to evaluate the impact of UCMyRx on HbA1c and systolic blood pressure (SBP) among black patients with type 2 diabetes, relative to usual care.

PARTICIPANTS

Individuals with type 2 diabetes identified as either black or African American in the EHR that were ≥ 18 years of age that had the following observations during the study window (03/02/2013-12/31/18: (1) HbA1C ≥ 8%, at least once, anywhere between 365 days before and 14 days after the UCMyRx visit and a follow-up HbA1c measure within 120 to 365 days after the visit and/or (2) SBP ≥ 140 mmHg at least once between 365 days before and 14 days after the UCMyRx visit that had a follow-up SBP measure within 120 to 450 days after the visit.

INTERVENTION

UCMyRx pharmacists review labs and vital signs, perform medication reconciliation, use a standardized survey to assess barriers to medication adherence, and develop tailored interventions to improve medication adherence.

MAIN MEASURES

Change in HbA1c and change in SBP from before to after the first UCMyRx visit.

KEY RESULTS

Having at least one visit with a UCMyRx clinical pharmacist was associated with a significant reduction in HbA1c (- 0.4%, p value = .01); however, there was no significant impact on SBP (- .051 mmHg, p value = 0.74).

CONCLUSIONS

The UCMyRx intervention is a useful strategy for improving HbA1c control among blacks with type 2 diabetes.

Cost-Related Medication Nonadherence in Adults With Atherosclerotic Cardiovascular Disease in the United States, 2013 to 2017

Background:

Medication nonadherence is associated with worse outcomes in patients with atherosclerotic cardiovascular disease (ASCVD), a group who requires long-term therapy for secondary prevention. It is important to understand to what extent drug costs, which are potentially actionable factors, contribute to medication nonadherence.

Methods:

In a nationally representative survey of US adults in the National Health Interview Survey (2013–2017), we identified individuals ≥18 years with a reported history of ASCVD. Participants were considered to have experienced cost-related nonadherence (CRN) if in the preceding 12 months they reported skipping doses to save money, taking less medication to save money, or delaying filling a prescription to save money. We used survey analysis to obtain national estimates.

Results:

Of the 14 279 surveyed individuals with ASCVD, a weighted 12.6% (or 2.2 million [95% CI, 2.1–2.4]) experienced CRN, including 8.6% or 1.5 million missing doses, 8.8% or 1.6 million taking lower than prescribed doses, and 10.5% or 1.9 million intentionally delaying a medication fill to save costs. Age <65 years, female sex, low family income, lack of health insurance, and high comorbidity burden were independently associated with CRN, with >1 in 5 reporting CRN in these subgroups. Survey respondents with CRN compared with those without CRN had 10.8-fold higher odds of requesting low-cost medications and 8.9-fold higher odds of using alternative, nonprescription, therapies.

Conclusions:

One in 8 patients with ASCVD reports nonadherence to medications because of cost. The removal of financial barriers to accessing medications, particularly among vulnerable patient groups, may help improve adherence to essential therapy to reduce ASCVD morbidity and mortality.

Determination of factors affecting medication adherence in type 2 diabetes mellitus patients using a nationwide claim-based database in Japan

BACKGROUND

The extent of medication adherence in patients with type 2 diabetes mellitus (T2DM) several years after starting treatment with hypoglycemic agents remains unknown. Most previous work on medication adherence targeting this group of patients has been undertaken across a single year or is questionnaire based. This study aimed to determine medication adherence status and factors affecting adherence 3 years after initiation of hypoglycemic agents, using a nationwide medical claim-based database in Japan.

METHODS

This retrospective study was conducted on data from 884 subjects with T2DM to better understand medication adherence, the effects of polypharmacy, and other factors. We also investigated the effects of medication nonadherence on hemoglobin A1c levels. Proportion of days covered was defined as the number of days for which a hypoglycemic agent was prescribed and in the patient's possession to the number of days in the observation period. A proportion of days covered ≥0.8 were considered adherent, and those with a value <0.8 as nonadherence. Polypharmacy was defined as taking ≥5 medications.

RESULTS

Of the 884 patients investigated, 440 were considered adherent during the study period. Significant factors related to adherence included number of medications (3 or 4, or ≥5), male sex, age 50-<60 years, and total number of visits ≥17. Medication adherence was also a factor related to patients with hemoglobin A1c values < 7.0% at the end of the observation period.

CONCLUSIONS

We surveyed medication adherence for 3 years with post medication initiation, and found that subjects aged 50-<60 years, those with ≥3 concomitant medications, and those with a total number of visits ≥17 were more likely to be adherent and persistent, and more likely to continue their hypoglycemic agents. A high degree of medication adherence was found to have a positive influence on hemoglobin A1c levels.

Self-reported barriers to medication use in older women: Findings from the Women's Health Initiative

OBJECTIVES

To describe the prevalence of, types of, and characteristics associated with self-reporting multiple (≥ 2) barriers to medication use in older women using long-term cardiovascular and oral hypoglycemic medications.

METHODS

This cross-sectional study set at the Women's Health Initiative during 2005-2010 included women who were using any chronic medication from 3 target classes (i.e., antilipemics, antihypertensives, oral hypoglycemics) for at least 1 month and who had answered questions about barriers to medication use at year 4 (2009) of the study period (N = 59,054). Measurements included common self-reported barriers to medication use, and sociodemographic, health characteristic, medication use, and access to care variables were evaluated. Multivariable logistic regression models were used to examine associations between participant characteristics and barriers to medication use.

RESULTS

Among the participants, 47,846 (81%) reported no barriers, 7105 (12%) reported 1 barrier, and 4103 (6.9%) reported 2 or more barriers to medication use. The most common barriers reported were having concerns about adverse effects, not liking to take medications, and medications costing too much. Several characteristics were found to be associated with reporting 2 or more barriers in multivariable modeling, including demographic (e.g., lower age, black race, Hispanic ethnicity) and health or medication (e.g., lower quality of life, lower physical function, higher number of concurrent medications) characteristics.

CONCLUSION

Among older women using chronic cardiovascular and oral hypoglycemic medications, approximately 20% reported at least 1 barrier to medication use, with 7% of women reporting multiple barriers. Pharmacists should prioritize identifying barriers to medication use in older women using chronic medications to improve patient care.

Evaluation of pharmacy-based telephone interventions on medication pick-up rates: a retrospective, quality improvement study at charity outpatient clinics

OBJECTIVES

To evaluate a live telephonic outreach intervention made by clinical pharmacists and clinical pharmacy technicians on medication pick-up rates.

METHODS

A retrospective, quality improvement study conducted at six outpatient charity clinics in Dallas-Fort Worth area between 1 January 2017 and 31 July 2017. A live telephonic call was made by a pharmacy team member if the patient did not pick-up at least one prescription item. Patients may receive more than one call if they did not pick-up medication(s) more than once during the study period. A live telephonic call resulted in three categories: contacted, left a voice message and unable to contact. Medication pick-up rates were obtained from a pharmacy claims database.

KEY FINDINGS

The study population included 1726 individual patients who failed to pick-up at least one medication from Baylor Scott & White Health pharmacy. A total of 2551 live telephonic calls were made for the study population. A total of 1175 live telephonic calls (46.1%, n = 2551) resulted in a patient picking up medication(s). Results from the generalized estimating equation logistic regression models showed that patients who received a voice message (OR: 1.37; 95% CI: 1.05 to 1.80; P < 0.021) or was contacted (OR: 1.99; 95% CI: 1.54 to 2.60; P < 0.001) were more likely to pick-up their medications as compared to the 'unable to contact' group.

CONCLUSIONS

Telephonic interventions from the pharmacy team can serve as a successful means to increase medication pick-up rates among charity clinic patients.

Opportunities to encourage mail order pharmacy delivery service use for diabetes prescriptions: a qualitative study

Background

Medication non-adherence is a major contributor to poor outcomes in diabetes. Previous research has shown an association between use of mail order pharmacy delivery and better medication adherence, but little is known about the barriers and facilitators to mail order pharmacy use in diabetes patients. This qualitative study examined factors related to mail order pharmacy use versus traditional “brick and mortar” pharmacies to refill prescriptions.

Methods

We conducted four 90-min focus groups in 2016 among 28 diabetes patients in the Hawaii and Northern California regions of Kaiser Permanente, a large integrated health care delivery system. We queried participants on their preferred mode for refilling prescriptions and perceived barriers and facilitators of mail order pharmacy use. One researcher independently coded each focus group transcript, with two of these transcripts double-coded by a second researcher to promote reliability. We employed thematic analysis guided by the Capability, Opportunity, Motivation, and Behavior (COM-B) framework using NVivo 11 software.

Results

A total of 28 diabetes patients participated. Participants’ average age was 64.1 years; 57% were female; and racial/ethnic backgrounds included Asian/Native Hawaiian/Pacific Islander (36%), Black/African-American (21%) Hispanic/Latino (7%), and non-Hispanic White (36%). Analysis uncovered 26 themes related to the decision to use mail order pharmacy, with each theme representing a barrier or facilitator mapped to the COM-B framework. Most themes (20/26) fell into the COM-B category of ‘Opportunity.’ Opportunity barriers to mail order pharmacy use included unpredictability of medication delivery date, concerns about mail security, and difficulty coordinating refill orders for multiple prescriptions. In contrast, facilitators included greater access and convenience (e.g., no need to wait in line or arrange transportation) compared to traditional pharmacies. Motivational facilitators to mail order pharmacy use included receiving a pharmacy benefit plan incentive of a free one-month supply of prescriptions.

Conclusions

This study found that while patients with diabetes may benefit from mail order pharmacy use, they perceive numerous barriers to using the service. These findings will inform the design of interventions and quality improvement initiatives to increase mail order pharmacy use, which in turn may improve medication adherence and outcomes in diabetes patients, across health care systems.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4250-7) contains supplementary material, which is available to authorized users.

Clair P, Goldman DP, Joyce G. Racial and ethnic disparities in medication adherence among privately insured patients in the United States

OBJECTIVE

To examine the association between socioeconomic status (SES) and racial and ethnic disparities in medication adherence for three widely prescribed therapeutic classes.

METHODS

We linked longitudinal claims data from a large US-based insurance provider (2011-2013) to detailed SES information to identify patients treated with oral antidiabetic (N = 56,720), antihypertensive (N = 156,468) or antihyperlipidemic (N = 144,673) medications. We measured adherence and discontinuation by therapeutic class, and conducted regression analysis to quantify the contributions of different factors in the association between race/ethnicity and medication adherence.

RESULTS

During an average follow-up period of 2.5 years, average adherence rates of Blacks and Hispanics were at least 7.5 percentage points lower than those of Whites. Controlling for demographics, health status, out-of-pocket costs, convenience of refilling prescriptions and SES attenuated the association by 30 to 50 percent, nonetheless substantial racial disparities persisted (4.1-5.8 percentage points), particularly for asymptomatic conditions. Separating adherence among existing users from those that discontinued therapies indicates that racial/ethnic disparities in adherence reflect inconsistent pill-taking rather than differential rates of discontinuation.

CONCLUSIONS

Racial/ethnic disparities in adherence are mitigated, but persist after controlling for detailed socioeconomic measures. Interventions should focus more on improving medication adherence of existing users, particularly in treating asymptomatic conditions.

Factors Related to Adherence to Opioids in Black Patients With Cancer Pain

CONTEXT

Cancer pain relief is often inadequate because of poor adherence to pain medication, especially for black patients.

OBJECTIVES

The purpose of this study is to describe factors related to adherence to around-the-clock opioids among 110 black patients being treated for cancer pain.

METHODS

Sociodemographic, clinical, symptoms, and social support data were collected at baseline; pain and adherence data were collected at 30 days. Associations between these variables and opioid adherence measured by Medication Event Monitoring System were estimated using multiple regression.

RESULTS

Mean age was 56 (±10.1), the majority were women (63%) and college educated (56%). Mean pain severity at baseline equaled 4.6 (±2.3). Mean dose adherence was 60% (±28.5), while mean schedule adherence was 33.0% (±31.0). In adjusted analysis, 26% of the variance in dose adherence was explained by recent chemotherapy, changes in pain, concerns about nausea, and doctors' focus on cure versus pain control (P<0.001); 27% of the variance in schedule adherence was explained by recent chemotherapy, changes in pain, symptom burden, and concerns about doctors focus on cure versus pain control (P<0.001).

CONCLUSION

Findings confirm pain medication adherence is poor and pain was not well relieved. Multiple factors influence adherence to around-the-clock opioids. Clinicians need to partner with patients by providing a personalized pain treatment plan including an in-depth assessment of treatment choices and adherence.

Differences in health outcomes associated with initial adherence to oral antidiabetes medications among veterans with uncomplicated Type 2 diabetes: a 5-year survival analysis

AIM

To determine the association of adherence to oral antidiabetes medication with macrovascular and microvascular complications, time to insulin therapy, revascularization, admissions, and death among veterans with uncomplicated diabetes.

METHODS

This was a retrospective cohort study using the Veterans Affairs Corporate Data Warehouse to examine 159 032 veterans diagnosed with uncomplicated diabetes during 2002-2014 and starting oral antidiabetes therapy for the first time. The first uncomplicated diabetes diagnosis was identified and confirmed by subsequent oral antidiabetes therapy initiation. Adherence was calculated from outpatient pharmacy records using the proportion of days covered over the first year of therapy. Health outcomes were observed up to 5 years beyond the first oral antidiabetes agent fill, and compared according to adherence status using Cox proportional hazards models adjusted for baseline demographic and clinical characteristics.

RESULTS

During the first 5 years of oral antidiabetes treatment, people initially non-adherent to oral antidiabetes therapy were more likely to experience myocardial infarction (hazard ratio 1.14, 95% CI 1.03-1.27) and ischaemic stroke (hazard ratio 1.22, 95% CI 1.05-0.1.42), or to die (hazard ratio 1.21; 95% CI 1.15-1.28). Veterans with <20% adherence to oral antidiabetes therapy in the first year had particularly high hazards for ischaemic stroke (hazard ratio 1.78, 95% CI 1.27-2.49) and all-cause death (hazard ratio 1.33, 95% CI 1.17-151). Adherent people were more likely to be diagnosed with a microvascular complication or chronic kidney disease.

CONCLUSIONS

People who are non-adherent to treatment were more likely to experience detrimental health outcomes within the first 5 years of antidiabetes therapy. Adherence is paramount to disease management and this should be stressed from the time at which treatment is initiated.

The association of metformin use with prostate cancer aggressiveness among Black Americans and White Americans in a population-based study

PURPOSE

Metformin has been associated with a reduced incidence of prostate cancer and improved prostate cancer outcomes. However, whether race modifies the association between metformin use and prostate cancer aggressiveness remains uncertain. The association between metformin use and prostate cancer aggressiveness was examined separately in Black Americans (Blacks) and White Americans (Whites).

METHODS

The study population consisted of 305 Black and 195 White research participants with incident prostate cancer and self-reported diabetes from the North Carolina-Louisiana Prostate Cancer Project. High-aggressive prostate cancer was defined using a composite measure of Gleason sum, prostate-specific antigen, and clinical stage. Multivariable logistic regression was used to assess the association between metformin use and high-aggressive prostate cancer at diagnosis, separately among Whites and Blacks, with adjustment for age, screening history, site, education, insurance, and body mass index.

RESULTS

Metformin use was associated positively with high-aggressive prostate cancer in Blacks (OR 2.01; 95% CI 1.05, 3.83). By contrast, a weak inverse association between metformin use and high-aggressive prostate cancer was found in Whites (OR 0.80, 95% CI 0.34, 1.85).

CONCLUSIONS

The association between metformin use and prostate cancer aggressiveness may be modified by race.

Disparities in Initial Oral Antidiabetic Medication Adherence Among Veterans with Incident Diabetes

BACKGROUND

Medication nonadherence is a prevalent public health issue, particularly among patients with diabetes mellitus (DM), and negatively affects health outcomes. Because of the prevalence of DM among U.S. veterans, it is crucial to understand how well these patients adhere to oral antidiabetic (OAD) medication and whether certain subgroups are more likely to be nonadherent.

OBJECTIVE

To assess initial OAD medication use among veterans with uncomplicated DM and determine factors associated with adherence in the first 2 years of treatment.

METHODS

This was a retrospective cohort study using data from the Veterans Affairs (VA) Corporate Data Warehouse from 2002 through 2014. The first diagnosis for uncomplicated DM was determined, and then medication use was assessed following OAD initiation. OAD use was assessed by proportion of days covered (PDC) for the first 2 years of therapy using outpatient VA pharmacy records. Adherence was determined both continuously and categorically, with a PDC of ≥ 80% used to indicate adherence. Logistic regression was used to determine if certain patient characteristics were associated with being adherent to OADs.

RESULTS

A total of 148,544 veterans with uncomplicated DM were assessed, most of whom were white, aged ≥ 55 years, and initiated OAD therapy on metformin. A large portion resided in the southern part of the United States. In the first year, PDC averaged 79.2% (SD = 25.9), and 63.2% were adherent to OAD therapy; however, these numbers declined in the second year, when the average PDC was 71.3% (SD = 35.8), and only 59.1% were adherent. Over the course of both years, PDC averaged 75.3% (SD = 28.4), and 50.9% were adherent. The odds of being adherent were higher among older adults and significantly lower among veterans self-identifying as either African American (OR = 0.61; 95% CI = 0.59-0.63), Native American (OR = 0.67; 95% CI = 0.61-0.75), or Hawaiian/Pacific Islander (OR = 0.84; 95% CI = 0.76-0.92) when compared with whites. Veterans who were either divorced/separated (OR = 0.86; 95% CI = 0.83-0.88) or never married (OR = 0.89; 95% CI = 0.86-0.93) also had lower odds of being initially adherent to OAD therapy compared with those who reported being married. Being nonadherent in year 1 was highly predictive of remaining nonadherent in year 2 (OR = 12.8; 95% CI = 12.23-12.94), with only 22.2% nonadherent in the first year (8.2% overall) becoming adherent in the second year of therapy. Across both years, all minorities were less likely to be adherent (compared with whites), and average adherence differed among all geographic regions of the country.

CONCLUSIONS

Within the first year of OAD therapy, medication adherence was suboptimal among veterans with DM, and second-year results indicate that adherence is likely to decline over time. Future studies should consider deeper regional and subgroup analysis to determine what contributes to variation in medication use in communities across the country.

DISCLOSURES

This study was supported by a KL2 Career Development Grant from the University of Tennessee Health Science Center's Institute for Research, Innovation, Synergy and Health Equity and by resources from the U.S. Department of Veterans Affairs. Hung and Kovesdy are employees of the Department of Veterans Affairs. Opinions expressed are those of the study authors and do not necessarily reflect the views of the Department of Veterans Affairs. None of the authors declared significant relevant financial conflicts of interest. Results of this study were presented as a poster at the Academy of Managed Care Pharmacy Nexus Conference on October 3-6, 2016, in National Harbor, Maryland.

Association of functional and structural social support with medication adherence among individuals treated for coronary heart disease risk factors: Findings from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study

Background

Functional social support has a stronger association with medical treatment adherence than structural social support in several populations and disease conditions. Using a contemporary U.S. population of adults treated with medications for coronary heart disease (CHD) risk factors, the association between social support and medication adherence was examined.

Methods

We included 17,113 black and white men and women with CHD or CHD risk factors aged ≥45 years recruited 2003–2007 from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study. Participants reported their perceived social support (structural social support: being partnered, number of close friends, number of close relatives, and number of other adults in household; functional social support: having a caregiver in case of sickness or disability; combination of structural and functional social support: number of close friends or relatives seen at least monthly). Medication adherence was assessed using a 4-item scale. Multi-variable adjusted Poisson regression models were used to calculate prevalence ratios (PR) for the association between social support and medication adherence.

Results

Prevalence of medication adherence was 68.9%. Participants who saw >10 close friends or relatives at least monthly had higher prevalence of medication adherence (PR = 1.06; 95% CI: 1.00, 1.11) than those who saw ≤3 per month. Having a caregiver in case of sickness or disability, being partnered, number of close friends, number of close relatives, and number of other adults in household were not associated with medication adherence after adjusting for covariates.

Conclusions

Seeing multiple friends and relatives was associated with better medication adherence among individuals with CHD risk factors. Increasing social support with combined structural and functional components may help support medication adherence.

Dose-Dependent Relationship Between Metformin and Colorectal Cancer Occurrence Among Patients with Type 2 Diabetes-A Nationwide Cohort Study

BACKGROUND: Increasing bodies of evidence suggest that metformin may be beneficial in the primary prevention of colorectal cancer (CRC), and a dose–response relationship has been reported. However, long-term epidemiological observations between the treatment period, cumulative dose, and intensity of metformin and CRC are rarely reported. The aim of this study was to identify the association between the effect of metformin and CRC development in a nationwide cohort study. METHODS: This nationwide population-based study examined a cohort of 1,000,000 patients randomly sampled from individuals enrolled in the Taiwan National Health Insurance system. Patients with newly diagnosed type 2 diabetes mellitus (DM) between 1997 and 2007 were enrolled. A statistical variables, including the demographic data, treatment period, cumulative dose, and intensity of metformin use, was compared between patients developing CRC and those without CRC. RESULTS: This study included 47,597 patients. The mean follow-time was 7.17 ± 3.21 years. After adjustment, metformin use was an independent protective factor against CRC development (P < .001). Although the protective ability of metformin against CRC development was reduced during long-term therapy, the risk of CRC decreased progressively with a higher cumulative dose or higher intensity of metformin use (both P < .001). CONCLUSION: This study revealed that metformin use significantly reduced the risk of CRC in a dose-dependent manner in patients with type 2 DM in the Taiwanese population. However, a gradual decline in medication adherence may reduce the protective ability of metformin against CRC development during long-term therapy.

Associations Among Depressive Symptoms, Wellness, Patient Involvement, Provider Cultural Competency, and Treatment Nonadherence: A Pilot Study Among Community Patients Seen at a University Medical Center

Treatment nonadherence is a pernicious problem associated with increasing rates of chronic diseases, escalating healthcare costs, and rising mortality in some patients. Although researchers have suggested numerous factors related to treatment nonadherence, several understudied aspects warrant attention, such as primary-care settings, provider cultural competence, and patient involvement. Adding to the research base, the present pilot study examined 88 primarily Black American and White American community patients from a large university medical center in the southern part of the United States. The study explored two research questions: (a) To what extent are there associations among depressive symptoms, wellness, patient involvement, cultural competency, and treatment nonadherence in a racially diverse community patient population? And (b) to what extent do the study exploratory variables and background characteristics predict treatment nonadherence, both separately and jointly? Depressive symptoms, the patient's perception of a provider's cultural competence, and marital/partnered status were found to be statistically significantly associated with treatment nonadherence, but not entirely in the directions expected.

Primary nonadherence to chronic disease medications: a meta-analysis

BACKGROUND

Medication nonadherence is a global problem that requires urgent attention. Primary nonadherence occurs when a patient consults with a medical doctor, receives a referral for medical therapy but never fills the first dispensation for the prescription medication. Nonadherence to chronic disease medications costs the USA ~$290 billion (USD) every year in avoidable health care costs. In Canada, it is estimated that 5.4% of all hospitalizations are due to medication nonadherence.

OBJECTIVES

The objective of this study was to quantify the extent of primary nonadherence for four of the most common chronic disease medications. The second objective was to identify factors associated with primary nonadherence to chronic disease medications.

MATERIALS AND METHODS

We conducted an extensive systematic literature review of eight databases with a wide range of keywords. We identified relevant articles for primary nonadherence to antihypertensives, lipid-lowering agents, hypoglycemics, and antidepressants. After further screening and assessment of methodologic quality, relevant data were extracted and analyzed using a random-effects model.

RESULTS

Twenty-four articles were included for our meta-analysis after full review and assessment for risk of bias. The pooled primary nonadherence rate for the four chronic disease medications was 14.6% (95% CI: 13.1%-16.2%). Primary medication nonadherence was higher for lipid-lowering medications among the four chronic disease medications assessed (20.8%; 95% CI: 16.0%-25.6%). The rates in North America (17.0%; 95% CI: 14.4%-19.5%) were twice those from Europe (8.5%; 95% CI: 7.1%-9.9%). The absence of social support (20%; 95% CI: 14.4%-26.6%) was the most common sociodemographic variable associated with chronic disease medication primary nonadherence.

CONCLUSION

Evidence suggests that a considerable percentage of patients do not initially fill their medications for treatable chronic diseases or conditions. This represents a major health care problem that can be successfully addressed. Efforts should be directed toward proper medication counseling, patient social support, and clinical follow-up, especially when the indications for the prescribed medication aim to provide primary prevention.

"I did not want to take that medicine": African-Americans' reasons for diabetes medication nonadherence and perceived solutions for enhancing adherence

BACKGROUND

Diabetes is disproportionally burdensome among African-Americans (AAs) and medication adherence is important for optimal outcomes. Limited studies have qualitatively examined reasons for nonadherence among AAs with type 2 diabetes, though AAs are less adherent to prescribed medications compared to whites. This study explored the reasons for medication nonadherence and adherence among AAs with type 2 diabetes and examined AAs' perceived solutions for enhancing adherence.

METHODS

Forty AAs, age 45-60 years with type 2 diabetes for at least 1 year prior, taking at least one prescribed diabetes medication, participated in six semistructured 90-minute focus groups. Using a phenomenology qualitative approach, reasons for nonadherence and adherence, as well as participants' perceived solutions for increasing adherence were explored. Qualitative content analysis was conducted.

RESULTS

AAs' reasons for intentional nonadherence were associated with 1) their perception of medicines including concerns about medication side effects, as well as fear and frustration associated with taking medicines; 2) their perception of illness (disbelief of diabetes diagnosis); and 3) access to medicines and information resources. Participants reported taking their medicines because they valued being alive to perform their social and family roles, and their belief in the doctor's recommendation and medication helpfulness. Participants provided solutions for enhancing adherence by focusing on the roles of health care providers, patients, and the church. AAs wanted provider counseling on the necessity of taking medicines and the consequences of not taking them, indicating the need for the AA community to support and teach self-advocacy in diabetes self-management, and the church to act as an advocate in ensuring medication use.

CONCLUSION

Intentional reasons of AAs with type 2 diabetes for not taking their medicines were related to their perception of medicines and illness. Solutions for enhancing diabetes medication adherence among AAs should focus on the roles of providers, patients, and the church.

Examining Factors Associated With Nonadherence And Identifying Providers Caring For Nonadherent Subgroups

Objectives

To examine racial/ethnic and regional differences in medication adherence in patients with diabetes taking oral anti-diabetic, anti-hypertensive, and cholesterol lowering medications and to identify the pharmacies and prescribers who serve these communities.

Methods

Administrative claims data was analyzed for members enrolled in a large health plan in Hawaii (2008-2010) with diabetes mellitus who were taking three types of medications: 1) oral anti-diabetic medications; 2) anti-hypertensive medications; 3) cholesterol lowering medications (n=5136). The primary outcome was medication adherence based on medication possession ratios. Multivariable logistic regression models were estimated to examine the association between race/ethnicity and region to adherence to each drug class separately, followed by non-adherence to all three. Covariates included age, gender, education level, chronic conditions, copayment level, and number of prescribers and pharmacies from which the patients received their medications.

Key Findings

After adjustment for other factors, Filipinos [OR=0.58, 95%CI(0.45,0.74)], Native Hawaiians [OR=0.74, 95%CI(0.56,0.98)], and people of other race [OR=0.67, 95%CI(0.55,0.82)] were significantly less adherent to anti-diabetic and anti-hypertensive medications than Japanese. For cholesterol-lowering medications, all racial and ethnic groups were significantly less adherent than Japanese, except mixed race. We also found that different racial/ethnic groups tended to use different pharmacies and prescribers, particularly in rural areas.

Conclusion

Adherence differed by race/ethnicity as well as age and region. Qualitative research involving subgroups (e.g. Filipinos, Native Hawaiians, people under age 50) is needed to identify how to adapt and enhance the effects of interventions shown to be efficacious in prior studies.

Psychosocial factors in medication adherence and diabetes self-management: Implications for research and practice

Diabetes is a chronic illness that places a significant self-management burden on affected individuals and families. Given the importance of health behaviors-such as medication adherence, diet, physical activity, blood glucose self-monitoring-in achieving optimal glycemic control in diabetes, interventions designed and delivered by psychologists hold promise in assisting children, adolescents, and adults with diabetes in improving their health status and lowering their risk of serious complications. This article first provides an overview of diabetes self-management and associated challenges and burdens. Socioeconomic status factors that may influence diabetes management and outcomes are briefly highlighted. We then review the evidence base for select psychosocial factors that may be implicated in diabetes self-management. Modifiable targets of psychological intervention are presented across 3 overarching domains: (a) knowledge, beliefs, and related cognitive constructs; (b) emotional distress and well-being; and (c) behavioral skills and coping. Important methodological issues facing future research are discussed, along with opportunities for psychologists in improving the care and treatment outcomes of individuals and families living with diabetes. In conclusion, we advocate for continued research emphasis on improving psychosocial aspects of living with diabetes, with greater attention to the situational context in which the self-regulatory processes underlying self-management occur. Psychologists have important roles to play in reducing emotional distress, improving patient knowledge, and providing training in behavioral skills to promote successful self-management and to support patient-centered diabetes care. (PsycINFO Database Record

Comparison of self-report and electronic monitoring of 6MP intake in childhood ALL: a Children's Oncology Group study

Adequate exposure to oral 6-mercaptopurine (6MP) during maintenance therapy for childhood acute lymphoblastic leukemia (ALL) is critical for sustaining durable remissions; accuracy of self-reported 6MP intake is unknown. We aimed to directly compare self-report to electronic monitoring (Medication Event Monitoring System [MEMS]) and identify predictors of overreporting in a cohort of 416 children with ALL in first remission over 4 study months (1344 patient-months for the cohort) during maintenance therapy. Patients were classified as "perfect reporters" (self-report agreed with MEMS), "overreporters" (self-report was higher than MEMS by ≥5 days/month for ≥50% of study months), and "others" (not meeting criteria for perfect reporter or overreporter). Multivariable logistic regression examined sociodemographic and clinical characteristics, 6MP dose intensity, TPMT genotype, thioguanine nucleotide levels, and 6MP nonadherence (MEMS-based adherence <95%) associated with the overreporter phenotype; generalized estimating equations compared 6MP intake by self-report and MEMS. Self-reported 6MP intake exceeded MEMS at least some of the time in 84% of patients. Fifty patients (12%) were classified as perfect reporters, 98 (23.6%) as overreporters, 2 (0.5%) as underreporters, and 266 (63.9%) as others. In multivariable analysis, the following variables were associated with the overreporter phenotype: non-white race: Hispanic, odds ratio (OR), 2.4, P = .02; Asian, OR, 3.1, P = .02; African American, P < .001; paternal education less than college (OR, 1.4, P = .05); and 6MP nonadherence (OR, 9.4, P < .001). Self-report of 6MP intake in childhood ALL overestimates true intake, particularly in nonadherent patients, and should be used with caution.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Mediators and Moderators of Improvements in Medication Adherence

OBJECTIVE

In a randomized controlled trial we compared two models of community health worker-led diabetes medication decision support for low-income Latino and African American adults with diabetes. Most outcomes were improved when community health workers used either an interactive e-Health tool or print materials. This article investigates mediators and moderators of improved medication adherence in these two models.

METHOD

Because both programs significantly improved satisfaction with medication information, medication knowledge, and decisional conflict, we examined whether improvements in each of these outcomes in turn were associated with improvements in self-reported medication adherence, and if so, whether these improvements were mediated by improvements in diabetes self-efficacy or diabetes distress. Potential moderators of improvement included gender, race/ethnicity, age, education, insulin use, health literacy, and baseline self-efficacy, diabetes distress, and A1c.

RESULTS

A total of 176 participants (94%) completed all assessments. After adjusting for potential confounders, only increased satisfaction with medication information was correlated with improved medication adherence ( p = .024). Improved self-efficacy, but not diabetes distress, was associated with improvements in both satisfaction with medication information and medication adherence. However, the Sobel-Goodman Mediation test did not support improvements in self-efficacy as a mechanism by which improved satisfaction led to better adherence. None of the examined variables achieved statistical significance as moderators.

CONCLUSIONS

Improvements in satisfaction with medication information but not in medication knowledge or decision conflict were associated with improvements in medication adherence. Interventions that target low-income ethnic and racial minorities may need to focus on increasing participants' satisfaction with information provided on diabetes medications and not just improving their knowledge about medications. Future research should explore in more depth other possible mediators and moderators of improvements in medication adherence in low-income minority populations.

Predictors of Change in Adherence Status from 1 Year to the Next Among Patients with Type 2 Diabetes Mellitus on Oral Antidiabetes Drugs

BACKGROUND

Diabetes is a leading cause of morbidity, mortality, and medical resource utilization in the United States and worldwide. Treatment is aimed at keeping blood glucose levels close to normal and preventing or delaying medical complications. It has been estimated that only 50% of patients with diabetes in the United States achieve glycosylated hemoglobin A1c level < 7%. Nonadherence to antidiabetic medications has been identified as a major factor related to poor glycemic control.

OBJECTIVES

To (a) assess adult patients with type 2 diabetes mellitus (T2DM) whose adherence status to oral antidiabetic drugs (OADs) changed from 1 year to the next and (b) identify predictors of change in adherence status.

METHODS

This retrospective study of the Humana Medicare Advantage Database included patients with T2DM and continuous enrollment between 2010 and 2012. Proportion of days covered (PDC) by OADs was calculated for each of the 3 study years (2010, 2011, 2012). Patients were classified as adherent (PDC ≥ 80%) or nonadherent (PDC < 80%) during each year. Patient characteristics from the baseline period (2010) were used as covariates, and adherence status changes from baseline to follow-up year (2011) were used as response variables. Data from the subsequent study periods (2011 as baseline, 2012 as follow-up) were used to validate the model (final model).

RESULTS

A total of 238,402 patients met inclusion criteria. Among them, 144,216 (60.5%) were adherent, and 94,186 (39.5%) were nonadherent during the baseline period. Change in adherence status from baseline to follow-up year was observed in 31,320 (21.7%) patients that were adherent and 39,284 (41.7%) patients that were nonadherent during the baseline year. The final model for baseline adherent patients had a receiver-operating characteristic (ROC) index of 73% and a misclassification rate of 39%. The predictors of highest importance were identified as total number of prescriptions filled with 90-day supply, diabetes-related pill burden, longest gap in OADs, total number of antidiabetic classes filled, and copay for the last OAD filled. The final model had a sensitivity value of 76.4%. The final model for baseline nonadherent patients had a ROC index of 68%, a misclassification rate of 36.4%, and sensitivity value of 52.9%. The predictors of highest importance were diabetes-related pill burden, longest gap in OADs, month-wise patient oscillation from adherent to nonadherent during baseline year, total number of prescriptions filled with a 90-day supply, and total pill burden during the baseline year.

CONCLUSIONS

One third of the T2DM patients changed adherence status from 1 year to the next, and factors associated with adherence status changes were identified. Predictive models such as those used in this study can serve as useful and cost-effective tools for payers, helping to identify members that should be targeted for adherence enhancement programs and, ultimately, to improve patients' long-term outcomes.

DISCLOSURES

Funding for this research was provided by Eli Lilly and Company. Comprehensive Health Insights, owned by Humana, completed this study. Peng, Fu, Ascher-Svanum, Ali, and Rodriguez are employees of Eli Lilly and Company. Saundankar and Louder are employed by Comprehensive Health Insights, and Slabaugh and Young are employed by Humana. Study concept and design were contributed by Peng, Ascher-Svanum, and Young. Saundankar and Louder took the lead in data collection, while Saundankar, Peng, Fu, and Louder interpreted the data. The manuscript was written by Saundankar, Peng, Fu, and Louder and revised by Saundankar, Rodriguez, Ali, and Louder.

Medication Adherence Does Not Explain Black-White Differences in Cardiometabolic Risk Factor Control among Insured Patients with Diabetes

BACKGROUND

Among patients with diabetes, racial differences in cardiometabolic risk factor control are common. The extent to which differences in medication adherence contribute to such disparities is not known. We examined whether medication adherence, controlling for treatment intensification, could explain differences in risk factor control between black and white patients with diabetes.

METHODS

We identified three cohorts of black and white patients treated with oral medications and who had poor risk factor control at baseline (2009): those with glycated hemoglobin (HbA1c) >8 % (n = 37,873), low-density lipoprotein cholesterol (LDL-C) >100 mg/dl (n = 27,954), and systolic blood pressure (SBP) >130 mm Hg (n = 63,641). Subjects included insured adults with diabetes who were receiving care in one of nine U.S. integrated health systems comprising the SUrveillance, PREvention, and ManagEment of Diabetes Mellitus (SUPREME-DM) consortium. Baseline and follow-up risk factor control, sociodemographic, and clinical characteristics were obtained from electronic health records. Pharmacy-dispensing data were used to estimate medication adherence (i.e., medication refill adherence [MRA]) and treatment intensification (i.e., dose increase or addition of new medication class) between baseline and follow-up. County-level income and educational attainment were estimated via geocoding. Logistic regression models were used to test the association between race and follow-up risk factor control. Models were specified with and without medication adherence to evaluate its role as a mediator.

RESULTS

We observed poorer medication adherence among black patients than white patients (p < 0.01): 50.6 % of blacks versus 39.7 % of whites were not highly adherent (i.e., MRA <80 %) to HbA1c oral medication(s); 58.4 % of blacks and 46.7 % of whites were not highly adherent to lipid medication(s); and 33.4 % of blacks and 23.7 % of whites were not highly adherent to BP medication(s). Across all cardiometabolic risk factors, blacks were significantly less likely to achieve control (p < 0.01): 41.5 % of blacks and 45.8 % of whites achieved HbA1c <8 %; 52.6 % of blacks and 60.8 % of whites achieved LDL-C <100; and 45.7 % of blacks and 53.6 % of whites achieved SBP <130. Adjusting for medication adherence/treatment intensification did not alter these patterns or model fit statistics.

CONCLUSIONS

Medication adherence failed to explain observed racial differences in the achievement of HbA1c, LDL-C, and SBP control among insured patients with diabetes.

Medication Adherence With Diabetes Medication: A Systematic Review of the Literature

PURPOSE

The primary purpose of this systematic review is to synthesize the evidence regarding risk factors associated with nonadherence to prescribed glucose-lowering agents, the impact of nonadherence on glycemic control and the economics of diabetes care, and the interventions designed to improve adherence.

METHODS

Medline, EMBASE, the Cochrane Collaborative, BIOSIS, and the Health and Psychosocial Instruments databases were searched for studies of medication adherence for the period from May 2007 to December 2014. Inclusion criteria were study design and primary outcome measuring or characterizing adherence. Published evidence was graded according to the American Association of Clinical Endocrinologists protocol for standardized production of clinical practice guidelines.

RESULTS

One hundred ninety-six published articles were reviewed; 98 met inclusion criteria. Factors including age, race, health beliefs, medication cost, co-pays, Medicare Part D coverage gap, insulin use, health literacy, primary nonadherence, and early nonpersistence significantly affect adherence. Higher adherence was associated with improved glycemic control, fewer emergency department visits, decreased hospitalizations, and lower medical costs. Adherence was lower when medications were not tolerated or were taken more than twice daily, with concomitant depression, and with skepticism about the importance of medication. Intervention trials show the use of phone interventions, integrative health coaching, case managers, pharmacists, education, and point-of-care testing improve adherence.

CONCLUSION

Medication adherence remains an important consideration in diabetes care. Health professionals working with individuals with diabetes (eg, diabetes educators) are in a key position to assess risks for nonadherence, to develop strategies to facilitate medication taking, and to provide ongoing support and assessment of adherence at each visit.

Self-Motivation Is Associated With Phosphorus Control in End-Stage Renal Disease

OBJECTIVE

Hyperphosphatemia is common in end-stage renal disease and associates with mortality. Phosphate binders reduce serum phosphorus levels; however, adherence is often poor. This pilot study aims to assess patients' self-motivation to adhere to phosphate binders, its association with phosphorus control, and potential differences by race.

DESIGN AND METHODS

Cross sectional design. Subjects were enrolled from one academic medical center dialysis practice from July to November 2012. Self-motivation to adhere to phosphate binders was assessed with the autonomous regulation (AR) scale (range: 1-7) and self-reported medication adherence with the Morisky Medication Adherence Scale. Linear regression models adjusting for age, sex, health literacy, and medication adherence were applied to determine associations with serum phosphorus level, including any evidence of interaction by race.

RESULTS

Among 100 participants, mean age was 51 years (±15 years), 53% were male, 72% were non-white, 89% received hemodialysis, and mean serum phosphorus level was 5.7 ± 1.6 mg/dL. More than half (57%) reported the maximum AR score (7). Higher AR scores were noted in those reporting better health overall (P = .001) and those with higher health literacy (P = .01). AR score correlated with better medication adherence (r = 0.22; P = .02), and medication adherence was negatively associated with serum phosphorus (r = -0.40; P < .001). In subgroup analysis among non-whites, higher AR scores correlated with lower serum phosphorus (high vs lower AR score: 5.55 [1.5] vs 6.96 [2.2]; P = .01). Associations between AR score (β 95% confidence interval: -0.37 [-0.73 to -0.01]; P = .04), medication adherence (β 95% confidence interval: -0.25 [-0.42 to -0.07]; P = .01), and serum phosphorus persisted in adjusted analyses.

CONCLUSIONS

Self-motivation was associated with phosphate binder adherence and phosphorus control, and this differed by race. Additional research is needed to determine if personalized, culturally sensitive strategies to understand and overcome motivational barriers may optimize mineral bone health in end-stage renal disease.

Initial Medication Adherence-Review and Recommendations for Good Practices in Outcomes Research: An ISPOR Medication Adherence and Persistence Special Interest Group Report

BACKGROUND

Positive associations between medication adherence and beneficial outcomes primarily come from studying filling/consumption behaviors after therapy initiation. Few studies have focused on what happens before initiation, the point from prescribing to dispensing of an initial prescription.

OBJECTIVE

Our objective was to provide guidance and encourage high-quality research on the relationship between beneficial outcomes and initial medication adherence (IMA), the rate initially prescribed medication is dispensed.

METHODS

Using generic adherence terms, an international research panel identified IMA publications from 1966 to 2014. Their data sources were classified as to whether the primary source reflected the perspective of a prescriber, patient, or pharmacist or a combined perspective. Terminology and methodological differences were documented among core (essential elements of presented and unpresented prescribing events and claimed and unclaimed dispensing events regardless of setting), supplemental (refined for accuracy), and contextual (setting-specific) design parameters. Recommendations were made to encourage and guide future research.

RESULTS

The 45 IMA studies identified used multiple terms for IMA and operationalized measurements differently. Primary data sources reflecting a prescriber's and pharmacist's perspective potentially misclassified core parameters more often with shorter/nonexistent pre- and postperiods (1-14 days) than did a combined perspective. Only a few studies addressed supplemental issues, and minimal contextual information was provided.

CONCLUSIONS

General recommendations are to use IMA as the standard nomenclature, rigorously identify all data sources, and delineate all design parameters. Specific methodological recommendations include providing convincing evidence that initial prescribing and dispensing events are identified, supplemental parameters incorporating perspective and substitution biases are addressed, and contextual parameters are included.

Telehealth program for type 2 diabetes: usability, satisfaction, and clinical usefulness in an urban community health center

BACKGROUND

We examined the usability, satisfaction, and clinical impact of a 3-month diabetes telehealth intervention for poorly controlled type 2 diabetes (T2D) patients. The urban community health center sample (n=30) was 56.7% female, mean age of 60.6 years, 56.7% high school education or higher, and 73% African American and 26% Latino.

MATERIALS AND METHODS

We integrated an electronic pillbox into an existing diabetes remote home monitoring (RHM) device suite comprising a Bluetooth(®) (Bluetooth SIG, Kirkland, WA)-enabled blood glucose meter and an automatic blood pressure monitor connected to a cellular hub for data upload to our clinical application. This telehealth program involved minimal clinician training and functioned as a nonurgent patient self-management support service to increase the scope of clinic services. Telehealth nurse interventionists received regular RHM data alerts and called patients by phone at scheduled intervals. A graphical report summarizing patient RHM data was sent to providers to inform clinical decision making during a scheduled clinic visit at the 3-month follow-up.

RESULTS

The results showed consistently high levels of RHM device use during the intervention period, high ratings of usability and program satisfaction from patients, and high ratings of provider satisfaction with the program. There was a clinically and statistically significant improvement in blood glucose control at 3 months, such that hemoglobin A1c improved 0.6% from a baseline level of 8.3% (p<0.05).

CONCLUSIONS

These findings provide encouraging empirical support for the usability and clinical value of a diabetes telehealth program integrating a user-friendly cellular pillbox and clinical decision support tools that was delivered to an urban poor T2D clinic population.

Factors affecting medication adherence trajectories for patients with heart failure

OBJECTIVES

To examine the relationship between patient characteristics and medication adherence trajectories for patients with congestive heart failure (CHF).

STUDY DESIGN

Historical prospective study.

METHODS

We conducted a secondary analysis of data assembled for the Practice Variation and Care Outcomes (PRAVCO) study, which examined patterns of cardiovascular care. We used group based trajectory modeling to define medication adherence trajectories, and then modeled factors associated with belonging to a trajectory group during the 6year period from 2005 to 2010 (n = 10,986). We focused on the use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) for secondary prevention of CHF.

RESULTS

Four trajectory groups were optimal in characterizing adherence level patterns: 1) low adherence group, with an initial average adherence rate of 62% that dropped to between 40% and 50%; 2) increasing adherence group, with an initial average adherence rate of 55% that increased to 90%; 3) decreasing adherence group, with an initial average adherence rate above 90% that decreased to 60%; 4) high adherence group, with an average adherence rate consistently above 90%. Age, region, education, smoking, and race were all significantly associated with the likelihood of belonging to a particular trajectory. Nonwhites were less likely to be in the high adherence group, and smoking was more common in the low adherence group (22%) than in the high group (10%); increasing body mass index and Charlson Comorbidity Index (CCI) scores were also associated with being in the low adherence group.

CONCLUSIONS

Population characteristics associated with sustained low adherence might be used to target interventions and improve vulnerable patients' prospects of heart health.

Retrospective study of adherence to glucagon-like peptide-1 receptor agonist therapy in patients with type 2 diabetes mellitus in the United States

INTRODUCTION

Greater adherence to medications has been broadly demonstrated to be associated with improved clinical outcomes. However, there is limited real-world evidence on adherence to glucagon-like peptide-1 receptor agonist (GLP-1RA) therapy in patients with type 2 diabetes mellitus (T2DM).

METHODS

This retrospective cohort study used United States administrative claims data to compare adherence to GLP-1RAs in T2DM patients initiating exenatide once weekly (QW), exenatide twice daily (BID), or once-daily liraglutide (initiated therapy = index therapy). Patients were included if they had T2DM, were GLP-1RA-naïve, initiated a GLP-1RA from 02/01/2012-01/31/2013 (date of initiation = index), were ≥18 years at index, and had continuous enrollment for 12 months before (baseline) to 6 months after index (follow-up). Study outcome was index GLP-1RA adherence (proportion of days covered [PDC] during follow-up, dichotomized at ≥80% vs. <80%, and at ≥90% vs. <90%). Multivariable logistic regressions compared adherence between the GLP-1RAs, adjusting for potential confounders. Sensitivity analyses were performed separating liraglutide by dose (1.2 mg/1.8 mg).

RESULTS

Study sample included 4,041 exenatide QW, 4,586 exenatide BID, and 14,211 liraglutide (6,641 1.2 mg, 7,570 1.8 mg) patients. Median unadjusted PDC values were 0.783 for exenatide QW, 0.500 exenatide BID, 0.722 liraglutide, 0.761 liraglutide 1.2 mg, and 0.683 liraglutide 1.8 mg. Compared with patients treated with either exenatide BID or liraglutide, patients treated with exenatide QW had a statistically significantly greater multivariable-adjusted odds of achieving adherence of ≥80% (odds ratio vs. exenatide QW (OR) = 0.41 for exenatide BID; 0.80, liraglutide; 0.87, liraglutide 1.2 mg; 0.75, liraglutide 1.8 mg) and ≥90% (OR = 0.31 for exenatide BID; 0.60 liraglutide; 0.66 liraglutide 1.2 mg; 0.56 liraglutide 1.8 mg) (all P < 0.001).

CONCLUSION

Patients initiating exenatide QW had significantly higher adjusted odds of adherence compared with patients initiating other GLP-1RAs. Given differences in adherence across the GLP-1RAs, research correlating these factors with clinical and economic outcomes is warranted.