A Pharmacist Telephone Intervention to Identify Adherence Barriers and Improve Adherence Among Nonadherent Patients with Comorbid Hypertension and Diabetes in a Medicare Advantage Plan

Group-based trajectory modeling to identify adherence patterns for direct oral anticoagulants in Medicare beneficiaries with atrial fibrillation: a real-world study on medication adherence

BACKGROUND

Suboptimal adherence to direct oral anticoagulants (DOACs) among atrial fibrillation (AF) patients remains currently a major concern due to the increased risk of cardiac and thromboembolic events.

AIM

To identify longitudinal distinct trajectories of DOAC adherence and sociodemographic and clinical factors associated with each trajectory.

METHOD

Patients with AF who were prescribed with DOAC from July 2016-December 2017 were identified among patients enrolled in the Medicare Advantage Plan. Patients were followed up for a year after the index date to calculate the monthly proportion of days covered (PDC). The monthly PDC was incorporated into the logistic group-based trajectory model to evaluate distinct patterns of adherence. A multinomial regression model was carried out to assess various predictors associated with each trajectory. Sub-group analysis was conducted among incident DOAC users.

RESULTS

Total of 1969 patients with AF, four distinct trajectories of adherence were selected: adherent 36.8%, gaps in adherence 9.3%, gradual decline in adherence 29.7%, and rapid decline in adherence 24.2%. Significant predictors associated with suboptimal adherence trajectories were age (75 years or older), gender (male vs female), low-income subsidy health plan, prevalent users, and presence of comorbidities. Among 933 incident users, three adherence trajectories were identified: adherent trajectory (31.8%), rapid decline in adherence (32.5%), and gradual decline in adherence (35.6%). The significant predictors among incident users were gender (male vs female), low-income subsidy health plan, HAS-BLED score ≥ 2, and presence of coronary artery disease.

CONCLUSION

Adherence to DOACs was suboptimal among the total population and incident users.

Improving Syrian refugees' knowledge of medications and adherence following a randomized control trial assessing the effect of a medication management review service

BACKGROUND

Syrian refugees living in Jordan have many chronic conditions and use many medications. Pharmacists delivering the Medication Management Review (MMR) service can have a role in improving this growing global refugees' problem.

OBJECTIVES

To assess the effect of the MMR service on adherence to treatment therapy and knowledge of chronic medications for Syrian refugees residing in Jordan.

METHODS

This randomized intervention control single-blinded study was conducted in Jordan. Syrian refugees were recruited and randomized into intervention and control groups. Two home visits were delivered to each participant, at baseline and three months later. All participants completed questionnaires regarding adherence and knowledge. As a part of the MMR service, treatment-related problems (TRPs) were recognized for all patients; recommendations to resolve these TRPs were only delivered to intervention group refugees' physicians; TRPs were corrected. At follow-up, TRPs assessment, adherence and medication knowledge were assessed for all refugee participants.

RESULTS

Participants (n = 106; intervention n = 53, control n = 53) had a number of medications and diagnosed chronic diseases of 5.8 ± 2.1 and 2.97 ± 1.16 per participant respectively. A significant improvement in the adherence and knowledge scores were noted in the intervention (P < 0.001 for both) but not the control group (P = 0.229, P = 0.07 respectively).

CONCLUSION

The MMR service can significantly improve refugees' TRPs, adherence to therapy and knowledge of chronic medications. If this approach was extended to the large scale, many refugees in need would be able to access a quality essential health-care service; a step towards achieving universal health coverage.

TRIAL REGISTRATION

Registry: ClinicalTrials.gov Identifier: NCT04554810.

A prediction model for nonpersistence or nonadherence to direct oral anticoagulants in hospitalized patients with atrial fibrillation

BACKGROUND: Medication adherence and persistence is fundamental for drug effectiveness, which is also true for the prevention of strokes in patients with atrial fibrillation (AF). Adherence to direct oral anticoagulants (DOACs) as first-line agents is often high in the early posthospital period. However, adherence often sharply declines (or eventually leads to nonpersistence) in the post-discharge ambulatory period, rendering stroke prevention ineffective. If patients at high risk of nonpersistence or nonadherence could be identified early, they could be offered early intervention measures to improve adherence and/or persistence. OBJECTIVE: To develop and internally validate a predictive model for medication nonadherence and nonpersistence to DOAC treatment in patients with AF after discharge using health insurance claims data. METHODS: We selected health insurance claims data between 2011 and 2016 from 8,055 patients with AF who were newly treated with rivaroxaban or apixaban after a hospital admission for stroke, transient ischemic attack, or AF. In the post-discharge ambulatory period, medication adherence was derived as the proportion of days covered, calculated from drug dispensation data. A maximum permissible 90-day gap between the end of a prescription and the next dispensation was used to estimate persistence. Candidate predictors were either derived from the index hospital admission or summarized from the previous year (eg, comorbidities or medication adherence to long-term treatments, such as ß-blockers, renin-angiotensin system inhibitors, statins, and thyroid hormones). A regularized logistic regression model was fitted using the least absolute shrinkage and selection operator in a split-sample approach (66.7% training data; 33.3% test data) to predict a composite of medication nonadherence/nonpersistence. Discrimination performance was assessed using the area under the receiver operating characteristic curve, the maximum sensitivity/specificity, and the scaled Brier score. A calibration curve fitted by linear regression was used to evaluate model calibration. RESULTS: The average age of the study participants was 79.7 years, 62% were female, and 3,515 patients (44%) were adherent and persistent (median follow-up of 185 days). Medication adherence to previous long-term treatments showed strong predictive properties. The developed model discriminated well (concordance statistic: 0.755), was well calibrated, and showed a scaled Brier score of 0.202 for identification of patients at risk. CONCLUSIONS: The model successfully predicted medication non-adherence/nonpersistence to DOAC treatment after discharge. Such a model could help ensure that targeted interventions are already in place at the time of hospital discharge, potentially preventing strokes and reducing costs. DISCLOSURES: Mr Wirbka is funded by the German Innovation Funds according to § 92a (2) Volume V of the Social Insurance Code (§ 92a Abs. 2, SGBV-Fünftes Buch Sozialgesetzbuch), grant number: 01VSF18019. Dr Haefeli received financial support from Daiichi-Sankyo, app development (https://www.easydoac.de/), and Bayer. He also received personal speaker fees from Bristol Myers-Squibb and Daiichi-Sankyo Online Seminar. Dr Meid is funded by the Physician-Scientist Programme of the Medical Faculty of Heidelberg University.

Towards Developing a Voice-activated Self-monitoring Application (VoiS) for Adults with Diabetes and Hypertension

The integration of motivational strategies and self-management theory with mHealth tools is a promising approach to changing the behavior of patients with chronic disease. In this manuscript, we describe the development and current architecture of a prototype voice-activated self-monitoring application (VoiS) which is based on these theories. Unlike prior mHealth applications which require textual input, VoiS app relies on the more convenient and adaptable approach of asking users to verbally input markers of diabetes and hypertension control through a smart speaker. The VoiS app can provide real-time feedback based on these markers; thus, it has the potential to serve as a remote, regular, source of feedback to support behavior change. To enhance the usability and acceptability of the VoiS application, we will ask a diverse group of patients to use it in real-world settings and provide feedback on their experience. We will use this feedback to optimize tool performance, so that it can provide patients with an improved understanding of their chronic conditions. The VoiS app can also facilitate remote sharing of chronic disease control with healthcare providers, which can improve clinical efficacy and reduce the urgency and frequency of clinical care encounters. Because the VoiS app will be configured for use with multiple platforms, it will be more robust than existing systems with respect to user accessibility and acceptability.

Scalability of effective adherence interventions for patients using cardiovascular disease medication - a realist synthesis inspired systematic review

Upscaling of medication adherence interventions to routine care is still challenging. This realist theory inspired review aimed to assess which intervention aspects are potentially important for the scalability of effective cardiovascular disease (CVD) medication adherence interventions and how they are reported in effectiveness studies. A total of 4097 articles from four databases were screened of which ultimately 31 studies were included. Relevant information on scalability was extracted using a theoretic framework based on the scalability assessment tool used in the QUALIDEC study for the following domains; (i) innovation, (ii) implementers and patients, (iii) adopting organizations and health system and (iv) socio-political context. Extracted articles were analysed for themes and chains of inference, which were grouped based on commonality and source of evidence to form new hypotheses. Six different domains relevant for scalability of adherence interventions were identified: 1) Complexity of the intervention 2) training; 3) customization of the intervention; 4) drivers of the intervention; 5) technical interventions 6) stakeholder involvement. These six domains might be useful for the development of more scalable interventions by bridging the gap between research and practice. Data relevant for scalability is not well reported on in effectiveness trials for CVD medication adherence interventions and only limited data on scalability has been published in additional papers. We believe the adoption and reach of effective CVD medication adherence interventions will improve with increased awareness for the necessity of scalability in all phases of intervention development.

Towards better reporting of the Proportion of Days Covered method in cardiovascular medication adherence: A scoping review and new tool TEN-SPIDERS

Although medication adherence is commonly measured in electronic datasets using the proportion of days covered (PDC), no standardized approach is used to calculate and report this measure. We conducted a scoping review to understand the approaches taken to calculate and report the PDC for cardiovascular medicines to develop improved guidance for researchers using this measure. After prespecifying methods in a registered protocol, we searched Ovid Medline, Embase, Scopus, CINAHL Plus and grey literature (1 July 2012 to 14 December 2020) for articles containing the terms “proportion of days covered” and “cardiovascular medicine”, or synonyms and subject headings. Of the 523 articles identified, 316 were reviewed in full and 76 were included (93% observational studies; 47% from the USA; 2 grey literature articles). In 45 articles (59%), the PDC was measured from the first dispensing/claim date. Good adherence was defined as 80% PDC in 61 articles, 56% of which contained a rationale for selecting this threshold. The following parameters, important for deriving the PDC, were often not reported/unclear: switching (53%), early refills (45%), in‐hospital supplies (45%), presupply (28%) and survival (7%). Of the 46 articles where dosing information was unavailable, 59% reported how doses were imputed. To improve the transparent and systematic reporting of the PDC, we propose the TEN‐SPIDERS tool, covering the following PDC parameters: Threshold, Eligibility criteria, Numerator and denominator, Survival, Presupply, In‐hospital supplies, Dosing, Early Refills, and Switching. Use of this tool will standardize reporting of the PDC to facilitate reliable comparisons of medication adherence estimates between studies.

Patient-Reported Barriers to Adherence Among ACEI/ARB Users from a Motivational Interviewing Telephonic Intervention

PURPOSE

Hypertension is a common comorbidity among type 2 diabetes mellitus (T2DM) patients, which increases the risk of cardiovascular diseases. Despite the proven benefit of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) in this population, poor medication adherence is prevalent, resulting in higher complications and mortality rate. Motivational interviewing (MoI) has demonstrated effectiveness in improving medication adherence and identifying barriers. This study aimed to assess and identify patient-reported barriers to adherence to ACEI/ARB from an MoI telephonic intervention conducted by student pharmacist interns.

PATIENTS AND METHODS

This retrospective study was conducted within an MoI intervention customized by past ACEI/ARB adherence trajectories for nonadherent patients with T2DM and hypertension enrolled in a Medicare Advantage Plan. Adherence barriers were extracted from the interviewers' notes by two independent researchers. Descriptive analysis was performed to summarize the overall frequency of barriers as well as across trajectory groups, identified from the initial and follow-up calls.

RESULTS

In total, 247 patients received the initial MoI call from which 41% did not communicate any barrier for ACEI/ARB use despite having low adherence. About 59% of the patients reported at least one barrier during the initial call. The most common barriers included forgetfulness, discontinuation by physicians, side effects, multiple comorbidities, polypharmacy, lack of knowledge about disease/medication, and cost issues. The follow-up calls helped with uncovering at least one new barrier for 28 patients who previously communicated a different issue with their medication during the first call. Additionally, 18 patients with initial denial for having any barrier to adherence reported at least one barrier throughout the follow-up calls.

CONCLUSION

This study summarized patient-reported barriers to ACEI/ARB adherence from an MoI telephonic intervention performed among nonadherent patients. Identifying specific barriers for patients may help to further design tailored interventions that address the barriers and improve adherence.

Factors associated with adherence to follow-up calls in cancer patients receiving care at a community oncology practice

BACKGROUND

Follow-up calls in the oncology setting are frequently used to augment care and encourage oral antineoplastic adherence. However, limited data are available on patient populations that would benefit from this intervention versus populations that may require alternative interventions. The purpose of this study was to identify characteristics among patients on oral antineoplastic agents that influence their likelihood to respond to follow-up calls.

METHODS

Patients receiving care from one of the eight community oncology clinics within the same branch were analyzed. Patients were included if they were ≥18 years, received a new oral antineoplastic agent that was electronically prescribed between August 2018-October 2018, and picked up their first fill from their pharmacy of choice. Patients received up to six follow-up calls after picking up their first prescription. Calls were categorized as adherent (≥3 monthly interactions) or non-adherent (<3 monthly interactions). Logistic regression models were used to evaluate factors associated with follow-up call adherence. Factors included demographics, cancer stage, marital status, employment, pharmacy setting (internal pharmacy versus external pharmacy), and insurance used by the patient. Descriptive analysis was performed to analyze response rates, cancer diagnosis, and to determine the best time and day patients responded to follow-up calls.

RESULTS

Data from 125 patients were analyzed, of which 65 patients (52%) were adherent to follow-up calls and the mean response rate over six months was 45% (range: 35% -- 54%). High success rates for follow-up calls were seen between 12-3 pm and on Tuesdays and Thursdays. After adjusting for covariates, patients with stage III-IV were 89% less likely to respond to follow-up calls compared to those with stage 0-II (95% CI: 0.02-0.64; p = 0.01), patients with commercial insurance were 79% less likely to adhere to follow-up calls compared to those on government insurance (95% CI: 0.06-0.71; p = 0.01), and patients using an external pharmacy had a 2.8 times increase odds of being adherent (95% CI 0.98-8.34; p = 0.05). All other factors were not significant.

CONCLUSIONS

For patients taking oral antineoplastics, non-adherence to follow-up calls was observed in more than 45% of patients receiving care from a community oncology clinic. Findings demonstrated that those with advanced stages of cancer, on commercial insurance, and going to an internal pharmacy were at higher risk for not adhering to follow up calls. Therefore, alternative methods for managing adherence and side effects in these populations are warranted.

Contact Tracing for COVID-19: The Use of Motivational Interviewing and the Role of Social Work

One method in mitigating the impact of COVID-19 is that of contact tracing. It is estimated that in the US, 35,000-100,000 contact tracers will be hired (and trained) to talk to recently-infected individuals, understand who they have exposed to the virus, and encourage those exposed to self-quarantine. The Center for Disease Control recommends the use of motivational interviewing (MI) by contact tracers to encourage compliance with contact tracing/quarantine. Contact tracers need to sensitively communicate with COVID-19-exposed individuals who may also be experiencing other issues caused by the pandemic, such as anxiety, depression, grief, anger, intimate partner violence, health problems, food insecurity, and/or unemployment. Social workers are particularly prepared to address the mental health and other psychosocial problems that may be encountered in the tracing process. This article describes contact tracing, its use in other diseases, the role of MI, psychosocial issues that contact tracers may encounter, and how social work can respond to these needs. A sample dialogue of contact tracing using MI is presented with a discussion of the content and skills used in the process.

A systematic review of mobile health technologies to support self-management of concurrent diabetes and hypertension

OBJECTIVE

This article reports results from a systematic literature review of the current state of mobile health (mHealth) technologies that have the potential to support self-management for people with diabetes and hypertension. The review aims to (a) characterize mHealth technologies used or described in the mHealth literature and (b) summarize their effects on self-management for people with diabetes and hypertension from the clinical and technical standpoints.

MATERIALS AND METHODS

A systematic literature review was conducted following PRISMA guidelines. Online databases were searched in September 2018 to identify eligible studies for review that had been published since 2007, the start of the smartphone era. Data were extracted from included studies based on the PICOS framework.

RESULTS

Of the 11 studies included for in-depth review, 5 were clinical research examining patient health outcomes and 6 were technology-focused studies examining users' experiences with mHealth technologies under development. The most frequently used mHealth technology features involved self-management support (n = 11) followed by decision support (n = 6) and shared decision-making (n = 6). Most clinical studies reported benefits associated with mHealth interventions. These included reported improvements in objectively measured patient health outcomes (n = 3) and perceptual or behavioral outcomes (n = 4).

DISCUSSION

Although most studies reported promising results in terms of the effects of mHealth interventions on patient health outcomes and experience, the strength of evidence was limited by the study designs.

CONCLUSION

More randomized clinical trials are needed to examine the promise and limitations of mHealth technologies as assistive tools to facilitate the self-management of highly prevalent comorbidity of chronic conditions, such as diabetes and hypertension.

Effect of Interactive eHealth Interventions on Improving Medication Adherence in Adults With Long-Term Medication: Systematic Review

Background

Medication nonadherence leads to suboptimal treatment outcomes, making it a major priority in health care. eHealth provides an opportunity to offer medication adherence interventions with minimal effort from health care providers whose time and resources are limited.

Objective

The aim of this systematic review is twofold: (1) to evaluate effectiveness of recently developed and tested interactive eHealth (including mHealth) interventions on medication adherence in adult patients using long-term medication and (2) to describe strategies among effective interventions.

Methods

MEDLINE, EMBASE, Cochrane Library, PsycINFO, and Web of Science were systematically searched from January 2014 to July 2019 as well as reference lists and citations of included articles. Eligible studies fulfilled the following inclusion criteria: (1) randomized controlled trial with a usual care control group; (2) a total sample size of at least 50 adult patients using long-term medication; (3) applying an interactive eHealth intervention aimed at the patient or patient’s caregiver; and (4) medication adherence as primary outcome. Methodologic quality was assessed using the Cochrane risk of bias tool. Selection and quality assessment of studies were performed by 2 researchers (BP and BvdB or JV) independently. A best evidence synthesis was performed according to the Cochrane Back Review Group.

Results

Of the 9047 records screened, 22 randomized clinical trials were included reporting on 29 interventions. Most (21/29, 72%) interventions specified using a (mobile) phone for calling, SMS text messaging, or mobile apps. A majority of all interactive interventions (17/29) had a statistically significant effect on medication adherence (P<.05). Of these interventions, 9 had at least a small effect size (Cohen d ≥ 0.2) and 3 showed strong odds for becoming adherent in the intervention group (odds ratio > 2.0). Our best evidence synthesis provided strong evidence for a positive effect of interventions using SMS text messages or interactive voice response, mobile app, and calls as mode of providing adherence tele-feedback. Intervention strategies “to teach medication management skills,” “to improve health care quality by coordinating medication adherence care between professionals,” and “to facilitate communication or decision making between patients and health care providers” also showed strong evidence for a positive effect.

Conclusions

Overall, this review supports the hypothesis that interactive eHealth interventions can be effective in improving medication adherence. Intervention strategies that improve patients’ treatment involvement and their medication management skills are most promising and should be considered for implementation in practice.

Understandings, Attitudes, and Barriers About Diabetes Care: Analysis of Factors Influencing Community Pharmacists in China

PURPOSE

Diabetes mellitus (DM) has been known as a major chronic health problem in China. Suboptimal management of diabetic patients may incur serious complications, even death. The quality of post-hospital care has a good relationship with community pharmacists. However, data describing the current situation from care between community pharmacists and patients in China are lacking. Our article is to investigate community pharmacists' activities, evaluate their attitudes towards providing diabetes care, assess their understandings, and identify perceived barriers.

METHODS

A survey divided into four parts was carried out randomly in China. The part of basic characteristics, understandings, and pharmacists' perceived barriers was rated with a few listed choices scales, while the Likert scale was used to identify on the part of attitudes. Quantitative data were shown in frequency and valid percent. One-way analysis of variance (ANOVA) and non-parametric test conducted on data. A P-value ≤0.05 was considered statistically significant.

RESULTS

A total of 737 surveys were collected. The respondent pharmacists maintained a simply moderate understanding of diabetes care and the pharmaceutical services provided met basic needs rather than clinical ones, though they showed a good momentum towards providing better service. The respondent pharmacists considered patients lacking knowledge on self-management, shortage of funds as the main barriers.

CONCLUSION

Efforts are supposed to make to expand pharmacists' scope of practice, lessen patients' reluctance, and create platforms for pharmacists receiving further education.

Adherence to and effectiveness of lenalidomide after 1 year of treatment in a real world setting

BACKGROUND

In combination with dexamethasone, lenalidomide is prescribed in the oral treatment of Multiple Myeloma for patients who have received at least one previous therapy.

OBJECTIVE

The objective of this study is to evaluate medication adherence to lenalidomide of Multiple Myeloma patients, as well as Progression Free Survival and Overall Survival one year from the beginning of the treatment.

SETTING

The study was carried out in Pescara Hospital, in Italy. All Multiple Myeloma patients who began lenalidomide therapy between January 1, 2012 and June 30, 2016 were included in our study.

METHODS

Adherence to treatment was calculated by using the ratio between the Received Daily Dose and the Prescribed Daily Dose. Effectiveness in real world has been evaluated as Progression Free Survival and Overall Survival one year from the beginning of the treatment.Main outcomes measure: We assessed medication adherence and effectiveness of lenalidomide in the treatment of Multiple Myeloma.

RESULTS

Adherence to the overall mean treatment was 0.73 ± 0.15, relative to 81 patients evaluated in our study. 32% of patients achieved an adherence equal to or greater than 80%. Real-life effectiveness in terms of Progression Free Survival and Overall Survival showed values of ​​53.75% and 88%, respectively, one year from the beginning of treatment.

CONCLUSION

The analysis of adherence in Multiple Myeloma patients treated with lenalidomide one year from the beginning of therapy reveal a concerning lack of adherence. Moreover, the lack of correlation of the levels of adherence with patient-related variables shows that, in the case of Multiple Myeloma, adherence is not related to personal, social and environmental characteristics that may determine each patient's correct treatment implementation, but is directly influenced by disease evolution.

Effective antihypertensive therapy: focus on adherence management

High medical adherence is a prerequisite for achieving goals in the treatment of hypertension (HTN). The majority of patients with HTN showed low adherence to treatment, which requires finding ways to solve this problem. This review describes the factors influencing adherence, ways of its assessment, and analyzes methods of increasing medical adherence in hypertensive patients. Noteworthy is the lack of publications describing the effectiveness of methods for increasing long-term (>2 years) adherence in hypertensive patients. The review also describes a not fully clear individualized approach, which consists in choosing a therapy regimen based on levels of medical adherence, medical follow-up and lifestyle modification.

Effectiveness of a targeted and tailored pharmacist-led intervention to improve adherence to antihypertensive drugs among patients with type 2 diabetes in Indonesia: A cluster randomised controlled trial

Aim

To assess the effects of a targeted and tailored pharmacist‐led intervention among patients with type 2 diabetes (T2DM) who are nonadherent to antihypertensive drugs.

Methods

A cluster‐randomised controlled trial was conducted in 10 community health centres (CHCs) in Indonesia among T2DM patients aged ≥18 years who reported nonadherence to antihypertensive drugs according to the Medication Adherence Report Scale (MARS‐5). Patients in CHCs randomised to the intervention group received a tailored intervention based on their adherence barriers (eg, forgetfulness, lack of knowledge, lack of motivation and/or other drug‐related problems) using a simple question‐based flowchart at baseline and 1‐month follow‐up. Patients in control CHCs received usual care. Primary outcome was the between‐group difference in change in MARS‐5 score from baseline to 3‐month follow‐up. Secondary outcomes included changes in patients' blood pressure and their medication beliefs. Differences in difference in primary and secondary outcomes between groups were assessed using general linear models.

Results

In total, 201 patients were screened for eligibility, 113 met the inclusion criteria and participated, and 89 (79%) patients had complete follow‐up. Forgetfulness (42%) and lack of knowledge (18%) were the most common adherence barriers identified at baseline. The intervention improved medication adherence by 4.62 points on the MARS‐5 scale (95% CI 0.93 to 8.34, P value = 0.008). There were no significant changes in blood pressure levels and beliefs about antihypertensive drugs.

Conclusion

A tailored low‐cost pharmacist‐led intervention aimed at nonadherent T2DM patients resulted in an improvement in medication adherence to antihypertensive drugs. There were no significant changes in secondary outcomes.

Impact of Telehealth Interventions on Medication Adherence for Patients With Type 2 Diabetes, Hypertension, and/or Dyslipidemia: A Systematic Review

Objective:

To describe telehealth interventions and determine their effect on medication adherence for patients with type 2 diabetes, hypertension, and/or dyslipidemia.

Data Sources:

PubMed/MEDLINE, EMBASE, Cochrane, CINAHL Plus, PsycINFO, Academic Search Ultimate, International Pharmaceutical Abstracts, Scopus, Web of Science, WHO Global Index Medicus, association websites, and gray literature were searched from January 1, 1998, to December 31, 2019.

Study Selection and Data Extraction:

Eligible studies reported eHealth, mobile health, and telehealth interventions for adult patients prescribed medications for chronic condition management (eg, type 2 diabetes, hypertension, and/or dyslipidemia). Studies were required to evaluate medication adherence outcomes (eg, medication possession ratio [MPR], proportion of days covered (PDC)]. Randomized controlled trials, cohort studies, and controlled before-and-after studies were included. Multiple reviewers independently extracted data and evaluated risk of bias.

Data Synthesis:

Of 8693 studies identified, 13 reported either an MPR or PDC and were included in the systematic review. The systematic review demonstrated that electronic health (eHealth) and telehealth interventions were successful at improving medication adherence, whereas mobile health interventions did not improve medication adherence.

Relevance to Patient Care and Clinical Practice:

This systematic review highlighted the available research and findings of studies assessing interventions to improve medication nonadherence among patients with type 2 diabetes, hypertension, and/or dyslipidemia. The evaluated findings lend support to the need for targeted medication adherence interventions based on patient population and practice settings.

Conclusions:

Telehealth modalities include telephonic outreach and specialized tools designed to increase health literacy. eHealth and telehealth medication adherence interventions were associated with improved MPR and/or PDC rates.

Impact of Adherence Education and Monitoring on Community Pharmacy Performance Scores and Patient Satisfaction

Background:

Adherence, specifically to noninsulin diabetes medications, statins, and renin-angiotensin system antagonists (i.e. angiotensin-converting-enzyme inhibitors (ACEi), angiotensin II receptor blockers (ARBs), and aliskiren), is a measure tracked by the Centers for Medicare and Medicaid Services (CMS) to give Medicare Part D plans a star rating; pharmacies are impacted by these star ratings. The pharmacy is given a performance score based on the measure. Some pharmacies use a performance information management platform (PIMP) that allows pharmacies to better understand performance information to impact patient care.

Objectives:

(1) To evaluate if a monthly adherence monitoring and education service impacts the percentage of patientsadherent determined by pharmacy performance scores; (2) To determine patient satisfaction with the service in a large community pharmacy chain.

Methods:

A six-month prospective interventional pilot study including patients with a proportion of days covered (PDC) of less than 80% for oral diabetes or renin-angiotensin system antagonists (RASA) medications was conducted in two pharmacies of a large community pharmacy chain in Southwest Virginia. Using pharmacy internal data analytics and PIMP data, the percentage of patients who are adherent to oral diabetes or RASA medications was determined including the baseline PDC for each patient. At the start of the study, the standard of care in this large community chain pharmacy was to address adherence, follow-up in one month and every three months thereafter. In this study, pharmacists provided monthly telephonic adherence monitoring and education for a six-month period. Each session was scripted for medication adherence history, education and data collection. The pharmacist provided guidance and counseling based on how the patient answered the questions. Pharmacists gathered information about adherence patterns and behaviors using a 14 item Likert-scale and multiple choice-based questionnaire during the first session. After completion of the final adherence monitoring and education session, pharmacists gathered patient satisfaction information using an eight item Likert-scale questionnaire. At the end of the six-month period, using PIMP data, the percentage of patients adherent to oral diabetes or RASA medications was determined based on pharmacy performance scores. The data was analyzed using uni-variate and bi-variate statistics to determine if there was a difference in pharmacy performance scores from the pre-study analysis. The adherence patterns and behaviors, as well as patient satisfaction with the program was evaluated to determine factors influencing nonadherence.

Results:

A total of 55 patients were identified in two pharmacies, ten of which were excluded or declined involvement, leaving 45 enrolled in the adherence monitoring and education service. Of the 45 enrolled patients, ten completed the adherence patterns and behaviors questionnaire. About half of the patients were men (50.95%) with an average age of 71.17 years and taking an average of 6.55 prescription medications. All patients had Medicare Part D insurance and majority had a yearly income of less than $40,000. The average baseline PDC was 68.92. In pharmacy 1, the average performance score for oral diabetes medications trended down and the average performance score for hypertension medications trended up over the study period. In pharmacy 2, the average performance score for oral diabetes medications trended up and the average performance score in hypertension medications trended up over the study period. The adherence patterns and behaviors questionnaire revealed the majority of patients rarely forgot to take medications or run out of medications. Additionally, cost of medications did not seem to impact adherence and majority of patients knew the names and indications of their medications. Only one patient completed the patient satisfaction survey.

Conclusions:

An adherence monitoring and education service had mixed results in improving patient adherence and pharmacy performance scores. Only one patient completed the satisfaction survey, thus no conclusions can be made regarding patient satisfaction of the program. More research needs to be done regarding telephonic adherence programs.

QardioArm Blood Pressure Monitoring in a Population With Type 2 Diabetes: Validation Study

BACKGROUND

Home blood pressure monitoring has many benefits, even more so, in populations prone to high blood pressure, such as persons with diabetes.

OBJECTIVE

The purpose of this research was to validate the QardioArm mobile device in a sample of individuals with noninsulin-dependent type 2 diabetes in accordance with the guidelines of the second International Protocol of the European Society of Hypertension.

METHODS

The sample consisted of 33 patients with type 2 diabetes. To evaluate the validity of QardioArm by comparing its data with that obtained with a digital sphygmomanometer (Omron M3 Intellisense), two nurses collected diastolic blood pressure, systolic blood pressure, and heart rate with both devices.

RESULTS

The analysis indicated that the test device QardioArm met all the validation requirements using a sample population with type 2 diabetes.

CONCLUSIONS

This paper reports the first validation of QardioArm in a population of individuals with noninsulin-dependent type 2 diabetes. QardioArm for home monitoring of blood pressure and heart rate met the requirements of the second International Protocol of the European Society of Hypertension.

Pharmacy Data as an Alternative Data Source for Implementation of a Data to Care Strategy

BACKGROUND

Data to Care (D2C) is a strategy for using health departments' HIV surveillance data (HIV viral load and CD4 laboratory reports) to identify and re-engage not-in-care persons with HIV. In the current D2C model, there is a delay in the identification of persons not in care due to the time interval between recommended monitoring tests (ie, every 3-6 months) and the subsequent reporting of these tests to the health department.

METHODS

Pharmacy claims and fulfillment data can be used to identify persons with HIV who have stopped filling antiretroviral therapy and are at risk of falling out of care. Because most antiretrovirals (ARVs) are prescribed as a 30-day supply of medication, these data can be used to identify persons who are not filling their medications on a monthly basis. The use of pharmacy claims data to identify persons not filling ARV prescriptions is an example of how "big data" can be used to conduct a modified D2C model.

RESULTS

Although a D2C strategy using pharmacy data has not been broadly implemented, a few health departments are implementing demonstration projects using this strategy. As the projects progress, processes and outcomes can be evaluated.

CONCLUSIONS

Tracking ARV refill data can be a more real-time indicator of poor adherence and can help identify HIV-infected persons at risk of falling out of HIV medical care.

Pharmacist intervention amid the coronavirus disease 2019 (COVID-19) pandemic: from direct patient care to telemedicine

The coronavirus disease (COVID-19) pandemic has placed enormous pressures on the Canadian healthcare system. Patients are expected to stay home in order to contain the spread of the virus, but understandably have numerous questions and concerns about their health. With physical distancing being of utmost importance during the pandemic, much of healthcare has been forced to move online or over the telephone. Virtual healthcare, in the form of video calls, email, or telephone calls with patients, can significantly enhance access to healthcare. Many clinics have moved their appointments online, and physicians are seeing their patients by means of online video calls. Similarly, patients are refilling their prescriptions online and calling pharmacists whenever they have questions about their medications or medical conditions. Pharmacists are considered the most accessible primary care providers, so it is crucial for patients to know that pharmacists are there to support them throughout the pandemic.

Evaluating Success Factors of a Medication Adherence Tracker Pilot Program in Improving Part D Medication Adherence Metrics in a Medicare Advantage Plan: Importance of Provider Engagement

BACKGROUND

Health plans and providers can increase quality by improving adherence to chronic disease medications included in star ratings among Medicare Advantage Part D (MAPD) plan enrollees. Research is needed to evaluate effective means of collaboration between health plans and providers. The Medication Adherence Tracker (MAT) is a health plan initiative to help primary care providers use outreach to improve their patients' adherence.

OBJECTIVE

To quantify the contribution of structural and process factors on the success of a health plan-initiated tracking system in improving chronic disease medication adherence over 6 months.

METHODS

The MAT quality improvement initiative was carried out in South Texas from June to December 2016. Health plan pharmacists used claims data to identify MAPD enrollees at risk of nonadherence to triple-weighted star medications: renin-angiotensin system antagonists, oral diabetes medications, and statins. Actionable reports were delivered biweekly to each provider, either by fax or in person, by embedded health plan nurses. Multivariable regression was used to evaluate sociodemographic and clinical factors as well as the role of provider outreach in increasing paid pharmacy claims and medication adherence as measured by proportion of days covered (PDC) > 0.8.

RESULTS

Of 3,542 patients in 5 Texas physician-organized delivery system groups whose 67 providers received tracking reports from June through December 2016, 1,901 (54%) patients had more than 1 related prescription, and 3,064 (87%) received provider outreach on at least 1 prescription. 2,493 (70%) had at least 1 paid pharmacy claim. Provider outreach was associated with greater likelihood of paid prescription claims (relative risk [RR] = 4.59, 95% CI = 3.74-5.62) and greater year-end adherence (PDC > 0.8, RR = 1.86, 95% CI = 1.63-2.12) in multivariable predictive models. 95% CIs for age, gender, low-income subsidy eligibility, and number of prescriptions did not exclude the null value.

CONCLUSIONS

Provider engagement is critical to effective health plan-provider partnerships to overcome barriers, change behavior, and improve chronic disease care quality and population outcomes.

DISCLOSURES

This study was funded by Cigna. The manuscript was prepared as a work for hire. Hong, Esse, Gallardo, Serna, Fosshat, and Mamvou are employees of CareAllies, a Cigna company. Bruce was employed by Cigna at the time of the study. Vadhariya reports a past internship at Regeneron Pharmaceuticals, unrelated to this work. Abughosh reports grants from Regeneron Pharmaceuticals, Valeant Pharmaceuticals, Sanofi, and BMS/Pfizer, unrelated to this work.

A randomized control trial assessing the effect of a pharmaceutical care service on Syrian refugees' quality of life and anxiety

Background:

Syrian refugees residing in Jordan suffer from chronic illnesses, low quality of life (QoL) and anxiety. Pharmacists delivering the medication review service can have a role in improving this growing worldwide problem.

Objectives:

To assess the effect of the medication review service on QoL and anxiety scores for Syrian refugees living with chronic medical conditions.

Methods:

This randomized single-blinded intervention control study was conducted in Jordan. Syrian refugees were recruited and randomized into intervention and control groups. Two home visits were organized with each participant, at baseline and three months later. The medication review service was delivered to the participants and questionnaires regarding QoL and anxiety were completed by all participants. As a part of the medication review service, drug-related problems (DRPs) were identified by a clinical pharmacist for all patients, but recommendations to resolve these DRPs were delivered to intervention group refugees’ physicians only (control group patients did not receive this part of the service till the end of the study); DRPs were corrected and pharmacist-delivered counseling and education were provided as well. At follow-up, DRPs assessment, QoL and anxiety scores were assessed for refugees in the intervention and control groups.

Results:

Syrian refugees (n=106) were recruited and randomized into intervention (n=53) and control (n=53) groups with no significant difference between both groups at baseline. The number of medications and diagnosed chronic diseases per participant was 5.8 (SD 2.1) and 2.97 (SD 1.16), respectively. At follow-up, a significant decrease in the number of DRPs for refugees in the intervention group was found (from 600 to 182, p<0.001), but not for the control group (number stayed at 541 DRPs, p=0.116). Although no significant difference between the groups was found with regards to QoL at follow-up (p=0.266), a significant difference was found in the anxiety scores between the groups (p<0.001).

Conclusion:

The medication review service delivered by clinical pharmacists can significantly improve refugees’ DRPs and anxiety scores. As for QoL, significant improvements can be seen for all refugee patients, regardless of whether the DRPs identified were resolved or not.

Non-Adherence to Pharmacotherapy: A Prospective Multicentre Study About Its Incidence and Its Causes Perceived by Chronic Pain Patients

OBJECTIVE

Pharmacological interventions remain the cornerstone of chronic pain treatment; however, nearly 40% of the prescription medicines are not taken as prescribed. The present study aims at understanding and describing non-adherence from the perspective of chronic pain patients during a 1-year follow-up study.

METHODS

A cohort of 950 consecutive patients referred to a first consultation in Multidisciplinary Chronic Pain Clinics was followed with a standardized protocol for 1 year. This included assessment of pain characteristics; prescribed medication; therapeutic adherence; effectiveness of treatment, non-adherence and its perceived reasons; clinical outcomes and quality of life. We used a mixed methods approach, including qualitative and quantitative analyses.

RESULTS

Forty-nine percent of the 562 patients who responded to all assessments during follow-up were adherent after 1 year of chronic pain treatment. The core associations between each "non-adherence reason" and Anatomical Therapeutic Chemical Code (ATC) group were perceived side effects (p=0.019) and delayed start (p=0.022) for narcotic analgesics (opioids); perceived non-efficacy (p=0.017) and delayed start (p=0.004) for antiepileptics and anticonvulsants; perceived low necessity (p=0.041) and delayed start (p=0.036) for analgesics antipyretics; change in prescriptions because of a new clinical condition for antidepressants (p=0.024); high concerns (p=0.045) and change in prescriptions because of a new clinical condition (p<0.001) for non-steroidal anti-inflammatory drugs; delayed start (p=0.016) and financial constraints (p=0.018) for other medications.

DISCUSSION

This study emphasizes the patient's perspective regarding non-adherence to pharmacological treatment of chronic pain, providing valuable and novel information to be used in future interventions to help patients make an informed choice about their adherence behavior.

Prevalence and Impact of Having Multiple Barriers to Medication Adherence in Nonadherent Patients With Poorly Controlled Cardiometabolic Disease

Adherence to medications remains poor despite numerous efforts to identify and intervene upon nonadherence. One potential explanation is the limited focus of many interventions on one barrier. Little is known about the prevalence and impact of having multiple barriers in contemporary practice. Our objective was to quantify adherence barriers for patients with poorly controlled cardiometabolic condition, identify patient characteristics associated with having multiple barriers, and determine its impact on adherence. We used a linked electronic health records and insurer claims dataset from a large health system from a recent pragmatic trial. Barriers to medication taking before the start of the intervention were elicited by clinical pharmacists using structured interviews. We used multivariable modified Poisson regression models to examine the association between patient factors and multiple barriers and multivariable linear regression to evaluate the relation between multiple barriers and claims-based adherence. Of the 1,069 patients (mean: 61 years of age) in this study, 25.1% had multiple barriers to adherence; the most common co-occurring barriers were forgetfulness and health beliefs (31%, n = 268). Patients with multiple barriers were more likely to be non-white (relative risk [RR] 1.57, 95% confidence interval [CI] 1.21 to 1.74), be single/unpartnered (RR 1.36, 95% CI 1.06 to 1.74), use tobacco (RR 1.54, 95% CI 1.13 to 2.11), and have poor glycemic control (RR 1.77, 95% CI 1.31 to 2.39) versus those with 0 or 1 barrier. Each additional barrier worsened average adherence by 3.1% (95% CI -4.6%, -1.5%). In conclusion, >25% of nonadherent patients present with multiple barriers to optimal use, leading to meaningful differences in adherence. These findings should inform quality improvement interventions aimed at nonadherence.

Primary Care Providers' Acceptance of Pharmacists' Recommendations to Support Optimal Medication Management for Patients with Diabetic Kidney Disease

BACKGROUND

Patients with diabetic kidney disease (DKD) often struggle with blood pressure control. In team-based models of care, pharmacists and primary care providers (PCPs) play important roles in supporting patients' blood pressure management.

OBJECTIVE

To describe whether PCPs' acceptance of pharmacists' recommendations impacts systolic blood pressure (SBP) at 36 months.

DESIGN

An observational analysis of a subset of participants randomized to the intervention arm of the Simultaneous risk factor control using Telehealth to slOw Progression of Diabetic Kidney Disease (STOP-DKD) study.

PARTICIPANTS

STOP-DKD participants for whom (1) the pharmacist made at least one recommendation to the PCP; (2) there were available data regarding the PCP's corresponding action; and (3) there were SBP measurements at baseline and 36 months.

INTERVENTION

Participants received monthly telephone calls with a pharmacist addressing health behaviors and medication management. Pharmacists made medication-related recommendations to PCPs.

MAIN MEASURES

We fit an unadjusted generalized linear mixed model to assess the association between the number of pharmacists' recommendations for DKD and blood pressure management and PCPs' acceptance of such recommendations. We used a linear regression model to evaluate the association between PCP acceptance and SBP at 36 months, adjusted for baseline SBP.

KEY RESULTS

Pharmacists made 176 treatment recommendations (among 59 participants), of which 107 (61%) were accepted by PCPs. SBP significantly declined by an average of 10.5 mmHg (p < 0.01) among 47 of 59 participants who had valid measurements at baseline and 36 months. There was a significant association between the number of pharmacist recommendations and the odds of PCP acceptance (OR 1.19; 95%CI 1.00, 1.42; p < 0.05), but no association between the number of accepted recommendations and SBP.

CONCLUSIONS

Pharmacists provided actionable medication-related recommendations. We identified a significant decline in SBP at 36 months, but this reduction was not associated with recommendation acceptance.

TRIAL REGISTRATION

NCT01829256.

Impact of Community Pharmacist Interventions With Managed Care to Improve Medication Adherence

BACKGROUND

Nonadherence to medications is a concern due to adverse outcomes and higher costs of care. The Centers for Medicare and Medicaid Services has made adherence a key measurement for Star ratings.

OBJECTIVE

To evaluate the impact of a collaborative pilot program between a third-party payer, local pharmacy organization, and academic institution focusing on improving medication adherence with community pharmacies.

METHODS

Twenty-five community pharmacies implemented adherence-based interventions in patients ≥65 years old, who were Medicare Advantage Plan members, taking targeted medications (statins, oral diabetic medications, angiotensin-converting enzyme inhibitors [ACE-Is] and angiotensin receptor blockers [ARBs]). Outcome measures were (1) pharmacy intervention completion rate, (2) type of adherence interventions, (3) change in the proportion of days covered (PDC) following pharmacist intervention based on adherence group, and (4) nonadherence barriers.

RESULTS

A total of 1263 interventions met the eligibility criteria, and common interventions included explaining the benefit of the medication (n = 453, 35.9%) and provider follow-up (n = 109, 8.6%). Among nonadherent subjects who became adherent, the mean PDC increased by 14% (74%-88%, P < .0001), with a 12% decrease in mean PDC score in the nonadherent who remained nonadherent group (71%-58%, P < .0001). Common patient barriers for nonadherence were forgetfulness (n = 451, 35.7%) and denial (n = 84, 6.7%). System and therapeutic barriers included complexity (n = 155, 12.3%) and adverse side effects (n = 42, 3.3%).

CONCLUSION

This collaborative effort successfully implemented a community pharmacist-led adherence intervention in 25 independent pharmacies. Our findings highlight increased interactions with patients and in some cases improved adherence measures. Future research must include implementation outcomes in order to effectively implement these interventions in the community pharmacy setting.

Scientometrics on interventions used for adherence of hypertension and diabetes therapies

Objective

To identify interventions aimed to improve adherence to medical and non-medical antihypertensive and antidiabetic therapy.

Methods

Scientometric study conducted in February and March 2018, based on data collected on PubMed ^® and SciELO databases, using the following search terms: “interventions to improve adherence to diabetes therapy”, “interventions to improve adherence to hypertension therapy” and “interventions to improve adherence to therapy for hypertension and diabetes”.

Results

A total of 95 articles were selected. Scientific production increased as of 2009, with a higher number of studies published between 2015 and 2017. Most interventions described in literature were aimed at diabetic patients (46.31%). Face-to-face interventions were more common (46.31%), followed by telephone-based (31.58%) and digital (26.31%) interventions. North America stood out as the continent with the highest number of publications (68.42%), followed by Europe (14.74%). Most studies (63.16%) were based on a single type of intervention.

Conclusion

Traditional intervention methods were more widely used to promote adherence to antihypertensive and antidiabetic therapy; digital technology emerged as a trend in interventions aimed to improve hypertension and diabetes-related health behaviors.

Impact of pharmacist educational intervention on disease knowledge, rehabilitation and medication adherence, treatment-induced direct cost, health-related quality of life and satisfaction in patients with rheumatoid arthritis: study protocol for a randomized controlled trial

Background

The objective of this study is to evaluate the effectiveness of pharmacist intervention in improving disease knowledge, adherence to treatment, health-related quality of life (HRQoL) and direct cost of treatment. The study also documents patient satisfaction with pharmacist counselling as a quality control measure.

Methods/design

This is a randomized, single-blind, two-arm, controlled trial in patients with rheumatoid arthritis visiting outpatient rheumatology clinics in Karachi, Pakistan. We will enroll patients with established diagnosis of rheumatoid arthritis over 3 months. The patients would be randomized through a computer-generated list into the control group, i.e., usual care or into the intervention group, i.e., pharmaceutical care, in a ratio of 1:1, after providing signed written consent. The study will take place in two patient-visits over the course of 3 months. Patients in the intervention group would receive intervention from the pharmacist while those in the control group will receive usual care. Primary outcomes include change in mean score from baseline (week 0) and at follow up (week 12) in disease knowledge, adherence to medications and rehabilitation/physical therapy. The secondary outcomes include change in the mean direct cost of treatment, HRQoL and patient satisfaction with pharmacist counselling.

Discussion

This is a novel study that evaluates the role of the pharmacist in improving treatment outcomes in patients with rheumatoid arthritis. The results of this trial could set the foundation for future delivery of care for this patient population in Pakistan. The results of this trial would be published in a peer-reviewed journal.

Trial registration

ClinicalTrials.gov, NCT03827148. Registered on February 2019.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3540-z) contains supplementary material, which is available to authorized users.

Impact of a novel pharmacist-delivered behavioral intervention for patients with poorly-controlled diabetes: The ENhancing outcomes through Goal Assessment and Generating Engagement in Diabetes Mellitus (ENGAGE-DM) pragmatic randomized trial

Background

Many factors contribute to suboptimal diabetes control including insufficiently-intensive treatment and non-adherence to medication and lifestyle. Determining which of these is most relevant for individual patients is challenging. Patient engagement techniques may help identify contributors to suboptimal adherence and address barriers (using motivational interviewing) and help facilitate choices among treatment augmentation options (using shared decision-making). These methods have not been used in combination to improve diabetes outcomes.

Objective

To evaluate the impact of a telephone-based patient-centered intervention on glycosylated hemoglobin (HbA1c) control for individuals with poorly-controlled diabetes.

Design

Two-arm pragmatic randomized control trial within an explanatory sequential mixed-methods design.

Subjects

1,400 participants 18–64 years old with poorly-controlled type 2 diabetes.

Intervention

The intervention was delivered over the telephone by a clinical pharmacist and consisted of a 2-step process that integrated brief negotiated interviewing and shared decision-making to identify patient goals and options for enhancing diabetes management.

Main measures

The primary outcome was change in HbA1c. Secondary outcomes were medication adherence measures. Outcomes were evaluated using intention-to-treat principles; multiple imputation was used for missing values in the 12-month follow-up. We used information from pharmacist notes to elicit factors to potentially explain the intervention’s effectiveness.

Key results

Participants had a mean age of 54.7 years (SD:8.3) and baseline HbA1c of 9.4 (SD:1.6). Change in HbA1c from baseline was -0.79 (SD:2.01) in the control arm and -0.75 (SD:1.76) in the intervention arm (difference:+0.04, 95%CI: -0.22, 0.30). There were no significant differences in adherence. In as-treated analyses, the intervention significantly improved diabetes control (-0.48, 95%CI: -0.91, -0.05). Qualitative findings provided several potential explanations for the findings, including insufficiently addressing patient barriers.

Conclusions

A novel telephone-based patient-centered intervention did not improve HbA1c among individuals with poorly-controlled diabetes, though as-treated analyses suggest that the intervention was effective for those who received it.

Trial registration

ClinicalTrials.gov NCT02910089

The Association Between Medication Adherence for Chronic Conditions and Digital Health Activity Tracking: Retrospective Analysis

Background

Chronic diseases have a widespread impact on health outcomes and costs in the United States. Heart disease and diabetes are among the biggest cost burdens on the health care system. Adherence to medication is associated with better health outcomes and lower total health care costs for individuals with these conditions, but the relationship between medication adherence and health activity behavior has not been explored extensively.

Objective

The aim of this study was to examine the relationship between medication adherence and health behaviors among a large population of insured individuals with hypertension, diabetes, and dyslipidemia.

Methods

We conducted a retrospective analysis of health status, behaviors, and medication adherence from medical and pharmacy claims and health behavior data. Adherence was measured in terms of proportion of days covered (PDC), calculated from pharmacy claims using both a fixed and variable denominator methodology. Individuals were considered adherent if their PDC was at least 0.80. We used step counts, sleep, weight, and food log data that were transmitted through devices that individuals linked. We computed metrics on the frequency of tracking and the extent to which individuals engaged in each tracking activity. Finally, we used logistic regression to model the relationship between adherent status and the activity-tracking metrics, including age and sex as fixed effects.

Results

We identified 117,765 cases with diabetes, 317,340 with dyslipidemia, and 673,428 with hypertension between January 1, 2015 and June 1, 2016 in available data sources. Average fixed and variable PDC for all individuals ranged from 0.673 to 0.917 for diabetes, 0.756 to 0.921 for dyslipidemia, and 0.756 to 0.929 for hypertension. A subgroup of 8553 cases also had health behavior data (eg, activity-tracker data). On the basis of these data, individuals who tracked steps, sleep, weight, or diet were significantly more likely to be adherent to medication than those who did not track any activities in both the fixed methodology (odds ratio, OR 1.33, 95% CI 1.29-1.36) and variable methodology (OR 1.37, 95% CI 1.32-1.43), with age and sex as fixed effects. Furthermore, there was a positive association between frequency of activity tracking and medication adherence. In the logistic regression model, increasing the adjusted tracking ratio by 0.5 increased the fixed adherent status OR by a factor of 1.11 (95% CI 1.06-1.16). Finally, we found a positive association between number of steps and adherent status when controlling for age and sex.

Conclusions

Adopters of digital health activity trackers tend to be more adherent to hypertension, diabetes, and dyslipidemia medications, and adherence increases with tracking frequency. This suggests that there may be value in examining new ways to further promote medication adherence through programs that incentivize health tracking and leveraging insights derived from connected devices to improve health outcomes.

[Effects of Using the Adherence Score Sheet According to Application Timing in Improving Medication Adherence in SETSUYAKU-BAG Campaign]

Maintaining medication adherence is a critical issue in determining health outcomes in patients with chronic diseases. However, many patients do not adhere to their prescribed regimens. This study aimed to determine the effects of using adherence score sheets according to application timing in improving medication adherence among non-adherent outpatients. In community pharmacies, both patients and pharmacists evaluated medication adherence based on application timing (morning, noon, evening, and before going to bed) in 11 levels (0-10) for >4 months. A total of 58 outpatients were included in the study. The median scores among application timing at intermediate (patient 9.3, pharmacist 9.0) and final (patient 9.5, pharmacist 9.5) analyses were significantly higher than that at baseline (patient 7.6, pharmacist 7.0). At the end of the investigation, the ratio of non-adherent patients prescribed with hyperlipidemic medications was higher than those prescribed with medications for other lifestyle diseases. Approximately 80% of the patients reported improved medication adherence based on the questionnaires regarding their understanding on diseases and medications, medication awareness, and communication with pharmacists. Therefore, the utilization of an adherence score sheet according to application timing improved medication adherence of patients with chronic diseases.

Clinical and other specialty services offered by pharmacists in the community: the international arena and Israel

The community pharmacy setting is a venue that is readily accessible to the public. In addition, it is staffed by a pharmacist, who is a healthcare provider, trained and capable of delivering comprehensive pharmaceutical care. As such, community pharmacists have a colossal opportunity to serve as key contributors to patients’ health by ensuring appropriate use of medications, preventing medication misadventures, identifying drug-therapy needs, as well as by being involved in disease management, screening, and prevention programs. This unique position gives the pharmacist the privilege and duty to serve patients in roles other than solely that of the stereotypical drug dispenser.

Worldwide, as well as in Israel, pharmacists already offer a variety of pharmaceutical services and tend to patients’ and the healthcare system’s needs. This article provides examples of professional, clinical or other specialty services offered by community pharmacists around the world and in Israel and describes these interventions as well as the evidence for their efficacy. Examples of such activities which were recently introduced to the Israeli pharmacy landscape due to legislative changes which expanded the pharmacist’s scope of practice include emergency supply of medications, pharmacists prescribing, and influenza vaccination. Despite the progress already made, further expansion of these opportunities is warranted but challenging. Independent prescribing, as practiced in the United Kingdom or collaborative drug therapy management programs, as practiced in the United States, expansion of vaccination programs, or wide-spread recognition and reimbursement for medication therapy management (MTM) programs are unrealized opportunities. Obstacles such as time constraints, lack of financial incentives, inadequate facilities and technology, and lack of professional buy-in, and suggested means for overcoming these challenges are also discussed.

Adherence to tyrosine kinase inhibitors among Medicare Part D beneficiaries with chronic myeloid leukemia

BACKGROUND

Tyrosine kinase inhibitors (TKIs) improve the survival of patients with chronic myeloid leukemia (CML) dramatically; however, nonadherence to TKI therapy may lead to resistance to the therapy. TKIs are very expensive and are covered under Part D insurance for Medicare patients. To the authors' knowledge, the impact of low-income subsidy status and cost sharing on adherence among this group has not been well studied in the literature.

METHODS

Surveillance, Epidemiology, and End Results (SEER) registry data linked with Medicare Part D data from the years 2007 through 2012 were used in the current study. The authors identified 836 patients with CML with Medicare Part D insurance coverage who were new TKI users. Treatment nonadherence was defined as a binary variable indicating the percentage of days covered was <80% during the 180-day period after the initiation of TKI therapy. Logistic regression was used to examine the relationship between out-of-pocket costs per 30-day drug supply, Medicare Part D plan characteristics, and treatment adherence while controlling for other patient characteristics.

RESULTS

Overall, 244 of the 836 patients with CML (29%) were nonadherent to targeted oral therapy during the 180 days after the initiation of treatment with TKIs. The multivariable logistic regression demonstrated that patients with heavily subsidized (odds ratio, 6.7; 95% confidence interval, 2.8-15.9) and moderately subsidized (odds ratio, 3.0; 95% confidence interval, 1.4-6.5) Medicare Part D plans were much more likely to demonstrate nonadherence compared with patients without a subsidy.

CONCLUSIONS

The current population-based study found a significantly higher rate of nonadherence among heavily subsidized patients with substantially lower out-of-pocket costs, which suggests that future research is needed to help lower the nonadherence rate among these individuals. Cancer 2018;124:364-73. © 2017 American Cancer Society.

A Motivational Interviewing Intervention by Pharmacy Students to Improve Medication Adherence

BACKGROUND

Diabetes mellitus (DM) patients with comorbid hypertension (HTN) are at a higher risk of developing microvascular and macrovascular DM complications. Through guideline-driven recommendations, angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) are highly recommended for these patients. Unfortunately, medication adherence to these products, though crucial to achieving therapeutic benefit, is frequently suboptimal. Motivational interviewing (MI) is a patient-centered collaborative communication style that is used to strengthen internal motivation for change that may prove effective in enhancing adherence.

OBJECTIVE

To examine the effect of an MI telephone intervention conducted by pharmacy students in improving adherence to ACEIs/ARBs among Medicare Advantage Plan (MAP) patients with both DM and HTN.

METHODS

A prospective study was conducted among patients enrolled in a Texas MAP. Medical claims data were used to identify patients with DM and HTN, and pharmacy claims were observed to recognize those who filled either an ACEI or an ARB during June 2014. Patients with a 6-month proportion of days covered (PDC) < 0.80 in the previous 6 months were determined nonadherent, and 75% of those were randomly selected to serve as potential subjects for the intervention, while 25% were randomly selected to serve as potential subjects for the control group. The intervention was a telephone call by a pharmacy student on rotation at the health plan, and 5 monthly follow-up calls. Before implementing calls, participating students attended a 3-day MI training course, where their proficiency for MI skills was evaluated. Refill data during the 6-month postintervention were evaluated to examine the intervention effect measured on 3 outcomes: PDC; PDC ≥ 0.80 versus < 0.80; and discontinuation versus continuation. Multivariate linear and logistic regression models were constructed to adjust for any imbalances in baseline characteristics, including age, gender, number of other medications, regimen complexity, health low-income subsidy status, prescriber specialty, comorbidities, 6-month previous hospitalization, baseline 6-month PDC, and Centers for Medicare & Medicaid Services risk score.

RESULTS

A total of 11 students participated in the intervention implementation. Patients receiving calls were randomly selected from those potential subjects for the intervention arm until a target of 250 was reached; 500 controls were randomly selected from the potential subjects for the control arm. The final cohort included in multivariate models consisted of 743 patients. Patients completing the initial call and at least 2 follow-ups were less likely to discontinue (OR = 0.29; 95% CI = 0.15-0.54; P < 0.001) and more likely to be adherent in the linear regression model (β = 0.0604, P < 0.001) and the logistic regression model (OR = 1.53; 95% CI = 1.02-2.28; P = 0.009). Other factors significantly associated with better adherence included higher baseline PDC and number of medications. Depression status was significantly associated with lower adherence.

CONCLUSIONS

Patients receiving 2 or more calls had significantly better adherence and less discontinuation during the 6 months following initial calls compared with those who did not receive calls. This finding indicates that an MI-based telephone intervention by pharmacy students may be a promising intervention to improve adherence. Future research should examine the sustainability of the intervention effect for longer time periods and its influence on associated clinical outcomes.

DISCLOSURES

This project was supported by the Pharmaceutical Research and Manufacturers of America Foundation (PhRMA). The content is solely the responsibility of the authors and does not necessarily represent the official views of PhRMA. The funding agency was not involved in research design, analysis, or reporting results. Funding was obtained by Abughosh. Holstad provided a consultation regarding the MI guide and provided the MI training. Study concept and design were contributed by Abughosh and Fleming, along with Serna, Esse, and Holstad. Serna, Esse, Mann, Holstad, and Masilamani collected the data, and data interpretation was performed by Abughosh, Wong, and Esse. The manuscript was written by Abughosh, Wong, and Esse and revised by Masilamani and Holstad, along with the other authors.