Pharmacy-based predictors of non-adherence, non-persistence and reinitiation of antihypertensive drugs among patients on oral diabetes drugs in the Netherlands

Comparative effectiveness of antihypertensive monotherapies in primary prevention of cardiovascular events-a real-world longitudinal inception cohort study

Introduction

Antihypertensive drugs are used preventatively to lower the risk of cardiovascular disease events. Comparative effectiveness studies on angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), beta-blockers (BBs), calcium channel blockers (CCBs), and thiazides have yielded inconsistent results and given little consideration to patient adherence. Using a longitudinal cohort and considering time-varying adherence and confounding factors, we aimed to estimate the real-world effectiveness of five major antihypertensive drug monotherapies in the primary prevention of cardiovascular events.

Methods

Eligible patients for a retrospective inception cohort study were selected using information obtained from the University of Groningen IADB.nl pharmacy prescription database. Cohort 1 comprised adherent patients with a follow-up time exceeding 1 year, and cohort 2 comprised all patients independent of adherence. The exposures were ACEIs, ARBs, BBs, CCBs, and thiazides. The primary outcome was the time to the first prescription for an acute cardiac drug therapy (CDT) measured using valid drug proxies to identify the first major cardiovascular event. A per-protocol analytical approach was adopted with inverse probability of treatment weighted (IPTW), time-varying Cox regression analysis to obtain the hazard ratios (HRs) and 95% confidence intervals (CIs).

Results

In cohort 1 (n = 22,441), 1,294 patients (5.8%) were prescribed an acute CDT with an average follow-up time of 4.2 ± 2.8 years. Following IPTW, the hazard measures of ARBs and thiazides were lower than those of BBs (HRs: 0.79 and 0.80, respectively; 95% CIs: 0.64-0.97 and 0.69-0.94, respectively). Among drug-treated diabetic patients, the hazard measures were even lower, with HR point estimates of 0.43 (CI: 0.19-0.98) for ARBs and 0.32 (CI: 0.13-0.82) for thiazides. In cohort 2 (n = 33,427) and sensitivity analysis, the comparative effectiveness results for thiazides and BBs were similar to those for cohort 1.

Conclusion

The findings of this real-world analysis suggest that the incidence of CDT associated with long-term thiazide or ARB monotherapy is lower than the incidence of CDT with BBs, notably among high-risk patients. Incidences of CDT associated with ACEIs and CCBs were comparable relative to those associated with BBs.

Association between health literacy and medication adherence in chronic diseases: a recent systematic review

BACKGROUND

Poor medication adherence is a serious barrier to successful chronic disease management. Previous reviews reported that low health literacy could be associated with medication non-adherence but conclusions were uncertain.

AIM

The aim of this systematic review was to clarify the relationship between health literacy and medication adherence in adults with chronic diseases. A secondary objective was to identify the factors that influence medication adherence.

METHOD

Publications analyzing the relationship between health literacy and adherence in adults with chronic diseases were identified through 6 databases between 2015 and 2020. A quality assessment was conducted in order to improve the interpretation of the relationship between health literacy and medication adherence. A narrative synthesis was then performed to describe the relationship between health literacy and medication adherence. The factors influencing medication adherence were then analyzed as a secondary outcome.

RESULTS

Among the 27 studies, 17 and 10 were considered to be of good and medium methodological quality, respectively. Concerning the relationship between health literacy and adherence, 14 reported a positive relationship, 1 study suggested a negative relationship, 3 found mixed results, and 9 reported not finding a relationship. Patient-related factors such as medication beliefs, self-efficacy, or medication knowledge, as well as demographic factors such as ethnic minority and incomes influence medication adherence.

CONCLUSION

The present review confirms an unclear relationship between health literacy and medication adherence. Although health literacy plays a substantial role in medication adherence, other factors must be taken into account when addressing non-adherence.

Reinitiation and Subsequent Discontinuation of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers among New and Prevalent Users Aged 65 Years or More with Peripheral Arterial Disease

Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin-receptor blockers (ARBs) are recommended in the treatment of arterial hypertension in patients with peripheral arterial disease (PAD). The aims of our study were: (a) to analyse the extent of reinitiation and subsequent discontinuation in older hypertensive PAD patients non-persistent with ACEIs/ARBs; (b) to determine patient and medication factors associated with reinitiation and subsequent discontinuation; and (c) to compare these factors between prevalent and new users. The analysis of reinitiation was performed on a sample of 1642 non-persistent patients aged ≥65 years with PAD newly diagnosed in 2012. Patients reinitiating ACEIs/ARBs were used for the analysis of subsequent discontinuation identified according to the treatment gap period of at least 6 months without any prescription of ACEI/ARB. In the group of non-persistent patients, 875 (53.3%) patients reinitiated ACEIs/ARBs during a follow-up (24.8 months on average). Within this group, subsequent discontinuation was identified in 414 (47.3%) patients. Being a new user was associated with subsequent discontinuation, but not with reinitiation. Myocardial infarction during non-persistence and after reinitiation was associated with reinitiation and lower likelihood of subsequent discontinuation, respectively. Being a prevalent or a new user is associated with the use of medication also after initial discontinuation.

The role of illness perceptions on medication nonadherence among patients with hypertension: A multicenter study in indonesia

Introduction: Nonadherence to antihypertensive medications is recognized as a significant cause of treatment failure. Therefore, identifying its underlying factors, particularly from the patient’s perspective, is essential for developing tailored intervention strategies. The objective of this study was to evaluate the associations between different domains of illness perception and medication nonadherence among patients with hypertension in Indonesia.

Patients and methods: A multicenter cross-sectional study was conducted among patients with hypertension aged 18 years old and older who were using antihypertensive medications in the last 3 months in the community health centers in the three cities in Indonesia. The different domains of illness perception (e.g., consequences, timeline, personal control, treatment control, identity, concerns, comprehension, and emotional response) and medication nonadherence were assessed using a validated Brief Illness Perceptions Questionnaire (BIPQ) and Medication Adherence Report Scale (MARS), respectively. A logistic regression analysis was conducted to evaluate the associations between the different domains of illness perception and medication nonadherence adjusting for confounders. The odds ratios (ORs) and 95% confidence intervals (CIs) were reported.

Results: A total of 440 participants were included, whom 41.8% reported nonadherence to antihypertensive medications. The majority of the participants were females (64.3%) and aged between 60 and 69 years old (39.5%). The treatment control (OR: 0.80, 95% confidence interval: 0.7–10.90), patient’s comprehension of hypertension (OR: 0.89, 95% CI: 0.820–0.97), and patient’s emotions (OR: 0.93, 95% CI: 0.88–0.99) were significantly associated with medication nonadherence. No significant associations were observed between the other domains of illness perception and medication nonadherence.

Conclusion: Different dimensions of illness perception were associated with non-adherence to antihypertensive medications. Educational interventions should be developed based on patients’ perception of their illness.

Healthcare Resource Utilization and Associated Costs in New Users of Empagliflozin versus DPP-4 Inhibitors and GLP-1 Agonists: A Comparative Analysis Based on Retrospective Real-World Data from German Sickness Funds

Purpose

Achieving good glycemic control in type 2 diabetes (T2DM) may require individualized pharmacological approaches. We aimed to compare direct healthcare costs in patients treated with empagliflozin (EMPA) compared to dipeptidyl peptidase-4 inhibitors (DPP-4i) or glucagon-like peptide-1 receptor agonists (GLP-1-RA).

Patients and Methods

This German claims data study included continuously insured persons with at least two outpatient diagnoses and/or one inpatient diagnosis of T2DM if they started EMPA, DPP-4i, or GLP-1-RA in 2015-2018. Healthcare costs were assessed from therapy initiation until the end of data availability, death, or therapy discontinuation and compared among propensity score-matched cohorts.

Results

Of 24,465 patients included, 3285 received EMPA, 19,443 DPP-4i, and 1747 GLP-1-RA. Matched cohorts were balanced on baseline characteristics (EMPA versus DPP-4i: n1/n2 = 3100/3100 and EMPA versus GLP-1-RA: n3/n4 = 1346/1346). Mean total costs after start of DPP-4i were €7009 (95%-CI: 6573-7444) versus €4274 (3982-4566) for EMPA. Costs associated with GLP-1-RA treatment were also significantly higher compared with EMPA (€6851 [6183-7518] versus €4895 [4345-5445]).

Conclusion

Although the individual clinical patient profile and physician assessment are paramount in treatment decisions, substantial differences in the economic impact of different antidiabetic therapies should be considered.

Determinants of Adherence to a "GRADIOR" Computer-Based Cognitive Training Program in People with Mild Cognitive Impairment (MCI) and Mild Dementia

BACKGROUND

Computer-based programs have been implemented from a psychosocial approach for the care of people with dementia (PwD). However, several factors may determine adherence of older PwD to this type of treatment. The aim of this paper was to identify the sociodemographic, cognitive, psychological, and physical-health determinants that helped predict adherence or not to a "GRADIOR" computerized cognitive training (CCT) program in people with mild cognitive impairment (MCI) and mild dementia.

METHOD

This study was part of a randomized clinical trial (RCT) (ISRCTN: 15742788). However, this study will only focus on the experimental group (n = 43) included in the RCT. This group was divided into adherent people (compliance: ≥60% of the sessions and persistence in treatment up to 4 months) and non-adherent. The participants were 60-90 age and diagnosed with MCI and mild dementia. We selected from the evaluation protocol for the RCT, tests that evaluated cognitive aspects (memory and executive functioning), psychological and physical health. The CCT with GRADIOR consisted of attending 2-3 weekly sessions for 4 months with a duration of 30 min Data analysis: Phi and Biserial-point correlations, a multiple logical regression analysis was obtained to find the adherence model and U Mann-Whitney was used.

RESULTS

The adherence model was made up of the Digit Symbol and Arithmetic of Wechsler Adult Intelligence Scale (WAIS-III) and Lexical Verbal Fluency (LVF) -R tests. This model had 90% sensitivity, 50% specificity and 75% precision. The goodness-of-fit p-value of the model was 0.02.

CONCLUSIONS

good executive functioning in attention, working memory (WM), phonological verbal fluency and cognitive flexibility predicted a greater probability that a person would be adherent.

Reinitiation and Subsequent Discontinuation of Antiplatelet Treatment in Nonpersistent Older Patients with Peripheral Arterial Disease

The successful treatment of peripheral arterial disease (PAD) depends on adequate adherence to medications including antiplatelet agents. The aims of this study were (a) to identify the proportion of nonpersistent patients who reinitiated antiplatelet therapy and how many of them discontinued therapy after reinitiation, and (b) to identify patient- and medication-related characteristics associated with the likelihood of reinitiation and discontinuation among reinitiators. The analysis of reinitiation was conducted on 3032 nonpersistent users of antiplatelet agents aged ≥65 years, with PAD newly diagnosed in 2012. Discontinuation (i.e., a treatment gap of ≥6 months without antiplatelet medication prescription) was analysed in 2006 reinitiating patients. To identify factors associated with the likelihood of reinitiation and discontinuation, Cox regression with time-dependent covariates was used. Reinitiation was recorded in 2006 (66.2%) of 3032 patients who had discontinued antiplatelet medication. Among these 2006 reinitiators, 1078 (53.7%) patients discontinued antiplatelet therapy again. Ischemic stroke and myocardial infarction during nonpersistence and bronchial asthma/chronic obstructive pulmonary disease were associated with an increased likelihood of reinitiation. University education was associated with discontinuation among reinitiators. Factors associated with the probability of reinitiation and discontinuation in reinitiators make it possible to identify older PAD patients in whom "stop-starting" behaviour may be expected.

An estimation of patients at potential risk for drug-induced sexual dysfunction using pharmacy dispensing data

BACKGROUND AND OBJECTIVES

Adverse drug reactions on sexual functioning (sADRs) may seriously decrease a person's quality of life. A multitude of diseases and drugs are known risk factors for sexual dysfunction. To inform patients better about these potential effects, more insight is needed on the estimated number of patients at high risk for sADRs and their characteristics.

METHODS

This cross-sectional study estimated the number of patients in the Netherlands who were dispensed drugs with a potential very high risk (>10%) or high risk (1-10%) for sADRs as registered in the Summary of Product Characteristics, the official drug information text in Europe.

RESULTS

In April 2019, 2.06% of the inhabitants of the Netherlands received drugs with >10% risk for sADRs and 7.76% with 1-10% risk. The majority of these patients had at least one additional risk factor for decreased sexual function such as high age or depression. Almost half of the patients were identified with two or more morbidities influencing sexual functioning. Paroxetine, sertraline and spironolactone were the most dispensed drugs with a potential >10% risk for sADRs. One-third of their first dispenses were not followed by a second dispense, with a higher risk of discontinuation for a decreasing number of morbidities.

CONCLUSION

About 1 in 11 inhabitants of the Netherlands was dispensed a drug with a potential high risk for sADRs, often with other risk factors for sexual complaints. Further research is needed whether these users actually experience sADRs, to understand its impact on multimorbid patients and to provide alternatives if needed.

Psychosocial Determinants of Treatment Adherence in Patients with Type 2 Diabetes - A Review

Less than 50% of patients with diabetes achieve the glycaemic goals recommended by the American Diabetes Association. The set of factors associated with adherence to treatment is very broad. Evidence suggests that psychosocial factors are related to medication adherence of patients with type 2 diabetes. Due to the lack of a clear statement from researchers regarding the relationship of psychosocial factors to adherence, an electronic search was conducted in PubMed, MEDLINE, Academic Search Ultimate, CINAHL Complete, Edition and Health Source: Nursing/Academic Edition using the following keywords "adherence", "diabetes", "social support", "stress", "anxiety and depression", "beliefs about medicine", "communication", "older age", "frailty", "cognitive impairment", "addiction", "acceptance of illness", "sense of coherence" obtaining 2758 results. After a narrowing of searches and reference scanning, 36 studies were qualified. The studies analysed showed negative effects of anxiety, diabetes distress, older age, poor communication with physicians, stress, concerns about medicines and cognitive impairment on levels of self-care and medication adherence. One study did not confirm the association of depression with adherence. Self-efficacy, social and family support, and acceptance of illness had a beneficial effect on medication adherence. In conclusion, the current evidence suggests that the relationship between psychosocial factors and adherence has reliable scientific support.

Medication adherence in multiple sclerosis as a potential model for other chronic diseases: a population-based cohort study

OBJECTIVE

To determine whether better medication adherence in multiple sclerosis (MS) might be due to specialised disease-modifying drug (DMD) support programmes by: (1) establishing higher adherence in MS than in other chronic diseases and (2) determining if higher adherence is associated with patient-specific or treatment-specific factors.

DESIGN

Retrospective cohort study with data from 1 January 1996 to 31 December 2015.

SETTING

Population-based health administrative data from three Canadian provinces.

PARTICIPANTS

Individual cohorts were created using validated case definitions for MS, epilepsy, Parkinson's disease (PD) and rheumatoid arthritis (RA). Subjects were included if they received ≥1 dispensation for a disease-related drug between 1 January 1997 and 31 December 2014.

MAIN OUTCOME MEASURES

Proportion of subjects with optimal adherence (≥80%) measured by the medication possession ratio 1 year after the index date (first dispensation of disease-related drug).

RESULTS

126 478 subjects were included in the primary analysis (MS, n=6271; epilepsy, n=55 739; PD, n=21 304; RA, n=43 164). Subjects with epilepsy (adjusted OR, aOR 0.29; 95% CI 0.19 to 0.45), PD (aOR 0.42; 95% CI 0.29 to 0.63) or RA (aOR 0.26; 95% CI 0.19 to 0.35) were less likely to have optimal 1-year adherence compared with subjects with MS. Within the MS cohort, adherence was higher for DMD than for chronic-use non-MS medications, and no consistent patient-related predictors of adherence were observed across all four non-MS medication classes, including having optimal adherence to DMD.

CONCLUSIONS

Subjects with MS were significantly more likely to have optimal 1-year adherence than subjects with epilepsy, RA and PD, and optimal adherence appears related to treatment-specific factors rather than patient-related factors. This supports the hypothesis that higher adherence to the MS DMDs could be due to the specialised support programmes; these programmes may serve as a model for use in other chronic conditions.

Comparing the Sensitivities of Measures of Adherence to Antihypertensive Drugs Using Korean National Health Insurance Claims Data

PURPOSE

Numerous studies have utilized various forms of adherence measures. However, methods for measuring adherence are inconsistent. Moreover, few studies are available that have compared sensitivities of the effects of several criteria on medication adherence. This study aims to compare measures of adherence using varied analytical decisions.

MATERIALS AND METHODS

We included three measures for adherence: proportion of days covered with one or more medications (PDC_with≥1), duration weighted mean PDC (PDC_wm), and daily polypharmacy possession ratio (DPPR). We compared the sensitivities of the measures by changing parameters in the Korean nationwide claims database. First, we used PDC_with≥1 as our base model. Then, we divided an adherence measure algorithm into three categories: (1) definition of data cleaning, (2) inclusion criteria and observation period, and (3) calculation methods of medication adherence. The categories included eight decision nodes that incorporated 25 alternative options. Finally, we assessed the medication adherence for the base-case with commonly used values and then varied to measure with each alternative option.

RESULTS

The base-case included 14,288 beneficiaries with antihypertensives. Among eight decisions, both handling an end-date-of-study and overlaps had the strongest impacts on measuring PDC_with≥1, PDC_wm, and DPPR, with small differences in sample size. Instead of the estimates of adherence from PDC_wm, those of PDC_with≥1 and DPPR were similar. Furthermore, a tendency toward a higher medication adherence was observed with a smaller study population.

CONCLUSION

The decisions regarding identifying an end-date-of-study and overlaps showed meaningful impacts of all three measures including PDC_with≥1, PDCwm, and DPPR on measuring medication adherence.

Non-Adherence to Statin Treatment in Older Patients with Peripheral Arterial Disease Depending on Persistence Status

The effectiveness of statins in secondary prevention of peripheral arterial disease (PAD) largely depends on patients’ adherence to treatment. The aims of our study were: (a) to analyze non-adherence during the whole follow-up in persistent patients, and only during persistence for non-persistent patients; (b) to identify factors associated with non-adherence separately among persistent and non-persistent patients. A cohort of 8330 statin users aged ≥65 years, in whom PAD was newly diagnosed between January 2012–December 2012, included 5353 patients persistent with statin treatment, and 2977 subjects who became non-persistent during the 5-year follow-up. Non-adherence was defined using the proportion of days covered <80%. Patient- and statin-related characteristics associated with non-adherence were identified with binary logistic regression. A significantly higher proportion of non-adherent patients was found among non-persistent patients compared to persistent subjects (43.6% vs. 29.6%; p < 0.001). Associated with non-adherence in both persistent and non-persistent patients was high intensity statin treatment, while in non-persistent patients, it was employment and increasing number of medications. In patients with a poor adherence during their persistent period, an increased risk for discontinuation may be expected. However, there is also non-adherence among persistent patients. There are differences in factors associated with non-adherence depending on patients’ persistence.

Sex differences in the adherence of antihypertensive drugs: a systematic review with meta-analyses

OBJECTIVES

Poor worldwide rate of blood pressure control is largely due to poor adherence to antihypertensive (AHT) drug treatment. The question of whether sex affects adherence has long been debated but conflicting findings have been reported on this issue. Our objective was to evaluate sex differences in the adherence to AHT therapy.

RESEARCH DESIGN AND METHODS

Studies were identified through a systematic search of PubMed, CINAHL, PsycINFO, Web of Science and Google Scholar (through January 2020) and manual handsearching of relevant articles. Observational studies reporting adherence to AHT drugs measured by self-report or pharmacy refill prescription-based methods among men and women were included. Summarised estimates of OR_s with 95% CIs were calculated using random-effects model and meta-regression models.

RESULTS

From 12 849 potentially relevant publications, 82 studies (15 517 457 men and 18 537 599 women) were included. No significant between-sex differences in adherence to AHT were observed, whether all study-specific estimates were summarised (OR_s 1.04, 95% CI 1.00 to 1.09, p=0.07), nor estimates were pooled according to the method for measuring adherence. Among patients aged 65 years or older, lower self-reported adherence was observed in women (OR_s 0.84, 95% CI 0.72 to 0.97, p=0.02), while the main result remained unchanged according to other subgroup analyses.

CONCLUSIONS

Definitive evidence of sex differences in adherence to AHT therapy cannot be drawn. Our little knowledge about factors affecting adherence, in particular of sex effect among elderly, urgently requires high-quality studies investigating these issues.

Factors Associated with Reinitiation of Statin Treatment in Older Patients with Peripheral Arterial Disease

BACKGROUND

Long-term persistence represents a basic precondition of successful statin treatment in patients with peripheral arterial disease (PAD).

OBJECTIVES

The aims of our study were evaluation of reinitiation in older PAD patients who were non-persistent with statin treatment, and identification of patient-related characteristics associated with the patient's probability of reinitiation.

METHODS

Our study cohort included 2977 older patients (≥ 65 years) who were non-persistent with statin treatment in whom PAD was newly diagnosed in 2012. Reinitiation was defined as the first statin prescription recorded after discontinuation. To analyze factors associated with the patient´s probability of reinitiation, Cox regression with time-dependent covariates was applied.

RESULTS

After post-discontinuation follow-up of a mean of 27 months, reinitiation of statin treatment was recorded for 1244 (41.8%) patients. Increasing age, Parkinson's disease, being a new statin user (patient in whom statin treatment was initiated in association with PAD diagnosis), general practitioner as the index prescriber who prescribed a statin for the first time after diagnosis of PAD, coadministration of loop diuretics, and longer persistence before discontinuation decreased the patient's likelihood of reinitiation, whereas myocardial infarction during non-persistence, high-intensity statin treatment, and increasing number of medications increased the patient's probability of reinitiation.

CONCLUSIONS

In patients with characteristics associated with a lower probability of reinitiation, more concentrated outreach and further evaluation of these groups to identify interventions that might be helpful to encourage reinitiation are needed.