Medication adherence behaviors of Medicare beneficiaries

Pharmacists' and patients' perceptions about the importance of pharmacist services types to improve medication adherence among patients with diabetes in Indonesia

BACKGROUND

Various pharmacist services are available to improve medication adherence, including consultation, brochure, etc. Challenges arise on which services are best implemented in practice. Knowledge about patients' and pharmacists' preferences can help to prioritize services. This study explores the pharmacists' and patients' perceptions about the importance of pharmacist services to improve medication adherence among patients with diabetes in Indonesia.

METHODS

This questionnaire-based cross-sectional study involved adult outpatients with diabetes type 2 and pharmacists from community health centers (CHCs) and hospitals in Surabaya, Indonesia. Random sampling was used to identify 57 CHCs in the study. In addition, based on convenient sampling, three hospitals participated. All pharmacists working at the CHCs and hospitals, who were willing to participate, were included in the study. For patients, minimum sample size was calculated using Slovin's formula. Patients and pharmacists were asked to rank five pharmacist service types (consultation, brochure/leaflet, patient group discussion, medication review, and phone call refill reminder) according to their importance to improve medication adherence. A face validity test of the self-developed questionnaire was conducted before the data collection. Rank ordered probit models were estimated (STATA 15th software).

RESULTS

A total of 457 patients from CHCs, 579 patients from hospitals, and 99 pharmacists from both medical facilities were included. Consultation (CHC patients 56.0% vs hospital patients 39.7% vs pharmacists 75.2%) and brochure (CHC patients 23.2% vs hospital patients 27.5% vs pharmacists 11.9%) were the most preferred pharmacist services. Patients with experience getting medication information from pharmacists valued consultation higher than brochure and patient group discussions. Older patients ranked a brochure higher than other services. Patients without formal education in CHCs had a lower probability of giving a high rank to a brochure to improve medication adherence. There was significant positive correlation between the ranking of phone call refill reminder and medication review (0.6940) for patients in CHCs.

CONCLUSION

For both patients and pharmacists, consultation, brochure, and group discussion were the highest-ranked services. Education, age, experience with pharmacist services, and medical facility features need to be considered when evaluating which pharmacist services to implement in Indonesia.

Enhancing Specific Health Literacy with a Digital Evidence-Based Patient Decision Aid for Hypertension: A Randomized Controlled Trial

INTRODUCTION

Health literacy is an important competency to make informed, shared decisions in line with patient's preferences. On the other hand, lower health literacy is associated with poorer health outcomes. Evidence-based patient decision aids (EbPDA) are validated instruments to support informed medical decisions and empower patients for relevant involvement in their care. This study aimed to investigate the effect of a digital EbPDA for hypertension on health literacy.

METHODS

In a randomized controlled trial, 124 participants were presented with a web-based scenario related to a newly diagnosed condition of arterial hypertension. The intervention group was provided with an online decision aid, while the control group was prompted to search for related information without support. Specific health literacy for hypertension was operationalized based on the European survey for health literacy (HLS-EU-Q47).

RESULTS

The intervention group showed a statistically significant increase in subjectively perceived overall specific health literacy regarding hypertension (p=0.02, Cohen's d=0.44). The effect was also statistically significant for the subcategories understanding, appraising, and applying health-related information (all p<0.05). At least equal results could be shown for participants with a lower level of education compared to participants with a high level.

CONCLUSION

The findings suggest that digital EbPDAs can be an effective and easily scalable instrument to improve populations' specific health literacy. A possible advantage of the measure could be that patients are addressed concerning important and pressing personal decisions, fostering awareness of the individual's need for health literacy to reflect one's options and preferences. EbPDAs may also be a promising approach to target vulnerable populations, as the investigated EbPDA seems to perform equally in less versus more educated individuals. For future research, it may be interesting to investigate whether EbPDAs have effects on general health literacy that go beyond the disease specifically addressed.

Impact of Social Determinants of Health and Demographics on Refill Requests by Medicare Patients Using a Conversational Artificial Intelligence Text Messaging Solution: Cross-Sectional Study

Background

Nonadherence among patients with chronic disease continues to be a significant concern, and the use of text message refill reminders has been effective in improving adherence. However, questions remain about how differences in patient characteristics and demographics might influence the likelihood of refill using this channel.

Objective

The aim of this study was to evaluate the efficacy of an SMS-based refill reminder solution using conversational artificial intelligence (AI; an automated system that mimics human conversations) with a large Medicare patient population and to explore the association and impact of patient demographics (age, gender, race/ethnicity, language) and social determinants of health on successful engagement with the solution to improve refill adherence.

Methods

The study targeted 99,217 patients with chronic disease, median age of 71 years, for medication refill using the mPulse Mobile interactive SMS text messaging solution from December 2016 to February 2019. All patients were partially adherent or nonadherent Medicare Part D members of Kaiser Permanente, Southern California, a large integrated health plan. Patients received SMS reminders in English or Spanish and used simple numeric or text responses to validate their identity, view their medication, and complete a refill request. The refill requests were processed by Kaiser Permanente pharmacists and support staff, and refills were picked up at the pharmacy or mailed to patients. Descriptive statistics and predictive analytics were used to examine the patient population and their refill behavior. Qualitative text analysis was used to evaluate quality of conversational AI.

Results

Over the course of the study, 273,356 refill reminders requests were sent to 99,217 patients, resulting in 47,552 refill requests (17.40%). This was consistent with earlier pilot study findings. Of those who requested a refill, 54.81% (26,062/47,552) did so within 2 hours of the reminder. There was a strong inverse relationship (r10=−0.93) between social determinants of health and refill requests. Spanish speakers (5149/48,156, 10.69%) had significantly lower refill request rates compared with English speakers (42,389/225,060, 18.83%; X²₁ [n=273,216]=1829.2; P<.001). There were also significantly different rates of refill requests by age band (X²₆ [n=268,793]=1460.3; P<.001), with younger patients requesting refills at a higher rate. Finally, the vast majority (284,598/307,484, 92.23%) of patient responses were handled using conversational AI.

Conclusions

Multiple factors impacted refill request rates, including a strong association between social determinants of health and refill rates. The findings suggest that higher refill requests are linked to language, race/ethnicity, age, and social determinants of health, and that English speakers, whites, those younger than 75 years, and those with lower social determinants of health barriers are significantly more likely to request a refill via SMS. A neural network–based predictive model with an accuracy level of 78% was used to identify patients who might benefit from additional outreach to narrow identified gaps based on demographic and socioeconomic factors.

The association of toll-like receptor 4 gene polymorphisms with primary open angle glaucoma susceptibility: a meta-analysis

Primary open angle glaucoma (POAG) and normal tension glaucoma (NTG) cause irreversible blindness while current medications cannot completely inhibit disease progression. An understanding of immunopathogenesis is thus a keystone to develop novel drug targets and genetic markers are still required for early diagnosis. Toll-like receptor 4 (TLR4) is an essential player in inflammation in various diseases. However, the TLR4 polymorphisms have not been completely elucidated in both types of glaucoma. The aim of the present study was to identify the association between TLR4 polymorphism and glaucoma (POAG and NTG) via the use of a comprehensive review and meta-analysis. The relevant studies were collected from PubMed, Excerpta Medica Database (EMBASE), and Web of Science to identify eight included articles, assessed for quality by a modified Newcastle-Ottawa Scale (NOS) for gene association study. A meta-analysis was applied to calculate the pooled odds-ratio and 95% confidence intervals (CIs) to evaluate the association between TLR4 polymorphism and glaucoma. The results revealed that TLR4 rs1927911 A/G, rs12377632 C/T, and rs2149356 G/T significantly decrease the risk of POAG and NTG in allele contrast models 0.71-, 0.71-, and 0.67-fold, respectively. Moreover, rs4986790 A/G and rs4986791 C/T showed a stringent association with POAG in allele contrast, heterozygous, recessive, and overdominant models. In conclusion, this meta-analysis represented a significant correlation between TLR4 polymorphisms and both types of glaucoma suggesting that TLR4 might be involved in the pathogenesis of glaucoma and may be applied as a genetic marker for disease screening.

Temporal effectiveness of interventions to improve medication adherence: A network meta-analysis

Introduction

Adherence-enhancing interventions have been assessed in the literature, however heterogeneity and conflicting findings have prohibited a consensus on the most effective approach to maintain adherence over time. With the ageing population and growth of chronic conditions, evaluation of sustainable strategies to improve and maintain medication adherence long term is paramount. We aimed to determine the comparative effectiveness of interventions for improving medication adherence over time among adults with any clinical condition.

Materials and methods

Meta-analyses evaluating interventions to improve medication adherence were searched in PubMed in January 2019 and reviewed for primary studies. Experimental studies with a comparison group assessing an intervention to enhance medication adherence in adult patients with reported adherence outcomes were included. Two authors extracted data for study characteristics, interventions and adherence outcomes. Interventions were categorized into four groups or combinations: educational, attitudinal, technical and rewards. Four network meta-analyses were performed to compare interventions based on patient follow-up time. Medication adherence effect sizes were reported as odds ratios (OR) with a 95% credibility interval (CrI) and surface under the cumulative ranking curve (SUCRA) to allow ranking probabilities. Risk of bias was assessed as per Cochrane guidelines.

Results

Data was obtained from 69 meta-analyses with 468 primary studies being included in qualitative synthesis. The four networks compromised of 249 studies in total (0–3 month follow-up: 99 studies, 4–6 months: 104, 7–9 months: 18, ≥10 months: 94). Interventions showing success in follow-ups of less than 10 months varied across time. Significant effects compared to standard of care (SOC) were found in technical (4–6 months: OR 0.34, 95% CrI 0.25–0.45) and attitudinal interventions (7–9 months: 0.37, 0.17–0.84). Multicomponent interventions demonstrated effectiveness compared to standard of care with an additive effect displayed, particularly in longer follow-ups (educational + attitudinal + technical interventions ≥10 months: OR 0.49, 95% CrI 0.27–0.88).

Discussion

All interventions reviewed improved medication adherence compared to standard of care. Multicomponent interventions displayed the most promising results in maintenance of long-term medication adherence. Technical and reward components enhanced adherence on a short-term basis, while educational and attitudinal interventions evolved over time to be more effective in follow-ups greater than 7 months. Sustainability of adherence to medications over time is dependent upon multicomponent interventions including educational, attitudinal and technical aspects to modify and enhance patient medication-taking behavior. Future research should focus on the most cost-effective approaches able to be integrated into routine practice.

Pilot-Reported Beta-Blockers Identified by Forensic Toxicology Analysis of Postmortem Specimens

Introduction

This study compared beta-blockers reported by pilots with the medications found by postmortem toxicology analysis of specimens received from fatal aviation accidents between 1999 and 2015. Several studies have compared drugs using the standard approach: Compare the drug found by toxicology analysis with the drug reported by the pilot. This study uniquely examined first the pilot-reported medication and then compared it to that detected by toxicology analysis. This study will serve two purposes: (i) to determine the capability of a toxicology laboratory to detect reported medications, and (ii) to identify pilots with medications below detectable limits.

Method

All information required for this study was extracted from the Toxicology Data Base system and was searched using ToxFlo or SQL Server Management Studio. The following information was collected and analyzed: pilot-reported trade and/or generic drug, date specimens received, time of accident, type of aviation operations (CFR), state, pilot level, age, class of medical, specimen type, specimen concentration, dose reported, frequency reported associated with the accident, quantity reported, National Transportation Safety Board (NTSB) accident event number, and all NTSB reports.

Results

There were 319 pilots that either reported taking a beta-blocker or were found to be taking a beta-blocker by postmortem toxicology analysis.

Discussion

Time of death, therapeutic concentration and specimen type were found to be factors in the ability of the laboratory to detect beta-blockers. Beta-blockers taken by pilots will, in most cases, be found by a competent postmortem forensic toxicology laboratory at therapeutic concentrations. The dose taken by the pilot was not found to be a factor in the ability of the laboratory to identify beta-blockers. Time of dose, route of administration, specimen tested and therapeutic concentration of the drug were found to be factors in the ability of the laboratory to identify beta-blockers in postmortem specimens.

Patient considerations in the treatment of COPD: focus on the new combination inhaler fluticasone furoate/umeclidinium/vilanterol

The pharmacological treatment for stable COPD is based on the use of inhaled bronchodilators (long-acting muscarinic receptor antagonists and long-acting beta-2 adrenoceptor agonists) and inhaled corticosteroids. The use of triple inhaled therapy is recommended to selected patients with COPD. Among the various inhaler combinations in triple therapy, a new combination by fluticasone furoate, umeclidinium, and vilanterol is available for COPD patients. Recently, a large clinical trial using this combination has been published, resulting in a reduction in exacerbation rate in COPD patients. Furthermore, this combination has demonstrated efficacy and safety, with a single administration a day, through a dry powder inhalator device, which has shown a good adherence and is a preference of the patient. This review focuses on the main characteristics of this inhaler combination evaluating the main clinical effects, the patients' adherence, and the safety.

Impact of late-to-refill reminder calls on medication adherence in the Medicare Part D population: evaluation of a randomized controlled study

OBJECTIVES

This study evaluates a nationwide pharmacy chain's late-to-refill (LTR) reminder program that entails local pharmacists placing reminder calls to Medicare Part D patients.

METHODS

We conducted a randomized controlled study among 735,218 patients who exhibited nonadherent behavior by not refilling a maintenance medication 3 days from an expected refill date. Patients were randomly assigned to an intervention group who received LTR reminder calls or to a control group. We used Walgreens pharmaceutical claims data from 2015 to estimate the impact of LTR calls on short-term and annual adherence.

RESULTS

The initial refill rate within the first 14 days of the expected refill date significantly increased in the intervention group by 22.8% (6.09 percentage points) compared to the control group (P<0.001). The proportion of days covered (PDC) in the intervention group increased significantly by 1.5% (0.856 percentage points) relative to the control group (P<0.001) over 365 days. Patients in the intervention group were significantly more adherent (PDC ≥80%) by 3% (0.97 percentage points) compared to the control group (P<0.001). Over a 270-day follow-up period, persistence significantly increased by 2.15 days in the intervention group (P<0.001).

CONCLUSION

Results from this study suggest that LTR reminder calls increased adherence for Medicare Part D patients who are late in refilling their medications and therefore have the potential to reduce their risk for hospitalization and health care costs. Additionally, the intervention increased the number of patients with PDC ≥80% by ~3%, positively impacting Medicare Part D plan quality rating.

Health beliefs and desire to improve cholesterol levels among patients with hyperlipidemia

OBJECTIVE

Because hyperlipidemia is asymptomatic, many veterans affairs (VA) patients may not perceive it seriously. We assessed key Health Belief model concepts to describe patients' cholesterol-related health beliefs and examine associations between patient-level factors and desire to improve cholesterol control.

METHODS

We used baseline data from an ongoing randomized clinical trial. Eligible patients were receiving care at the Durham VA and had CVD risk-total cholesterol levels >130 mg/dL and/or <80% medication adherence in the previous 12 months. A survey assessed patients' health beliefs about high cholesterol and self-reported medication adherence. Multivariable logistic regression examined whether there was an association between desire to control cholesterol and cholesterol status.

RESULTS

Approximately 64% (n=155) of patients perceived high cholesterol as 'very serious'. In multivariable logistic regression analysis, patients who perceived high cholesterol as 'very serious' (OR 2. 26, p=0.032) and/or with high self-efficacy (OR 4.70, p<0.001) had increased odds of desiring cholesterol control.

CONCLUSION

The factors most significantly associated with desire to improve cholesterol control were perceiving hyperlipidemia as 'very serious and self-efficacy for cholesterol control.

PRACTICE IMPLICATION

Educating patients, with the goal of appropriately increasing their perceived risk of disease, is likely necessary to impact cholesterol control.

Patient considerations in the treatment of COPD: focus on the new combination inhaler umeclidinium/vilanterol

Medication adherence among patients with chronic diseases, such as COPD, may be suboptimal, and many factors contribute to this poor adherence. One major factor is the frequency of medication dosing. Once-daily dosing has been shown to be an important variable in medication adherence in chronic diseases, such as COPD. New inhalers that only require once-daily dosing are becoming more widely available. Combination once-daily inhalers that combine any two of the following three agents are now available: 1) a long-acting muscarinic antagonist; 2) a long acting beta2 agonist; and 3) an inhaled corticosteroid. A new once-daily inhaler with both a long-acting muscarinic antagonist, umeclidinium bromide, and a long acting beta2 agonist, vilanterol trifenatate, is now available worldwide for COPD treatment. It provides COPD patients convenience, efficacy, and a very favorable adverse-effects profile. Additional once-daily combination inhalers are available or will soon be available for COPD patients worldwide. The use of once-daily combination inhalers will likely become the standard maintenance management approach in the treatment of COPD because they improve medication adherence.