Pill count, self-report, and pharmacy claims data to measure medication adherence in the elderly

Effects of Spirulina platensis supplementation on quality of life, severity of disease and serum total antioxidant capacity, malondialdehyde and zonulin in constipation-predominant irritable bowel syndrome: protocol for a randomised, double-blinded, placebo-controlled clinical trial from Iran

INTRODUCTION

Irritable bowel syndrome (IBS) is one of the most common chronic gut-brain interaction disorders. Nevertheless, there is currently no treatment for IBS. Low-grade inflammation and oxidative stress are contributing factors to the increased perception of abdominal pain and heightened sensitivity of the nervous system in these patients. Spirulina platensis is a rich source of essential nutrients, including amino acids, vitamins, minerals, phytochemicals, essential fatty acids and fibre. It has been found that Spirulina possesses a variety of therapeutic properties such as antioxidant, anti-inflammatory and antidepressant effects, which may be advantageous in reducing complications of IBS. The aim of present randomised clinical trial (RCT) is to assess the efficacy of Spirulina supplementation on IBS.

METHODS AND ANALYSIS

This study is a 12-week, 1:1 parallel-group, double-blinded, randomised controlled trial. Sixty adult individuals diagnosed with IBS according to the Rome IV criteria will be randomised to consume either Spirulina capsules (500 mg) or a placebo, two times a day. The primary outcomes of this RCT are the changes in the IBS quality of life, severity of IBS symptoms, and gut permeability from baseline to 12 weeks of the intervention. The secondary outcomes are the changes in the serum total antioxidant capacity and serum malondialdehyde from baseline to the end of intervention. If this RCT demonstrates significant results in gut permeability, antioxidant status and reduction in IBS symptoms, it could support the use of Spirulina in managing IBS and could potentially reduce healthcare costs.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Medical Ethics Committee of Isfahan University of Medical Sciences, Isfahan, Iran (ID: IR.MUI.

RESEARCH

REC.1401.370). Findings will be presented in subsequent publications.

TRIAL REGISTRATION NUMBER

IRCT20140208016529N8; Iranian Registry of Clinical Trials; registered on 25 April 2023.

The impact of telemonitoring on correct drug use, complications and quality of life among patients with multiple myeloma (ITUMM): A study protocol for an open-label, parallel-group, randomized controlled trial

INTRODUCTION

Multiple myeloma (MM) is the second most common hematologic malignancy. MM is associated with significant morbidity due to its end-organ destruction and is a disease of the older population. Although survival rates for MM have improved over the last decade, due to an increase in treatment options, the disease remains incurable. Expensive (oral) agents are widely used in MM patients; however, tools for supporting patients in complex treatment regimens are scarce. To investigate if a tool will support MM patients and healthcare professionals, the MM e-coach was developed and tested. The aim of this study is to study the impact of telemonitoring on adherence, complications and quality of life in patients with MM (ITUMM study).

METHODS

A two-arm open-label parallel-group randomized controlled trial will be conducted between March 2021 and June 2024 to compare the telemonitoring (MM e-coach) with standard MM care. This study aimed to recruit 150 patients with recently diagnosed multiple myeloma (RDMM), starting first or second line of treatment. Blinded primary outcome is adherence by pill count after start of treatment at 1-3 months. Secondary outcomes are patient reported outcomes: GFI, EQ-5D-5L, EORTC-QLQ-C30, SDM-Q-9, MARS-5, single item questions, PREMs, adverse events, OS and PFS. Patient reported outcomes were developed and integrated in the e-coach MM to regularly measure digitized outcomes of MM patients from time of RDMM until 12 months post-diagnosis. Online measurements will be performed at baseline (0), 3, 6, 9 and 12 months.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the Ethics Committee of the Isala klinieken in The Netherlands (No. 201111) at 25 February 2021. Study results will be disseminated to the relevant healthcare communities by publication in peer-reviewed journals, and at scientific and clinical conferences.

STUDY REGISTRATION NUMBER

ClinicalTrials.gov number: NCT05964270 and ABR number: NL75771.075.20.

Validating methods used to identify non-adherence adverse drug events in Canadian administrative health data

AIMS

Medication non-adherence is a type of adverse drug event that can lead to untreated and exacerbated chronic illness, and that drives healthcare utilization. Research using medication claims data has attempted to identify instances of medication non-adherence using the proportion of days covered or by examining gaps between medication refills. We sought to validate these measures compared to a gold standard diagnosis of non-adherence made in hospital.

METHODS

This was a retrospective analysis of adverse drug events diagnosed during three prospective cohorts in British Columbia between 2008 and 2015 (n = 976). We linked prospectively identified adverse drug events to medication claims data to examine the sensitivity and specificity of typical non-adherence measures.

RESULTS

The sensitivity of the non-adherence measures ranged from 22.4% to 37.5%, with a proportion of days covered threshold of 95% performing the best; the non-persistence measures had sensitivities ranging from 10.4% to 58.3%. While a 7-day gap was most sensitive, it classified 61.2% of the sample as non-adherent, whereas only 19.6% were diagnosed as such in hospital.

CONCLUSIONS

The methods used to identify non-adherence in administrative databases are not accurate when compared to a gold standard diagnosis by healthcare providers. Research that has relied on administrative data to identify non-adherent patients both underestimates the magnitude of the problem and may label patients as non-adherent who were in fact adherent.

Adherence to doxycycline for uncomplicated genitourinary chlamydia: A prospective observational study

Objectives

Since 2020, the Center for Disease Control and Prevention (CDC) no longer recommends single-dose azithromycin as first-line therapy for uncomplicated genitourinary chlamydia, advising instead a 7-day course of doxycycline. Our study investigates self-reported adherence to the new regimen, reasons for nonadherence, and the impact of dispensing the regimen on-site compared to prescribing it.

Methods

We performed a prospective observational study of adult patients treated for suspected or laboratory-confirmed uncomplicated genitourinary chlamydia at three urban emergency departments (EDs), where patients receive a prescription for doxycycline, and in a sexually transmitted infection (STI) clinic, where the 14 doxycycline pills are dispensed on-site. Clinical data were extracted from electronic medical records and patients were interviewed regarding adherence via telephone 2-4 weeks after their index visit.

Results

We enrolled 127 STI clinics and 201 ED patients. Therapeutic adherence was reported by 85% of STI clinic patients and 77% of ED patients. In the ED setting, younger age and female sex were associated with nonadherence, with only 67% of female patients reporting adherence. Reported reasons for nonadherence included medication adverse effects, financial and transportation barriers, skepticism of the need for therapy, and misunderstanding of discharge instructions, among others.

Conclusion

A considerable portion of patients treated for uncomplicated genitourinary chlamydia in urban EDs and STI Clinics report nonadherence to the 7-day doxycycline regimen. The CDC recommendation to consider azithromycin when nonadherence is a "substantial concern" should be applied broadly in these settings by routinely discussing barriers to adherence when selecting the optimal antimicrobial regimen. The benefit of dispensing the doxycycline regimen on-site compared to prescribing it could not be determined given differences in baseline characteristics between the two groups.

Evaluation of methods measuring medication adherence in patients with polypharmacy: a longitudinal and patient perspective

PURPOSE

To explore patients' willingness to have medication adherence measured using different methods and evaluate the feasibility and validity of their combination (i.e., pill counts, a medication diary and a questionnaire assessing adherence two months post-discharge).

METHODS

(1) A cross-sectional evaluation of the willingness of patients with polypharmacy to have their medication adherence measured post-discharge. (2) Medication adherence was monitored during two months using pill counts based on preserved medication packages and a diary in which patients registered their adherence-related problems. During a home visit, the Probabilistic Medication Adherence Scale (ProMAS) and a questionnaire on feasibility were administered.

RESULTS

A total of 144 participants completed the questionnaire at discharge. The majority was willing to communicate truthfully about their adherence (97%) and to share adherence-related information with healthcare providers (99%). More participants were willing to preserve medication packages (76%) than to complete a medication diary (67%) during two months. Most participants reported that preserving medication packages (91%), completing the diary (99%) and the ProMAS (99%) were no effort to them. According to the majority of participants (60%), pill counts most accurately reflected medication adherence, followed by the diary (39%) and ProMAS (1%). Medication adherence measured by pill counts correlated significantly with ProMAS scores, but not with the number of diary-reported problems. However, adherence measured by the medication diary and ProMAS correlated significantly.

CONCLUSION

Combining tools for measuring adherence seems feasible and can provide insight into the accordance of patients' actual medication use with their prescribed regimen, but also into problems contributing to non-adherence.

The effects of curcumin-piperine supplementation on inflammatory, oxidative stress and metabolic indices in patients with ischemic stroke in the rehabilitation phase: a randomized controlled trial

BACKGROUND

Stroke is a leading cause of death worldwide, which is associated with a heavy economic and social burden. The purpose of this study was to investigate the effects of supplementation with curcumin-piperine combination in patients with ischemic stroke in the rehabilitation stage.

METHODS

In this randomized controlled trial, 66 patients with stroke were randomized into two groups receiving curcumin-piperine tablets (500 mg curcumin + 5 mg piperine) and matched placebo tablets for 12 weeks. High-sensitivity C-reactive protein (hs-CRP), carotid intima-media thickness (CIMT), thrombosis, total antioxidant capacity (TAC), lipid profile, anthropometric indices, blood pressure, and quality of life were assessed before and after the intervention. Statistical data analysis was done using SPSS22 software.

RESULTS

A total of 56 patients with a mean age of 59.80 ± 4.25 years completed the trial. Based on ANCOVA test, adjusted for baseline values, curcumin-piperine supplementation for 12 weeks resulted in significant reductions in serum levels of hs-CRP (p = 0.026), total cholesterol (TC) (p = 0.009), triglycerides (TG) (p = 0.001), CIMT (p = 0.002), weight (P = 0.001), waist circumference (p = 0.024), and systolic and diastolic blood pressure (p < 0.001), and a significant increase in TAC (p < 0.001) in comparison to the placebo. Pain score significantly increased in both groups; however, its increase was significantly higher in the placebo group compared with the intervention group (p = 0.007). No significant changes were observed between the two groups in terms of serum fibrinogen, low-density lipoprotein (LDL), high-density lipoprotein (HDL), and quality of life indices.

CONCLUSION

Curcumin-piperine supplementation had beneficial effects on CIMT, serum hs-CRP, TC, TG, TAC, and systolic and diastolic blood pressure in patients with ischemic stroke in the rehabilitation stage.

Association of combination antiretroviral therapy with risk of neurological diseases in patients with HIV/AIDS in Taiwan: a nested case-control study

Heterogeneous neurocognitive impairment remains an important issue, even in the era of combination antiretroviral therapy (cART), with an incidence ranging from 15% to 65%. Although ART drugs with higher penetration scores to the central nervous system (CNS) show better HIV replication control in the CNS, the association between CNS penetration effectiveness (CPE) scores and neurocognitive impairment remains inconclusive. To explore whether ART exposure is associated with the risk of neurological diseases among patients with HIV/AIDS, this study in Taiwan involved 2,571 patients with neurological diseases and 10,284 matched, randomly selected patients without neurological diseases between 2010 and 2017. A conditional logistic regression model was used in this study. The parameters for ART exposure included ART usage, timing of exposure, cumulative defined daily dose (DDD), adherence, and cumulative CPE score. Incident cases of neurological diseases, including CNS infections, cognitive disorders, vasculopathy, and peripheral neuropathy, were obtained from the National Health Insurance Research Database in Taiwan. Odds ratios (ORs) for the risk of neurological diseases were conducted using a multivariate conditional logistic regression model. Patients with a history of past exposure (OR: 1.68, 95% confidence interval [CI]:1.22-2.32), low cumulative DDDs (< 2,500) (OR: 1.28, 95% CI: 1.15-1.42), low adherence (0 < adherence (ADH) ≤ 0.8) (OR: 1.46, 95% CI: 1.30-1.64), or high cumulative CPE scores (>14) (OR: 1.34, 95% CI: 1.14-1.57) had a high risk of neurological diseases. When stratified by classes of ART drugs, patients with low cumulative DDDs or low adherence had a high risk of neurological diseases, including NRTIs, PIs, NNRTIs, INSTIs, and multi-drug tablets. Subgroup analyses also suggested that patients with low cumulative DDDs or low adherence had a high risk of neurological diseases when they had high cumulative CPE scores. Patients with high cumulative DDDs or medication adherence were protected against neurological diseases only when they had low cumulative CPE scores (≤ 14). Patients may be at risk for neurological diseases when they have low cumulative DDDs, low adherence, or usage with high cumulative CPE scores. Continuous usage and low cumulative CPE scores of ART drugs may benefit neurocognitive health in patients with HIV/AIDS.

Bone microstructure in proton pump inhibitor users

OBJECTIVES

We assessed skeletal microstructure and stiffness in proton pump inhibitor (PPI) users compared to non-users with high resolution peripheral quantitative computed tomography (HRpQCT) and microfinite element analysis (μFEA) and other modalities. Relationships between PPI dose/frequency and bone parameters were evaluated.

METHODS

We cross-sectionally assessed skeletal health in 601 older (≥age 65 years) adults (130 PPI users and 471 non-users) participating in a multi-ethnic population-based study of aging.

RESULTS

PPI users tended to have more comorbidities and take more medications than non-users. Female PPI users (n = 100) were more likely to be non-Caucasian, shorter with higher BMI, and more likely to have diabetes, lower physical activity and be using anti-depressants and thiazide diuretics compared to non-users (n = 302). Male PPI users (n = 30) were more likely to have liver disease than non-users (n = 169). In women, historical fractures (53.0 % vs. 43.4 %, p = 0.05) and falls (38 % vs. 26.8 %, p = 0.04) tended to be more frequent in PPI users compared to non-users. Number of falls was higher in women reporting daily rather than intermittent PPI use (1.8/year vs. 1.0/year, p < 0.001). In women, there were no differences in any HRpQCT or μFEA parameter. By HRpQCT, covariate-adjusted cortical volumetric bone density (Ct.vBMD) was 4.2 % lower in male PPI users vs. non-users at the tibia (p = 0.04), but this did not result in reduced stiffness. There were no other differences by HRpQCT at the tibia or radius.

CONCLUSIONS

PPI use was not associated with altered skeletal microstructure or stiffness in elderly men and women. The results do not support a relationship between PPI use and microstructure.

Patient Pill Organization Strategies and Adherence Measured in a Cross-Sectional Study of Hypertension

BACKGROUND

The strategies patients use to organize medications (eg, pill dispenser) may be reflected in adherence measured at follow-up. We studied whether medication organization strategies patients use at home are associated with adherence measured using pharmacy-fills, self-report, and pill counts.

DESIGN

Secondary analysis of data from a prospective randomized clinical trial.

SETTING

Eleven US safety-net and community primary care clinics.

PATIENTS

Of the 960 enrolled self-identified non-Hispanic Black and White patients prescribed antihypertensive medications, 731 patients reported pill organization strategies and were included.

VARIABLE

Patients were asked if they use any of the following medication organization strategies: finish previous refills first; use a pill dispenser; combine same prescriptions; or combine dissimilar prescriptions.

OUTCOMES

Adherence to antihypertensive medications using pill counts (range, 0.0-1.0% of the days covered), pharmacy-fill (proportion of days covered >90%), and self-report (adherent/non-adherent).

RESULTS

Of the 731 participants, 38.3% were men, 51.7% were age ≥65, 52.9% self-identified as Black or African American. Of the strategies studied, 51.7% finished previous refills first, 46.5% used a pill dispenser, 38.2% combined same prescriptions and 6.0% combined dissimilar prescriptions. Median (IQR) pill count adherence was 0.65 (0.40-0.87), pharmacy-fill adherence was 75.7%, and self-reported adherence was 63.2%. Those who combined same prescriptions had significantly lower measured pill count adherence than those who did not (0.56 (0.26-0.82) vs 0.70 (0.46-0.90), p<0.01) with no significant difference in pharmacy-fill (78.1% vs 74%, p=0.22) or self-reported adherence (63.0% vs 63.3%, p=0.93).

CONCLUSION

Self-reported medication organization strategies were common. Combining same prescriptions was associated with lower adherence as measured using pill counts but not pharmacy-fills or self-report. Clinicians and researchers should identify the pill organization strategies used by their patients to understand how these strategies may influence measures of patient adherence.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03028597; https://clinicaltrials.gov/ct2/show/NCT03028597 (Archived by WebCite at http://www.webcitation.org/72vcZMzAB).

Evaluation of pharmacist-led telemedicine medication management for hypertension established patients during COVID-19 pandemic: A pilot study

Aim

To evaluate the impact of a telemedicine medication management service in patients with hypertension.

Methods

Participants were allocated to either a telemedicine service (N = 173) or usual care (UC) (N = 179). The primary outcome was blood pressure (BP) reduction from baseline to the 6-month follow-up visit, the proportion of the target BP achievement, overall adherence to prescribed medication as well as a composite of non-fatal stroke, non-fatal myocardial infarction and cardiovascular death.

Results

At 6 months, BP was controlled in 89.6% (n = 155) of intervention patients and 78.8% (n = 141) of UC patients (OR = 1.14, 95% CI = 1.04-1.25, P = 0.006), giving a mean difference of -6.0 (-13.0 to -2.5 mmHg) and -2.0 mmHg (-4.0 to -0.1 mmHg) in SBP and DBP, respectively. 17.9% (n = 31) of the patients in the intervention group were non-adherent with medications, compared with 29.1% (n = 52) in the UC group (P = 0.014). The composite clinical endpoints were reached by 2.9% in the intervention group and 4.5% in the control group with no significant differences (OR = 1.566, 95% CI = 0.528-4.646).

Conclusion

Telemedicine medication management for hypertension management had led to better BP control and medication adherence improvement than UC during COVID-19 epidemic, resulting in a reduction of overall adverse cardiovascular events occurrence.

Impact of conditional economic incentives and motivational interviewing on health outcomes of adolescents living with HIV in Anambra State, Nigeria: A cluster-randomised trial

Background

Adolescents living with HIV (ALHIV) have had worse outcomes compared to adults. They face enormous difficulty in accessing HIV care services. We hypothesize that conditional economic incentives (CEI) and motivational interviewing could increase retention in care, medication adherence and ultimately viral load suppression. Therefore, we evaluated the one-year impact of conditional economic incentives and motivational interviewing on the health outcomes of ALHIV in Anambra State, Nigeria.

Methods

Using a cluster-randomised design, we examined the one-year (from December 1, 2018, to November 30, 2019), individual-level impact of an Incentive Scheme comprising conditional economic incentives and motivational interviewing on achieving undetectable viral load (primary outcome), CD4⁺ count, adherence to antiretroviral therapy and retention in care (secondary outcomes) by ALHIV in Anambra State, Nigeria. Twelve HIV treatment hospitals were stratified according to the type of clinic (secondary or tertiary) and randomly assigned to the intervention arm or control arm to receive the Incentive Scheme or routine care, respectively. ALHIV aged 10–19 years, initiated into HIV care for a minimum of 6 months, and who adhered poorly to medications (<100% adherence rate) were eligible for the study. Participants in the intervention arm received motivational interviewing at the study baseline and every visit. They also received US$5.6 when HIV viral load (VL) was <20 copies/mL at month 3, US$2.8 if the VL remained suppressed at months 6 and 9, and US$5.6 if the VL remained <20 copies/mL at month 12.

Results

Of the 246 trial participants, 119 were in the intervention while 127 were in the control arm. There was no difference in the baseline characteristics of the participants between the intervention and control arm except for the number of participants with undetectable viral load and the number of participants with ≥95% adherence. Although participants in the intervention arm had a 10.1% increase while those in the control arm had a 1.6% decrease in proportion with undetectable viral load (≤20 copies/ml) after 12 months, the change in the primary outcome was not statistically significant. Similarly, the differences in the secondary outcomes were not statistically significant.

Conclusion

The Incentive Scheme did not improve the virologic outcome of ALHIV after 12 months. Differences in the secondary outcomes after 12 months were also not significantly different from the baseline.

Trial registration

We registered the trial retrospectively with The Pan African Clinical Trials Registry: https://pactr.samrc.ac.za/(PACTR201806003040425) on 2/2/2018.

Data on medication adherence in adults with neurological disorders: The NeuroGerAd study

Nonadherence to medication is a common issue that goes along with increased morbidity and mortality and immense health care costs. To improve medication adherence and outcome in ill people, their reasons of not taking their prescribed medication must be known. Here a dataset is presented based on the longitudinal observational NeuroGerAd study in adults with neurological disorders (N = 910). The dataset contains demographic background variables as well as measures of adherence, medication changes after hospital discharge, comprehensive geriatric assessments, personality, patient-physician relationship, and health-related quality of life. As such, the dataset offers unique opportunities to enable a plethora of analyses on personal, social, and institutional factors influencing medication adherence.

A Critical Review of Medication Adherence in Hypertension: Barriers and Facilitators Clinicians Should Consider

Hypertension is a global public health problem, and its prevalence is increasing worldwide. Impacting all human societies and socioeconomic strata, it remains the major modifiable risk factor for global burden of cardiovascular disease all-cause mortality and the leading cause of loss of disability-adjusted life years. Despite increased awareness, the rate of blood pressure control remains unsatisfactory, particularly in low- to middle-income countries. Apparent treatment-resistant hypertension is associated with worse adverse health outcomes. It includes both true resistant and pseudo-resistant hypertension, which requires out-of-office blood pressure monitoring to exclude white-coat effect and confirmation of adherence to the agreed recommended antihypertensive therapy. The depth of medication non-adherence remains poorly recognized among medical practitioners, thus presenting an underestimated modifiable risk factor. Medication non-adherence is a complex and multidimensional variable with three quantifiable phases: initiation, implementation, and discontinuation, collectively called persistence. Non-adherence can be both intentional and non-intentional and usually involves several interconnected factors. Persistence declines over time in the treatment of chronic diseases like hypertension. The risk is higher in patients with new diagnosis, poor insurance status, polypharmacy, and multiple comorbidities, particularly psychiatric disorders. The World Health Organization divides the contributing factors impacting adherence into five categories. Screening and detection for medication non-adherence are challenging due to its dynamic nature and potential white-coat effect. Easy-to-conduct screening methods have low reliability and validity, whereas more reliable and valid methods are costly and difficult to perform. Medication non-adherence is associated with poor clinical outcome and potential negative impact on health-care costs. Evaluation of adherence should become an integral part of assessment of patients treated for hypertension. Medication adherence can significantly improve with a patient-centered approach, non-judgmental communication skills, and collaborative multidisciplinary management, including engagement of the patients in their care by self-blood pressure monitoring.

Factors associated with anti-retroviral therapy adherence among patients living with HIV during the COVID-19 pandemic: A cross-sectional study

BACKGROUND

The coronavirus disease (COVID-19) pandemic causes fear and anxiety symptoms on some vulnerable populations such as patients living with human immunodeficiency virus (HIV) (PLWH). Physical distancing (during consultation in the clinic) and isolation restrictions will likely have a negative impact on/disruption to all care continuum services of HIV diseases although healthcare services and access to anti-retroviral therapy (ART) have continued to operate.

OBJECTIVE

To investigate the factors associated with ART adherence among PLWH during the COVID-19 pandemic.

METHODOLOGY

A cross-sectional study was conducted on 324 PLWH who had been on ART for at least 6 months between June 2020 and January 2021. A semi-structured questionnaire was used to interview participants to collect data on sociodemographic characteristics and other factors.

RESULTS

Of 324 PLWH taking ART, 264 (81.48%) had high adherence (≥95%) and 60 (18.52%) had low adherence (< 95%). Factors independently associated with high ART adherence were employment status (adjusted odds ratio (AOR): 0.030, 95% confidence interval (CI): 0.010-0.088; p < 0.001), type of antiretroviral (ARV) (AOR: 3.101, 95% CI: 1.137-8.456; p = 0.027), family support (AOR: 0.157, 95% CI: 0.052-0.475; p = 0.001), the perception that the COVID-19 pandemic negatively impacts the ability to attend clinics (AOR: 7.339, 95% CI: 1.46-36.79; p = 0.015), and the perception that the COVID-19 pandemic negatively impacts the ability to take ART (AOR: 10.611, 95% CI: 2.98-37.72; p < 0.001).

CONCLUSIONS

During the COVID-19 pandemic, factors associated with high ART adherence among PLWH attending the Hospital of Wangaya in Denpasar, Bali, Indonesia were employment status, ART type [non-fixed dose combination (FDC)], family support, and the perception that the COVID-19 pandemic negatively impacts the ability to attend clinics and to take ART.

Evidence of the association between adherence to treatment and mortality among patients with COPD monitored at a public disease management program in Brazil

Objective

To evaluate the association between adherence to treatment and mortality among Chronic Obstructive Pulmonary Disease (COPD) patients treated in the Brazilian public health system.

Methods

This is cohort study of moderate-to-severe COPD patients monitored in a public pharmaceutical care-based Disease Management Program (DMP). All subjects who died one year after the beginning of the cohort were age-matched with those who remained alive at the end of the cohort period. Treatment adherence was measured through pharmacy records. Patients who received at least 90% of the prescribed doses were considered adherent to treatment.

Results

Of the 333 patients (52.8% age ≥ 65 years, 67.9% male), 67.3% were adherent to treatment (adherence rate, 87.2%). Mortality was associated with lack of adherence (p = 0.04), presence of symptoms (mMRC ≥ 2) and COPD treatment use. The death was associated with non-adherence, presence of symptoms and previous hospitalization. After adjustment, non-adherent patients to treatment were almost twice times likely to die compared to those adherents (Hazard Ratio (HR) 1.86; CI 1.16-2.98, p = 0.01).

Conclusion

Non-adherence to treatment was associated with higher mortality among moderate-to-severe COPD patients treated in the Brazilian public health system. Strategies to monitor and optimize adherence should be strengthened to reduce COPD-related mortality.

A systematic review of community pharmacy initiatives to improve treatment of depression and pain: Focus on types of programs and patient-reported outcomes

INTRODUCTION

Depression and pain are common, disabling, mutually exacerbating conditions. Many patients living with these conditions present to community pharmacies on a regular schedule to purchase both prescribed and over-the-counter medications. Community-pharmacy based programs have been developed to improve depression and pain outcomes.

METHODS

The PRISMA guidelines were utilized to answer the following question: In patients with depression and/or pain, what is the effect of the existing community pharmacy programs on depression and/or pain outcomes. Queried databases included Pubmed, EMBASE, and PsychINFO. DistillerSR was used to organize the screening, abstraction, and review of data. All potential articles were evaluated by two authors, and conflicts were discussed to achieve resolution. In addition to primary outcomes, sources of potential bias and quality indicators were abstracted for every article.

RESULTS

Three thousand nine hundred and twenty articles were reviewed, and 13 studies met eligibility criteria (n = 7 for depression; n = 6 for pain). Most studies demonstrated improvement in measures of depression or pain. However, compared to usual care or other control conditions, most of the depression and pain-specific interventions did not provide additional symptomatic benefit. The community pharmacy-based interventions were superior for other outcomes including medication adherence, reducing stigma, improvement in self-efficacy, and improvement in general management of disease.

CONCLUSION

Community pharmacies may be uniquely positioned to deliver interventions that improve outcomes associated with successful depression and pain treatment outcomes. However, the benefits of published community pharmacy-based treatments for actually improving depression and pain severity has not yet been established. Innovative interventions and additional research may be needed to achieve clinical success for pharmacy interventions for depression and pain.

Comparing the cost, glycaemic control and medication adherence of utilizing patients' own medicines (POMs) versus usual dispensing among diabetic patients in an outpatient setting

BACKGROUND

Millions worth of unused drugs particularly those indicated for chronic diseases such as diabetes were returned and disposed leading to substantial wastage. Use of patients' own medications (POMs) in the inpatient setting has reduced wastage and saved cost. The impact of utilizing POMs in the outpatient setting has hitherto not been determined.

PURPOSE

This study aims to compare the cost, medication adherence and glycaemic control of utilizing POMs versus usual dispensing.

METHODS

Prospective randomized controlled study was conducted among diabetic patients that required monthly medication refill in the Outpatient Pharmacy in 2017. Patients who consented were equally divided into POMs and control groups. Both groups brought excess medications from home at week-0 and week-12. Patients in the POMs group brought excess medications monthly and sufficient amount of drugs were added until the next refill date. Drugs were dispensed as usual in the control group. Total cost consisting of the cost of drugs, staff and building was calculated. Glycosylated haemoglobin (HbA1c) was measured at baseline and week-12. Adherence was measured based on pill counting.

RESULTS

Thirty patients aged 56.77 ± 14.67 years with 13.37 ± 7.36 years of diabetes participated. Baseline characteristics were similar between the groups. POMs minimized the total cost by 38.96% which translated to a cost saving of USD 42.76 ± 6.98, significantly different versus USD 0.02 ± 0.52 in the control group, p = 0.025. Mean HbA1c reduced significantly (-0.79%, p = 0.016) in the POMs group but not significant in the control group (-0.11%, p = 0.740). Medication adherence improved significantly in both groups at week-12 (p < 0.010). Nevertheless, patients in the POMs group were more adherent, 87.20% vs. 66.32%, p = 0.034.

CONCLUSION

Utilizing POMs resulted in cost saving, improved adherence and better glycaemic control. Use of POMs should be practiced in the outpatient pharmacy to reduce wastage and cost.

Development of a PATIENT-Medication Adherence Instrument (P-MAI) and a HEALTHCARE PROFESSIONAL-Medication Adherence Instrument (H-MAI) using the nominal group technique

To date, several medication adherence instruments have been developed and validated worldwide. However, most instruments have only assessed medication adherence from the patient’s perspective. The aim was to develop and validate the PATIENT-Medication Adherence Instrument (P-MAI) and the HEALTHCARE PROFESSIONAL-Medication Adherence Instrument (H-MAI) to assess medication adherence from the patient’s and healthcare professional (HCP)’s perspectives. The P-MAI-12 and H-MAI-12 were developed using the nominal group technique. The face and content validity was determined by an expert panel and piloted. The initial version of these instruments consisted of 12 items were validated from October-December 2018 at a primary care clinic in Malaysia. Included were patients aged ≥21 years, diagnosed with diabetes mellitus, taking at least one oral hypoglycaemic agent and who could understand English. The HCPs recruited were family medicine specialists or trainees. To assess validity, exploratory factor analysis (EFA) and concurrent validity were performed; internal consistency and test-retest were performed to assess its reliability. A total of 120/158 patients (response rate = 75.9%) and 30/33 HCPs (response rate = 90.9%) agreed to participate. EFA found three problematic items in both instruments, which was then removed. The final version of the P-MAI-9 and the HMAI-9 had 9 items each with two domains (adherence = 2 items and knowledge/belief = 7 items). For concurrent validity, the total score of the P-MAI-9 and the H-MAI-9 were not significantly different (p = 0.091), indicating that medication adherence assessed from both the patient’s and HCP’s perspectives were similar. Both instruments achieved acceptable internal consistency (Cronbach’s α: P-MAI-9 = 0.722; H-MAI-9 = 0.895). For the P-MAI-9, 7/9 items showed no significant difference between test and retest whereas 8/9 items in the H-MAI-9 showed significant difference at test and retest (p>0.05). In conclusion, the P-MAI-9 and H-MAI-9 had low sensitivity and high specificity suggesting that both instruments can be used for identifying patients more likely to be non-adherent to their medications.

Mediators of the association between low socioeconomic status and poor glycemic control among type 2 diabetics in Bangladesh

Although low socioeconomic status (SES) is related to poor glycemic control, the underlying mechanisms remain unclear. We examined potentially modifiable factors involved in the association between low SES and poor glycemic control using data from the baseline survey of a multicenter, prospective cohort study. Five hundred adult type 2 diabetes patients were recruited from three diabetes centers. Glycemic control was poorer in diabetic individuals with low SES than in those with higher SES. Adverse health-related behaviors, such as non-adherence to medication (adjusted odds ratio [AOR] = 1.07, 95% confidence interval [CI] 1.04–1.13) and diet (AOR = 1.04, 95% CI 1.02–1.06); existing comorbidities, such as depressive symptoms (AOR = 1.05, 95% CI 1.04–1.09); and non-adherence to essential health service-related practices concerning diabetes care, such as irregular scheduled clinic visits (AOR = 1.04, 95% CI 1.03–1.06) and not practicing self-monitoring of blood glucose (AOR = 1.05, 95% CI 1.03–1.07), mediated the relationship between social adversity and poor glycemic control specially in urban areas of Bangladesh. Those identified factors provide useful information for developing interventions to mitigate socioeconomic disparities in glycemic control.

Development and validation of a compact on-person storage device (SMHeartCard) for emergency access to acetylsalicylic acid and nitroglycerin

BACKGROUND

Guidelines recommend that patients with coronary artery disease (CAD) carry and immediately use acetylsalicylic acid (ASA) and sublingually administered nitroglycerin at the onset of chest pain; however, compliance with these recommendations is poor. We designed and tested a compact on-person storage device for these medications.

METHODS

We designed an airtight, light-proof and chemically inert holder to carry four 81-mg ASA tablets and three 0.3-mg Nitrostat (nitroglycerin, Pfizer) tablets. After establishing the temperatures ranges in wallets and pockets, we tested nitroglycerin dissolution and release of the stored Nitrostat tablets across a range of relevant temperatures and a variety of tablet enclosure systems.

RESULTS

Microcalorimeter thermal conduction studies as well as dissolution and release testing showed that nitroglycerin tablets were stable at temperatures ranging from -20°C to 60°C for 1 week. In testing up to 24 weeks, 0.3-mg Nitrostat tablets enclosed completely in polytetrafluoroethylene (PTFE) performed similarly to those stored in the manufacturer's borosilicate glass packaging across a wide range of temperatures relevant to on-person carriage. Real-world on-person testing for 24 weeks confirmed these results. Non-PTFE enclosures performed poorly.

INTERPRETATION

The PTFE enclosure with a PTFE-coated cap liner maintained long-term performance of 0.3-mg Nitrostat tablets under laboratory and real-world conditions. This storage device is now commercially available as the SMHeartCard to improve compliance and provide immediate access to emergency cardiac medications.

Development of the NIH Patient-Reported Outcomes Measurement Information System (PROMIS) Medication Adherence Scale (PMAS)

Poor medication adherence is associated with reduced drug effectiveness, poor health-related quality of life, increased morbidity and mortality, and increased healthcare utilization and cost. Including the patient's voice is essential in understanding barriers to adherence. Useful patient-reported adherence measures are brief, inexpensive, non-invasive; can indicate barriers to adherence; and can be incorporated in electronic health records. The NIH Patient-Reported Outcomes Measurement Information System (PROMIS^®) includes high-quality, freely available patient-reported measures covering many important constructs in patient-centered research but does not include a medication adherence measure. To fill this gap, we developed the PROMIS Medication Adherence Scale (PMAS) using the rigorous PROMIS instrument development guidelines. To develop the PMAS, we first conducted a review of the reviews, which enabled us to identify content areas relevant to medication adherence behavior. Then, we conducted qualitative research to elicit patients' views of and experiences with medication adherence. This process identified the following important content areas to guide item writing: extent medication is taken, knowledge of medication regimen, beliefs about medication, remembering to take medication, skipping due to side effects, skipping due to feeling better, and cost of medications. Based on the results of these activities, we wrote items and aimed to retain 1-2 items per content area. The final item set included 9 total adherence items, which were then refined through intensive comprehension and translatability review, as well as cognitive interviews. Future steps include testing the PMAS's validity.

Anticholinergic and benzodiazepine medication use and risk of incident dementia: a UK cohort study

Background

Studies suggest that anticholinergic medication or benzodiazepine use could increase dementia risk. We tested this hypothesis using data from a UK cohort study.

Methods

We used data from the baseline (Y0), 2-year (Y2) and 10-year (Y10) waves of the Medical Research Council Cognitive Function and Ageing Study. Participants without dementia at Y2 were included (n = 8216). Use of benzodiazepines (including nonbenzodiazepine Z-drugs), anticholinergics with score 3 (ACB3) and anticholinergics with score 1 or 2 (ACB12) according to the Anticholinergic Cognitive Burden scale were coded as ever use (use at Y0 or Y2), recurrent use (Y0 and Y2), new use (Y2, but not Y0) or discontinued use (Y0, but not Y2). The outcome was incident dementia by Y10. Incidence rate ratios (IRR) were estimated using Poisson regression adjusted for potential confounders. Pre-planned subgroup analyses were conducted by age, sex and Y2 Mini-Mental State Examination (MMSE) score.

Results

Dementia incidence was 9.3% (N = 220 cases) between Y2 and Y10. The adjusted IRRs (95%CI) of developing dementia were 1.06 (0.72, 1.60), 1.28 (0.82, 2.00) and 0.89 (0.68, 1.17) for benzodiazepines, ACB3 and ACB12 ever-users compared with non-users. For recurrent users the respective IRRs were 1.30 (0.79, 2.14), 1.68 (1.00, 2.82) and 0.95 (0.71, 1.28). ACB3 ever-use was associated with dementia among those with Y2 MMSE> 25 (IRR = 2.28 [1.32–3.92]), but not if Y2 MMSE≤25 (IRR = 0.94 [0.51–1.73]).

Conclusions

Neither benzodiazepines nor ACB12 medications were associated with dementia. Recurrent use of ACB3 anticholinergics was associated with dementia, particularly in those with good baseline cognitive function. The long-term prescribing of anticholinergics should be avoided in older people.

Retraction: Caractérisation des premiers épisodes de schizophrénie à partir de bases de données administratives de santé jumelées. [Characterization of First Episodes of Schizophrenia from Combined Administrative Databases]. Beaudoin, M., Potvin, S., Dellazizzo, L., Surprenant, M., Lesage, A., Vanasse, A., Ngamini-Ngui, A.† et Dumais, A. Santé mentale au Québec. 2018 Fall ; 43(2) : 83-105.PMID : 32338687

This corrects the article DOI: https://doi.org/10.7202/1058611ar.

Medication Management Performance and Associated Cognitive Correlates in Healthy Older Adults and Older Adults with aMCI

OBJECTIVE

Difficulties managing medications, particularly among older adults experiencing cognitive deficits, is an important contributing factor to medication nonadherence that may have significant negative financial and health outcomes. The current study examined the performance of healthy older adults' (HOA) and individuals with amnestic mild cognitive impairment (aMCI) on the medication management abilities assessment's (MMAA, a performance-based measure of medication management) original scoring criteria and derived error process measures, assessing medication overtaking and undertaking magnitude. Exploratory correlations between performances on the MMAA and self-reported confidence in medication management skills and cognitive abilities were also examined.

METHOD

A sample of 25 HOAs with aMCI and 25 age- and education-matched HOAs completed the MMAA, a self-reported medication management confidence rating and a battery of neuropsychological tests.

RESULTS

HOAs performed significantly better on the MMAA score and committed significantly less process errors than individuals with aMCI. Despite these differences in MMAA performance, the HOA and aMCI groups rated similar high levels of confidence in their ability to manage a new medication routine. Notably, while the HOA group's performance on all of the MMAA measures did not relate to cognitive measures, the aMCI group's performance on the MMAA score was significantly related to memory and executive functioning and a new process error score for overtaking was related to processing speed.

CONCLUSIONS

Although these results present promising potential for the MMAA as a measure of medication management in a clinical setting, further studies need to examine the validity of the MMAA against real-world adherence measures.

Technological Interventions for Medication Adherence in Adult Mental Health and Substance Use Disorders: A Systematic Review

BACKGROUND

Medication adherence is critical to the effectiveness of psychopharmacologic therapy. Psychiatric disorders present special adherence considerations, notably an altered capacity for decision making and the increased street value of controlled substances. A wide range of interventions designed to improve adherence in mental health and substance use disorders have been studied; recently, many have incorporated information technology (eg, mobile phone apps, electronic pill dispensers, and telehealth). Many intervention components have been studied across different disorders. Furthermore, many interventions incorporate multiple components, making it difficult to evaluate the effect of individual components in isolation.

OBJECTIVE

The aim of this study was to conduct a systematic scoping review to develop a literature-driven, transdiagnostic taxonomic framework of technology-based medication adherence intervention and measurement components used in mental health and substance use disorders.

METHODS

This review was conducted based on a published protocol (PROSPERO: CRD42018067902) in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review guidelines. We searched 7 electronic databases: MEDLINE, EMBASE, PsycINFO, the Cochrane Central Register of Controlled Trials, Web of Science, Engineering Village, and ClinicalTrials.gov from January 2000 to September 2018. Overall, 2 reviewers independently conducted title and abstract screens, full-text screens, and data extraction. We included all studies that evaluate populations or individuals with a mental health or substance use disorder and contain at least 1 technology-delivered component (eg, website, mobile phone app, biosensor, or algorithm) designed to improve medication adherence or the measurement thereof. Given the wide variety of studied interventions, populations, and outcomes, we did not conduct a risk of bias assessment or quantitative meta-analysis. We developed a taxonomic framework for intervention classification and applied it to multicomponent interventions across mental health disorders.

RESULTS

The initial search identified 21,749 results; after screening, 127 included studies remained (Cohen kappa: 0.8, 95% CI 0.72-0.87). Major intervention component categories include reminders, support messages, social support engagement, care team contact capabilities, data feedback, psychoeducation, adherence-based psychotherapy, remote care delivery, secure medication storage, and contingency management. Adherence measurement components include self-reports, remote direct visualization, fully automated computer vision algorithms, biosensors, smart pill bottles, ingestible sensors, pill counts, and utilization measures. Intervention modalities include short messaging service, mobile phone apps, websites, and interactive voice response. We provide graphical representations of intervention component categories and an element-wise breakdown of multicomponent interventions.

CONCLUSIONS

Many technology-based medication adherence and monitoring interventions have been studied across psychiatric disease contexts. Interventions that are useful in one psychiatric disorder may be useful in other disorders, and further research is necessary to elucidate the specific effects of individual intervention components. Our framework is directly developed from the substance use disorder and mental health treatment literature and allows for transdiagnostic comparisons and an organized conceptual mapping of interventions.

Methods for Measuring Multiple Medication Adherence: A Systematic Review-Report of the ISPOR Medication Adherence and Persistence Special Interest Group

BACKGROUND

A broad literature base exists for measuring medication adherence to monotherapeutic regimens, but publications are less extensive for measuring adherence to multiple medications.

OBJECTIVES

To identify and characterize the multiple medication adherence (MMA) methods used in the literature.

METHODS

A literature search was conducted using PubMed, PsycINFO, the International Pharmaceutical Abstracts, the Cumulative Index to Nursing and Allied Health Literature and the Cochrane Library databases on methods used to measure MMA published between January 1973 and May 2015. A two-step screening process was used; all abstracts were screened by pairs of researchers independently, followed by a full-text review identifying the method for calculating MMA. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed to conduct this systematic review. For studies that met the eligibility criteria, general study and adherence-specific characteristics and the number and type of MMA measurement methods were summarized.

RESULTS

The 147 studies that were included originated from 32 countries, in 13 disease states. Of these studies, 26 used proportion of days covered, 23 used medication possession ratio, and 72 used self-reported questionnaires (e.g., the Morisky Scale) to assess MMA. About 50% of the studies included more than one method for measuring MMA, and different variations of medication possession ratio and proportion of days covered were used for measuring MMA.

CONCLUSIONS

There appears to be no standardized method to measure MMA. With an increasing prevalence of polypharmacy, more efforts should be directed toward constructing robust measures suitable to evaluate adherence to complex regimens. Future research to understand the validity and reliability of MMA measures and their effects on objective clinical outcomes is also needed.

Pharmacist-led telehealth disease management program for patients with diabetes and depression

INTRODUCTION

The aim of this study was to determine whether a pharmacist-led telehealth disease management program is superior to usual care of nurse-led telehealth in improving diabetes medication adherence, haemoglobin A1C (A1C), and depression scores in patients with concomitant diabetes and depression.

METHODS

Patients with diabetes and depression were randomized to pharmacist-led or nurse-led telehealth. Veterans with type 1 or type 2 diabetes, an A1C ≥ 7.5%, diagnosis of depression, and access to a landline phone were invited to participate. Patients were randomized to usual care of nurse-led telehealth or pharmacist-led telehealth. Patients were shown how to use the telehealth equipment by the nurse or pharmacist. In the pharmacist-led group, the patients received an in-depth medication review in addition to the instruction on the telehealth equipment.

RESULTS

After six months, the pharmacist-led telehealth arm showed significant improvements for cardiovascular medication adherence (14.0; 95% confidence interval (CI) 0.4 to 27.6), antidepressant medication adherence (26.0; 95% CI 0.9 to 51.2), and overall medication adherence combined (13.9; 95% CI 6.6 to 21.2) from baseline to six-month follow-up. There was a significant difference in A1C between each group at the six-month follow-up in the nurse-led telehealth group (6.9 ± 0.9) as compared to the pharmacist-led telehealth group (8.8 ± 2.0). There was no significance in the change in patient health questionnaire-9 (PHQ-9) and Center for Epidemiologic Studies Depression Scale (CES-D) from baseline to follow-up in both groups.

DISCUSSION

Pharmacist-led telehealth was efficacious in improving medication adherence for cardiovascular, antidepressants, and overall medications over a six-month period as compared to nurse-led telehealth. There was no significant improvement in overall depression scores.

Effects of Medication Nonadherence and Comorbidity on Health Resource Utilization in Schizophrenia

BACKGROUND

Medication nonadherence to antipsychotic drugs, which is commonly seen in patients with schizophrenia who have comorbidities, not only affects the quality of life of individuals suffering from the condition, but can also lead to worsening of disease condition, adverse outcomes, excessive use of health care resources, and higher medical costs.

OBJECTIVE

To determine the effect of nonadherence to antipsychotics and related disease comorbidities on medical care utilization with respect to inpatient hospital visits, outpatient visits, office visits, and emergency room (ER) visits.

METHODS

Retrospective, cross-sectional research data was obtained from the Medical Expenditure Panel Surveys (MEPS) for the years 2010-2014. The proportion of days covered (PDC) adherence measure was used to identify and classify individuals as adherent (PDC ≥ 80%) or nonadherent (PDC < 80%). A logistic regression analysis was used to further examine the effect of key study variables and comorbidity on medication nonadherence in patients with schizophrenia. Using the Student's t-test, population characteristics were statistically compared between the adherent and nonadherent populations and between populations with comorbidities and without comorbidities with respect to inpatient, outpatient, office, and ER visits.

RESULTS

Of 1.2 million people who reported having schizophrenia in MEPS from 2010 to 2014, as many as 71% were found to be nonadherent to antipsychotic medications (PDC < 80%). Results showed that women (OR = 3.594, 95% CI = 1.33-11.40, P = 0.030) and people with less than 15 years of education (OR = 20.85, 95% CI = 3.91-111.09, P = 0.0005) were more likely to be nonadherent to antipsychotic medications than all other demographics. Compared with the adherent schizophrenia population (n = 353,349), the nonadherent population (n = 868,737) had greater utilization of outpatient visits (0.68 vs. 1.92, P < 0.0001) and office visits (10.95 vs. 18.21, P < 0.0001) but had lower utilization of inpatient visits (0.82 vs. 0.45, P < 0.0001) and ER visits (1.03 vs. 0.79, P = 0.1036). Compared with the schizophrenia population without comorbidities, the population with comorbidities (a classification based on a Charlson Comorbidity Index score of ≥ 1) had greater utilization of inpatient (0.39 vs. 0.76, P < 0.0001); office (13.39 vs. 19.34, P < 0.0001); and ER visits (0.39 vs. 1.41, P < 0.0001) but had lower utilization of outpatient visits (1.86 vs. 1.21, P < 0.0001).

CONCLUSIONS

Greater medical care resources are used by nonadherent populations with schizophrenia and comorbidities than those without comorbidities. Together, nonadherence and comorbidities pose significant risks to patients with schizophrenia, in clinical and financial terms, and addressing problems stemming from such risks should be an area of priority in schizophrenia management.

DISCLOSURES

No outside funding supported this study. The authors have no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Estimating Adherence Based on Prescription or Dispensation Information: Impact on Thresholds and Outcomes. A Real-World Study With Atrial Fibrillation Patients Treated With Oral Anticoagulants in Spain

Objective: To estimate drug exposure, Proportion of Days Covered (PDC) and percentage of patients with PDC ≥ 80% from a cohort of atrial fibrillation patients initiating oral anticoagulant (OAC) treatment. We employed three different approaches to estimate PDC, using either data from prescription and dispensing (PD cohort) or two common designs based on dispensing information only, requiring at least one (D1) or at least two (D2) refills for inclusion in the cohorts. Finally, we assessed the impact of adherence on health outcomes according to each method. Methods: Population-based retrospective cohort of all patients with Non Valvular Atrial Fibrillation (NVAF), who were newly prescribed acenocoumarol, apixaban, dabigatran or rivaroxaban from November 2011 to December 2015 in the region of Valencia (Spain). Patients were followed for 12 months to assess adherence using three different approaches (PD, D1 and D2 cohorts). To analyze the relationship between adherence (PDC ≥ 80) defined according to each method of calculation and health outcomes (death for any cause, stroke or bleeding) Cox regression models were used. For the identification of clinical events patients were followed from the end of the adherence assessment period to the end of the available follow-up period. Results: PD cohort included all patients with an OAC prescription (n = 38,802), D1 cohort excluded fully non-adherent patients (n = 265) and D2 cohort also excluded patients without two refills separated by 180 days (n = 2,614). PDC ≥ 80% ranged from 94% in the PD cohort to 75% in the D1 cohort. Drug exposure among adherent (PDC ≥ 80%) and non-adherent (PDC < 80%) patients was different between cohorts. In adjusted analysis, high adherence was associated with a reduced risk of death [Hazard Ratio (HR): from 0.82 to 0.86] and (except in the PD cohort) the risk for ischemic stroke (HR: from 0.61 to 0.64) without increasing the risk of bleeding. Conclusion: Common approaches to assess adherence using measures based on days' supply exclude groups of non-adherent patients and, also, misattribute periods of doctors' discontinuation to patient non-adherence, misestimating adherence overall. Physician-initiated discontinuation is a major contributor to reduced OAC exposure. When using the PDC80 threshold, very different groups of patients may be classified as adherent or non-adherent depending on the method used for the calculation of days' supply measures. High adherence and high exposure to OAC treatment in NVAF patients is associated with better health outcomes.

Measuring adherence to antipsychotic medications for schizophrenia: Concordance and validity among a community sample in rural China

BACKGROUND

Despite the abundance of measures to assess medication adherence by persons suffering schizophrenia, few studies have evaluated their concordance and validity against a reference standard in resource-poor community settings. We explored the concordance and validity of several measures to assess antipsychotic medication adherence in a resource-poor community.

METHOD

Based on a random sample of 278 villagers diagnosed with schizophrenia from Liuyang, Hunan Province, China, we used a concordance correlation coefficient (rc) and Kappa statistic to assess agreement among pill counts, refill records, clinician rating, Drug Attitude Inventory (DAI), and the Brief Adherence Rating Scale (BARS). The validity of various measures was evaluated by their concordance and sensitivity/specificity to home-based unannounced pill count (UPC) as the reference standard.

RESULTS

The estimated proportion of adherent patients according to all measures (41% ~ 88%) was substantially higher than identified by UPC (35%). Concordance between any two measures was poor (rc/Kappa mostly <0.30). Validity of various measures also was poor against the UPC (rc < 0.20; Kappa <0.16), although refill records and the structured instruments (BARS) performed better than office-based pill counts and clinician impression. BARS, DAI and clinician rating were not sensitive to changes in adherence and would likely underestimate any program effect.

CONCLUSION

In resource-poor community settings, most measures assessed in this study should not be used alone as they overestimated adherence, underestimated program effect, and had poor validity. A combination of UPC and several other measures may provide more insight into clinical trials and programmatic management.

Adherence to oral chemotherapy: Challenges and opportunities

Purpose

There is very little data on the effect of combining methods to better predict and improve oral antineoplastic adherence in cancer patients. The goal of this study was to evaluate the effectiveness of an intensive pharmacist intervention at the beginning of oral antineoplastic therapy versus nurse-led control group on adherence.

Methods

This was a prospective, randomized, open-label controlled trial performed in a single center hematology/oncology outpatient service to compare the effectiveness of repetitive pharmacist educational intervention on adherence rates measured at four and eight weeks after prescribing oral antineoplastic medication compared to a nurse-led control group. Both groups included investigator pill counts and self-report adherence questionnaires.

Results

Two-hundred patients were enrolled between 2009 and 2015. Fourteen of the 101 (14%) patients in the pharmacist group and 7 (7%) of the 99 patients in the nurse-led control group dropped out ( p = 0.166). The majority of patients who remained in the study were 90–100% adherent to oral antineoplastic therapy in both groups. The pharmacist group slightly underperformed at Pill Count 2, possibly due to barriers for non-adherence. Statistically significant correlations associated with non-adherence were forgetfulness ( p = 0.009), wanting to avoid side effects ( p = 0.02), feeling depressed or overwhelmed ( p = 0.032), or falling asleep before taking medication ( p = 0.048) in both groups.

Conclusion

The combination of pill count and patient self-report adherence is a way of improving oral antineoplastic adherence. However, significant barriers to adherence were identified such as forgetfulness, wanting to avoid side effects, feeling depressed or overwhelmed, and falling asleep before taking medications.

Repurposing existing medications as cancer therapy: design and feasibility of a randomized pilot investigating propranolol administration in patients receiving hematopoietic cell transplantation

BACKGROUND

Repurposing existing medications for antineoplastic purposes can provide a safe, cost-effective, and efficacious means to further augment available cancer care. Clinical and preclinical studies suggest a role for the ß-adrenergic antagonist (ß-blocker) propranolol in reducing rates of tumor progression in both solid and hematologic malignancies. In patients undergoing hematopoietic cell transplantation (HCT), the peri-transplant period is a time of increased activity of the ß-adrenergically-mediated stress response.

METHODS

We conducted a proof-of-concept randomized controlled pilot study assessing the feasibility of propranolol administration to patients between ages 18-75 who received an autologous HCT for multiple myeloma. Feasibility was assessed by enrollment rate, tolerability, adherence, and retention.

RESULTS

One hundred fifty-four patients underwent screening; 31 (20%) enrolled in other oncology trials that precluded dual trial enrollment and 9 (6%) declined to enroll in the current trial. Eighty-nine (58%) did not meet eligibility requirements and 25 (16%) were eligible; of the remaining eligible patients, all were successfully enrolled and randomized. The most common reasons for ineligibility were current ß-blocker use, age, logistics, and medical contraindications. 92% of treatment arm patients tolerated and remained on propranolol for the study duration; 1 patient discontinued due to hypotension. Adherence rate in assessable patients (n = 10) was 94%. Study retention was 100%.

CONCLUSIONS

Findings show that it is feasible to recruit and treat multiple myeloma patients with propranolol during HCT, with the greatest obstacle being other competing oncology trials. These data support further studies examining propranolol and other potentially repurposed drugs in oncology populations.

TRIAL REGISTRATION

This randomized controlled trial was registered at clinicaltrials.gov with the identifier NCT02420223 on April 17, 2015.

Utilizing Consumer Health Informatics to Support Management of Hypertension by Clinical Pharmacists in Primary Care: Study Protocol

BACKGROUND

Hypertension (HTN) is a major public health concern in the United States given its wide prevalence, high cost, and poor rates of control. Multiple strategies to counter this growing epidemic have been studied, and home blood pressure (BP) monitoring, mobile health (mHealth) interventions, and referrals to clinical pharmacists for BP management have all shown potential to be effective intervention strategies.

OBJECTIVE

The purpose of this study is to establish feasibility and acceptability of BPTrack, a clinical pharmacist-led mHealth intervention that aims to improve BP control by supporting home BP monitoring and medication adherence among patients with uncontrolled HTN. BPTrack is an intervention that makes home-monitored BP data available to clinical pharmacists for use in HTN management. Secondarily, this study seeks to understand barriers to adoption of this intervention, as well as points of improvement among key stakeholders, so that larger scale dissemination of the intervention may be achieved and more rigorous research can be conducted.

METHODS

This study is recruiting up to 25 individuals who have poorly controlled HTN from a Family Medicine clinic affiliated with a large Midwestern academic medical center. Patient participants complete a baseline visit, including installation and instructions on how to use BPTrack. Patient participants are then asked to follow the BP monitoring protocol for a period of 12 weeks, and subsequently complete a follow-up visit at the conclusion of the study period.

RESULTS

The recruitment period for the pilot study began in November 2016, and data collection is expected to conclude in late-2017.

CONCLUSIONS

This pilot study seeks to document the feasibility and acceptability of a clinical pharmacist-led mHealth approach to managing HTN within a primary care setting. Through our 12-week pilot study, we expect to lend support for this approach, and lay the foundation for translating this approach into wider-scale implementation. This mHealth intervention seeks to leverage the multidisciplinary care team already in place within primary care, and to improve health outcomes for patients with uncontrolled HTN.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02898584; https://clinicaltrials.gov/ct2/show/NCT02898584 (Archived by WebCite® at http://www.webcitation.org/6u3wTGbe6).

Nurse interventions to improve medication adherence among discharged older adults: a systematic review

Background

discharged older adult inpatients are often prescribed numerous medications. However, they only take about half of their medications and many stop treatments entirely. Nurse interventions could improve medication adherence among this population.

Objective

to conduct a systematic review of trials that assessed the effects of nursing interventions to improve medication adherence among discharged, home-dwelling and older adults.

Method

we conducted a systematic review according to the methods in the Cochrane Collaboration Handbook and reported results according to the PRISMA statement. We searched for controlled clinical trials (CCTs) and randomised CCTs (RCTs), published up to 8 November 2016 (using electronic databases, grey literature and hand searching), that evaluated the effects of nurse interventions conducted alone or in collaboration with other health professionals to improve medication adherence among discharged older adults. Medication adherence was defined as the extent to which a patient takes medication as prescribed.

Results

out of 1,546 records identified, 82 full-text papers were evaluated and 14 studies were included-11 RCTs and 2 CCTs. Overall, 2,028 patients were included (995 in intervention groups; 1,033 in usual-care groups). Interventions were nurse-led in seven studies and nurse-collaborative in seven more. In nine studies, adherence was higher in the intervention group than in the usual-care group, with the difference reaching statistical significance in eight studies. There was no substantial difference in increased medication adherence whether interventions were nurse-led or nurse-collaborative. Four of the 14 studies were of relatively high quality.

Conclusion

nurse-led and nurse-collaborative interventions moderately improved adherence among discharged older adults. There is a need for large, well-designed studies using highly reliable tools for measuring medication adherence.

Predictors of Nonadherence to Topical Intraocular Pressure Reduction Medications Among Medicare Members: A Claims-Based Retrospective Cohort Study

BACKGROUND

Reported adherence rates with ocular hypotensive medications typically range from 51% to 56% over the first year of therapy. As intraocular pressure (IOP) reduction slows the progression of vision loss from glaucoma, early identification of nonadherent members is crucial to effective disease management.

OBJECTIVES

To (a) identify member characteristics and other factors related to nonadherence with topical IOP-lowering medications available in administrative claims data and (b) create a predictive model incorporating these variables.

METHODS

This retrospective cohort study analyzed data from Humana's administrative claims database. The study cohort included members aged 65-89 years enrolled in a Medicare Advantage Prescription Drug plan (MAPD; medical and pharmacy benefits), with > 1 topical IOP-lowering medication claims between January 2011 and September 2012 and a minimum of 24 months of continuous enrollment-12 months before and 12 months after the initial (index) prescription claim for a topical IOP-lowering medication. Adherence was defined as the proportion of days covered (PDC) with drug supply (calculated from the number of drops per bottle and dose) over the first year after the index prescription. Members with PDC > 0.80 were considered adherent, while members with PDC < 0.80 were considered nonadherent. Multivariable stepwise logistic regression with backward elimination was used to construct a predictive model for the likelihood of nonadherence (PDC < 0.80). The model was developed using 28 input variables*#x2013;10 variables were retained in the final model.

RESULTS

73,256 MAPD members were included in this study; most (69%) of these members were continuing topical IOP-lowering medication users. The proportion of patients adherent (PDC > 0.80) to IOP-lowering medications was 51%. The study sample was split, using a 2:1 ratio, into a development sample (n = 48,840 members) and a validation sample (n=24,416 members). The model performed equally well in the development sample and the validation sample (area under the curve = 0.71 for development and validation sets), making it appear robust in this Medicare population. In the final predictive model, characteristics increasing the likelihood (P < 0.01) of nonadherence to IOP-lowering medication within the MAPD population included index IOP prescription filled through mail order, higher medical costs during the pre-index period, being a new IOP-lowering medication user, and being male. Characteristics that lowered the likelihood of nonadherence included advanced age, higher pharmacy costs during the pre-index period, receiving a low-income subsidy, residing in the South, and a previous diagnosis of open-angle glaucoma or history of glaucoma surgery.

CONCLUSIONS

Nonadherence to topical IOP-lowering medication can be predicted with 10 commonly available demographic, clinical, and treatment-related variables generally available in administrative claims data for an MAPD population. Given that this predictive model was constructed using these generally available data, it could potentially be replicated by other health plans for use in predicting nonadherence to topical IOP-lowering medications among MAPD plan members. This predictive model can be used to identify members that are likely to be nonadherent in order to target interventions intended to improve ocular hypotensive medication adherence.

DISCLOSURES

Funding for this study was contributed by Allergan. Comprehensive Health Insights was contracted by Allergan to conduct this study. Sheer, Bunniran, and Uribe are employed by Comprehensive Health Insights/Humana and own stock in Humana. Fiscella, Chandwani, and Patel are employed by Allergan. Study concept and design were contributed by Sheer, Fiscella, and Patel, along with Bunniran and Uribe. Sheer and Bunniran took the lead in data collection, and data interpretation was performed by Bunniran and Uribe, along with the other authors. The manuscript was written and revised by Sheer, Bunniran, Chandwani, and Uribe, with assistance from Fiscella and Patel.

Optimal secondary prevention medication use in acute myocardial infarction patients with nonobstructive coronary artery disease is modified by management strategy: insights from the TRIUMPH Registry

BACKGROUND

Patients with acute myocardial infarction (AMI) and nonobstructive coronary artery disease (nonobCAD) may be perceived to be at lower risk for cardiac events, relative to those with obstructive CAD (obCAD), and thus less likely to receive optimal preventive medications in the year following AMI.

HYPOTHESIS

We aimed to determine if AMI patients with nonobCAD, compared to obCAD, received lower rates of prevention medications in the year following AMI.

METHODS

We compared optimal prevention medication use at hospital discharge, 1, 6, and 12 months after hospitalization. Optimal medication use was defined as the receipt of all prevention medications for which that patient was eligible (eg, aspirin, clopidogrel, statins, β-blockers, and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers). We used multivariable logistic regression analyses to determine the association between nonobCAD to medication use and adjusted for potential confounders.

RESULTS

Three thousand six hundred thirty AMI patients were studied, of whom 200 (5.2%) had nonobCAD. Fewer nonobCAD patients received optimal medication use compared to obCAD patients at discharge (31% vs 65%, P < 0.001), driven primarily by lower rates of clopidogrel use (40.5% vs 83.3%, P < 0.001). After adjustment for percutaneous coronary intervention (PCI), differences in medication use were similar at discharge and 1 year after hospitalization. Stratified analyses by receipt of PCI suggested patients confined to medical management had less optimal medication use, regardless of their CAD burden.

CONCLUSIONS

Lower rates of unadjusted optimal medication use were seen in nonobCAD patients, driven by low clopidogrel use among medically managed patients, suggesting improvement efforts should focus on these patients.

Out-of-pocket costs and adherence to antihypertensive agents among older adults covered by the public drug insurance plan in Quebec

OBJECTIVE

To evaluate the effect of patient out-of-pocket costs on adherence to antihypertensive agents (AHA) in community-dwelling older adults covered by the public drug insurance plan in Quebec.

METHODS

This is a secondary analysis of data from the "Étude sur la santé des aînés" study (2005-2008) on community-dwelling older adults in Quebec aged 65 years and older (N=2,811). The final sample included 881 participants diagnosed with arterial hypertension and treated with AHA. Medication adherence was measured with the proportion of days covered over a 2-year follow-up period (<80% and ≥80%). Out-of-pocket costs for AHA, in Canadian dollars (CAD), at cohort entry were categorized as follows: $0, $0.01-$5.00, $5.01-$10.00, $10.01-$15.00 and $15.01-$36.00. Multivariable logistic regression models were constructed to study adherence to AHA as a function of out-of-pocket costs while controlling for several confounders. Models were also stratified by annual household income (<$15,000 CAD and ≥$15,000 CAD).

RESULTS

In this study, 80.8% of participants were adherent to their AHA. Among participants reporting an annual household income <$15,000 CAD, those with an out-of-pocket cost of $10.01-$15.00 CAD were significantly less adherent to their AHA than those with no contribution (OR =0.175, 95% CI: 0.042-0.740). Among participants reporting an income of ≥$15,000 CAD, those with out-of-pocket costs of $0.01-$5.00 CAD (OR =0.194; 95% CI: 0.048-0.787), $5.01-$10.00 CAD (OR =0.146; 95% CI: 0.036-0.589), $10.01-$15.00 CAD (OR =0.192; 95% CI: 0.047-0.777) and $15.01-$36.00 CAD (OR =0.160, 95% CI: 0.039-0.655) were significantly less adherent to their AHA than participants with no contribution.

CONCLUSION

Increased out-of-pocket costs are associated with non-adherence to AHA in older adults covered by a public drug insurance plan, more importantly in those reporting an annual household income ≥$15,000 CAD. A reduction in the amount of out-of-pocket costs and yearly maximum contribution for drugs may improve adherence to treatment.

Factors associated with false-positive self-reported adherence to antihypertensive drugs

Self-reported medication adherence is known to overestimate true adherence. However, little is known about patient factors that may contribute to the upward bias in self-reported medication adherence. The objective of this study is to examine whether demographic, behavioral, medication and mood factors are associated with being a false-positive self-reported adherer (FPA) to antihypertensive drug treatment. We studied 175 patients (mean age: 50 years; 57% men) from primary-care clinics starting antihypertensive drug treatment. Self-reported adherence (SRA) was measured with the Medication Adherence Report Scale (MARS) and by the number of drug doses missed in the previous week/month, and compared with pill count adherence ratio (PCAR) as gold standard. Data on adherence, demographic, behavioral, medication and mood factors were collected at baseline and every 3 months up to 1 year. FPA was defined as being a non-adherer by PCAR and an adherer by self-report. Mixed effect logistic regression was used for the analysis. Twenty percent of participants were FPA. Anxiety increased (odds ratio (OR): 3.00; P=0.01), whereas smoking (OR: 0.40; P=0.03) and drug side effects (OR: 0.46, P=0.03) decreased the probability for FPA by MARS. Education below high-school completion increased the probability of being an FPA as measured by missing doses in the last month (OR: 1.66; P=0.04) and last week (OR: 1.88; P=0.02). The validity of SRA varies significantly according to drug side effects, behavioral factors and patient's mood. Careful consideration should be given to the use of self-reported measures of adherence among patients likely to be false-positive adherers.

Rationale and design of mDOT-HuA study: a randomized trial to assess the effect of mobile-directly observed therapy on adherence to hydroxyurea in adults with sickle cell anemia in Tanzania

Background

Hydroxyurea (HU) has been demonstrated to be efficacious in reducing complications in individuals with sickle cell anemia (SCA) but poor adherence is a barrier. Directly Observed Therapy (DOT) has been shown to improve adherence in various chronic diseases but there is limited data in adults with SCA.

Methods and design

To examine the effect of mobile-directly observed therapy (mDOT) on adherence to HU (mDOT-HuA) in adults with SCA at Muhimbili National Hospital in Tanzania. The mDOT-HuA study is a single centre, prospective, randomized, open label clinical trial. One-hundred individuals with SCA with haemoglobin SS genotype, aged ≥18 years, living in Dar es Salaam, able and willing to record and submit videos electronically will be included. Participants will be divided into two treatment arms; 50 in the standard monitoring (SM) arm will receive mobile phones and fixed dose HU therapy with standard monitoring; 50 in the mDOT arm will receive mobile phones, fixed dose HU therapy with standard monitoring and a mobile directly observed web based medication adherence monitoring system. The primary outcome is the proportion of participants achieving ≥80 % HU adherence compared between the two arms as assessed through medication possession ratio at the end of 3 months of treatment. REDCap, an open source software application will be used to collect data using clinical research forms. The proportions of adherence in the two arms will be compared by Fisher’s exact test. Analysis of outcomes will have performed by both the intention-to treat and per-protocol methods.

Discussion

Should this study become sucessful, it will have the potential for the development of novel strategies for improving HU adherence in SCA.

Trial registration

ClinicalTrials.gov Identifier: NCT02844673, registered on 25^tht July 2016 (retrospectively registered).

Drug treatment and adherence of subjects <40 years with diagnosis of heterozygous familial hypercholesterolemia

BACKGROUND AND AIMS

We aimed at describing the therapeutic approach in young adult patients diagnosed with heterozygous familial hypercholesterolemia (HeFH) and their adherence and persistence to treatment.

METHODS

From regional administrative databases, individuals aged ≤40 years, who received exemption for HeFH between January 1, 2003 and December 31, 2011, and concomitantly started statin treatment, were identified. Within the first year of treatment, we evaluated therapeutic changes, adherence as MPR (medication possession ratio), persistence as continuous drug coverage without gaps ≥60 days, and influencing factors using log binomial models.

RESULTS

Of 1404 patients, 42.4% were initially treated with a high-efficacy statin. 23.4% of patients showed at least one treatment change. Mean MPR was 68.7% (29.9), and patients showing continued statin use were 47.0%. Therapy modification was significantly associated with a past cardiovascular event (relative risk, RR [95% confidential interval] 2.28 [1.69-3.09]) and at least one lipid test (RR 1.82 [1.31-2.53]). MPR ≥80% was significantly associated with the first statin prescribed (atorvastatin RR 1.28 [1.09-1.51] and rosuvastatin RR 1.21 [1.01-1.44], vs. simvastatin), a past cardiovascular event (RR 1.33 [1.12-1.59]), at least one therapy change (RR 1.28 [1.15-1.43]), at least a lipid test (RR 1.26 [1.07-1.49]). A similar pattern was observed for persistence.

CONCLUSIONS

This analysis of young adult HeFH patients showed that therapy change was quite frequent, and probably reflected adjustments according to individual response. Adherence and persistence were inadequate, even in this population at high cardiovascular risk, and they need to be improved through proper patient education and shared treatment decision-making approach.

Adherence to Antiretroviral Therapy: The Emerging Role of HIV Pharmacotherapy Specialists

Despite the availability of 25 antiretroviral agents to treat HIV infection and the significant progresses made in the clinical pharmacology of HIV drugs, viral suppression and immune restoration remain problematic in a large number of HIV-infected persons. One of the main factors responsible for this partial therapeutic success is the difficulty patients have adhering consistently to antiretroviral therapy. Barriers to adherence are diverse and complex and evolve over time, complicating the monitoring of medication-taking behaviors. Consequently, multilevel interventions are often needed to address thoroughly adherence issues. Given the rapid and constant evolution of HIV treatments, innovative multidisciplinary programs integrating HIV pharmacotherapy specialists, as the “medication expert,” are being implemented. Because of his or her advanced knowledge of antiretrovirals, the HIV pharmacotherapy specialist is highly qualified to evaluate patients with complex regimens who are facing barriers to successful care and who need tailored interventions and long-term follow-up.

How effectively are your patients taking their medicines? A critical review of the Strathclyde Compliance Risk Assessment Tool in relation to the 'MMAS' and 'MARS'

RATIONALE, AIMS AND OBJECTIVES

A useful assessment tool that can support health care professionals in anticipating elderly patients' care needs regarding additional support in managing their own medicines is essential, but currently lacking. Thus, the aim of the study was to assess whether the 13-item Strathclyde Compliance Risk Assessment Tool (SCRAT) is an appropriate instrument for identifying community-dwelling elderly people who may be at risk of medication non-adherence.

METHOD

An 8-week survey was performed from October to November 2009. Patients were ≥65 years old, receiving ≥3 medications and were either using multi-compartment compliance aids or receiving social care support, or both. The data were collected in 45 face-to-face structured interviews using the 13-item SCRAT, 5-item Medication Adherence Rating Scale (MARS) and 8-item Modified Morisky Adherence Scale (MMAS) in sheltered housing complexes in Glasgow, Scotland. Interviews were analysed quantitatively using SPSS version 21 software.

RESULTS

The SCRAT instrument showed substantial inter-rater reliability (Cohen's kappa of 0.730 for the 13-item scale). There was a significant strong negative correlation between the 13-item SCRAT total risk score and 8-item MMAS (r = -0.654; P = 0.0036), and the 13-item SCRAT total risk score and 5-item MARS (r = -0.481; P = 0.0084). The SCRAT instrument showed satisfactory internal consistency (Cronbach's alpha of 0.853 for the 13-item scale). The area under the receiver operator characteristic curve (AUC ± standard error; 95% confidence interval) showed that the SCRAT had good discriminatory capacity and was able to distinguish between adherent and non-adherent participants on the MARS (0.729 ± 0.17; 0.39, 1.00). The best cut-off (sensitivity, specificity) was <3 (75%, 45%). In the sub-analyses, there was a significant difference in total risk score (3 vs. 2, P = 0.011) between users and non-users of multi-compartment compliance aids.

CONCLUSION

The study shows that the 13-item SCRAT has the potential to be used in identifying elderly participants who may have problems managing their own medicines and it may help to determine the level and type of assistance that patients require to manage their medicines.

Toward appropriate criteria in medication adherence assessment in older persons: Position Paper

Nonadherence to medication regimens is a worldwide challenge; adherence rates range from 38 to 57 % in older populations with an average rate of less than 45 % and nonadherence contributes to adverse drug events, increased emergency visits and hospitalisations. Accurate measurement of medication adherence is important in terms of both research and clinical practice. However, the identification of an objective approach to measure nonadherence is still an ongoing challenge. The aim of this Position Paper is to describe the advantages and disadvantages of the known medication adherence tools (self-report, pill count, medication event monitoring system (MEMS) and electronic monitoring devices, therapeutic drug monitoring, pharmacy records based on pharmacy refill and pharmacy claims databases) to provide the appropriate criteria to assess medication adherence in older persons. To the best of our knowledge, no gold standard has been identified in adherence measurement and no single method is sufficiently reliable and accurate. A combination of methods appears to be the most suitable. Secondly, adherence assessment should always consider tools enabling polypharmacy adherence assessment. Moreover, it is increasingly evident that adherence, as a process, has to be assessed over time and not just at one evaluation time point (drug discontinuation). When cognitive deficits or functional impairments may impair reliability of adherence assessment, a comprehensive geriatric assessment should be performed and the caregiver involved. Finally, studies considering the possible implementation in clinical practice of adherence assessment tools validated in research are needed.

Adherence to prescribed medications of Iranian traditional medicine in a group of patients with chronic disease

OBJECTIVE

The extent to which a person's health-related behavior corresponds with medical instructions (adherence) is an important modifier of health system effectiveness. This study was designed to determine the patients' adherence to Iranian traditional medicine in a group of patients with chronic disease.

METHODS

Convenience sampling was used to enroll 320 patients with chronic diseases from January 2014 to January 2015 in clinics of traditional medicine affiliated with medical universities in Tehran. Morisky Medication Adherence Scale (MMAS) was used to measure the adherence. After describing the variables and the frequency of adherence, logistic regression analysis was used to determine the influencing factors.

FINDINGS

Mean age was 40.8 (standard deviation [SD] =13) years. The mean of the duration of disease was 54.6 (SD = 56.1) months and mean of the duration of referring to the clinics 6.5 (SD = 6.9) months. Total score of MMAS was zero in 33 (10.3%) of patients (high adherence), one or two in 128 (40%) of patients (moderate adherence), and more than two in 159 (49.7%) of patients (low adherence). Forgetfulness, bad taste, not availability, and the high cost of the drugs were the most commonly reported causes of non-adherence. Adherence was associated with age (odds ratio [OR] =1.05, 95% confidence interval [95% CI] 1-1.1), marriage (OR = 10.8, 95% CI 2.05-57.6), number of prescribed drugs (OR = 0.05, 95% CI 0.02-0.14), and duration of disease (OR = 1.01, 95% CI 1-1.02).

CONCLUSION

Considering the low adherence in users of medications of Iranian traditional medicine, health care practitioners need to be trained in adherence and the influencing factors and also to use some interventions to increase the adherence.

Effective universal health coverage and improved 1-year survival after acute myocardial infarction: the Chilean experience

In 2005, Chile implemented a universal system of health guarantees (AUGE) aimed at improving equitable access to quality medical care for priority health conditions, including acute myocardial infarction (MI).

OBJECTIVE

To evaluate 1-year survival in MI patients before and after AUGE.

METHODS

Retrospective cohorts of patients with MI (with and without ST segment elevation) discharged alive from six public hospitals between January 2001-June 2005 (pre-AUGE) and July 2008-March 2009 (post-AUGE). Chilean national mortality and MI Registry (hospital-based) databases were linked using a unique identification number (ICD-10 codes I00-I99 were used to identify cardiovascular deaths). One-year survival was assessed using Weibull multivariate regression.

RESULTS

About 1867 patients were discharged alive pre-AUGE and 534 post-AUGE; 25% were women in both periods. When comparing pre-AUGE and post-AUGE, there was an increase in the use of primary and elective angioplasty (1.7 vs 23.6% and 7.3 vs 20.0%), beta-blockers (62 vs 71%) and statins (40 vs 90%); P  <  0.001 all. One-year survival was 92% pre-AUGE (95% CI: 91-93%) and 96% post-AUGE (95% CI: 94-97%) (HR  =  0.50, 95% CI: 0.31-0.82; P  =  0.003). The post-AUGE improvement persisted after adjusting for variables associated with long-term case-fatality (HR  =  0.44, 95% CI: 0.26-0.75). Percutaneous coronary intervention (HR  =  0.31, 95% CI: 0.09-0.99) and statins use at discharge (HR  =  0.45, 95% CI: 0.31-0.66) had the highest effects associated with lower case-fatality and both treatments increased in the post-AUGE period.

CONCLUSIONS

The implementation of AUGE in Chile appears to have contributed to improved treatment of MI in public hospitals and increased 1-year survival, which is consistent with its aim to improve access to quality medical care and to reduce health inequities.