Enhancing patient compliance in the elderly. Role of packaging aids and monitoring

Dose Administration Aid Service in Community Pharmacies: Characterization and Impact Assessment

Adherence to therapies is a primary determinant of treatment success. Lack of medication adherence is often associated with medical and psychosocial issues due to complications from underlying conditions and is an enormous waste of medical resources. Dose Administration Aid Service (DAAS) can be seen as part of the solution, allowing individual medicine doses to be organized according to the dosing schedule determined by the patient’s prescriber. The most recent systematic reviews admit the possibility of a positive impact of this service. In line with this background, the study reported in this paper aimed to characterize DAAS implementation in Portugal and understand the perceptions of pharmacists and owners of community pharmacies regarding the impact of DAAS, preferred methodology types, and State contribution. The study was guided by qualitative description methodology and reported using the consolidated criteria for reporting qualitative research (COREQ) checklist. Data were collected through semi-structured interviews with 18 pharmacists and/or owners of community pharmacies. Using qualitative content analysis, we identified categories that revealed that automated weekly methodology is the preferred methodology, because of its easiness of use and lower cost of preparation. However, the investment cost was felt to be too high by the participants considering the number of potential users for implementation in practice. Participants were also unanimous in recognizing that DAAS has a very positive impact in terms of safety and medication adherence, and the majority agreed that it also helped reduce medication waste. Implications of these findings for medication adherence are discussed.

Impact of Beliefs about Medicines on the Level of Intentional Non-Adherence to the Recommendations of Elderly Patients with Hypertension

Background: Non-adherence to pharmaceutical treatment is one of the most common causes of uncontrolled hypertension. Non-adherence may be intentional or unintentional. In the case of intentional non-adherence, it is crucial to understand the reasons behind it. The literature increasingly addresses the issue of beliefs and concerns about medication, but studies on this subject performed in a Polish population of hypertensive patients are still lacking. The aim of the study was to assess the level of intentional non-adherence among patients with hypertension, and to determine the relationship between beliefs about medication and the level of intentional non-adherence to treatment in elderly patients with hypertension. Material and methods: The study included 300 patients (106 of whom were male, mean age (SD) 71.71 (8.12) years) with hypertension, treated at a hypertension clinic. The following instruments were used: the Intentional Non-Adherence Scale (INAS) for evaluating intentional non-adherence, and the Beliefs about Medicines Questionnaire (BMQ) for evaluating patients’ beliefs and opinions regarding medication. Socio-demographic and clinical data were obtained from patients’ medical records. Results: The mean (SD) INAS score in the study was 47.28 (19.12). Patients were most concerned about the harm caused by medication, and least concerned about the necessity to take medication (mean score per item 3.49 vs. 2.14). Correlation analysis demonstrated weak correlations between BMQ and INAS: higher scores for necessity were associated with more intentional non-adherence (r = 0.174, p = 0.003), while higher scores for overuse, harm, and concerns were associated with less intentional non-adherence (respectively: r = −0.253, p < 0.001 vs. r = −0.336, p < 0.001 vs. r = −0.351, p < 0.001). In multiple-factor analysis, factors increasing the level of intentional non-adherence were elderly age (β = −0.352, p = 0.009), multimorbidity (β = −2.374, p = 0.035), and a higher BMQ concerns score (β = −1.376, p < 0.001), while being single was an independent predictor decreasing intentional non-adherence (β = 5.646, p = 0.013). Conclusions: The overall level of intentional non-adherence among patients with hypertension is moderate, but approximately one third of patients with hypertension demonstrate a high level of non-adherence. Independent determinants of intentional non-adherence include concerns, elderly age, multimorbidity, and being single.

Supporting the Medication Adherence of Older Mexican Adults Through External Cues Provided With Ambient Displays: Feasibility Randomized Controlled Trial

BACKGROUND

Problems with prospective memory, which refers to the ability to remember future intentions, cause deficits in basic and instrumental activities of daily living, such as taking medications. Older adults show minimal deficits when they rely on mostly preserved and relatively automatic associative retrieval processes. On the basis of this, we propose to provide external cues to support the automatic retrieval of an intended action, that is, to take medicines. To reach this end, we developed the Medication Ambient Display (MAD), a system that unobtrusively presents relevant information (unless it requires the users' attention) and uses different abstract modalities to provide external cues that enable older adults to easily take their medications on time and be aware of their medication adherence.

OBJECTIVE

This study aimed to assess the adoption and effect of external cues provided through ambient displays on medication adherence in older adults.

METHODS

A total of 16 older adults, who took at least three medications and had mild cognitive impairment, participated in the study. We conducted a 12-week feasibility study in which we used a mixed methods approach to collect qualitative and quantitative evidence. The study included baseline, intervention, and postintervention phases. Half of the participants were randomly allocated to the treatment group (n=8), and the other half was assigned to the control group (n=8). During the study phases, research assistants measured medication adherence weekly through the pill counting technique.

RESULTS

The treatment group improved their adherence behavior from 80.9% at baseline to 95.97% using the MAD in the intervention phase. This decreased to 76.71% in the postintervention phase when the MAD was no longer being used. Using a one-way repeated measures analysis of variance and a post hoc analysis using the Tukey honestly significant difference test, we identified a significant statistical difference between the preintervention and intervention phases (P=.02) and between the intervention and postintervention phases (P=.002). In addition, the medication adherence rate of the treatment group (95.97%) was greater than that of the control group (88.18%) during the intervention phase. Our qualitative results showed that the most useful cues were the auditory reminders, followed by the stylized representations of medication adherence. We also found that the MAD's external cues not only improved older adults' medication adherence but also mediated family caregivers' involvement.

CONCLUSIONS

The findings of this study demonstrate that using ambient modalities for implementing external cues is useful for drawing the attention of older adults to remind them to take medications and to provide immediate awareness on adherence behavior.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04289246; https://tinyurl.com/ufjcz97.

Effect of dose administration aids on adherence to self-administered medications: a systematic review protocol

INTRODUCTION

Forgetting to take a medication is the most common reason for non-adherence to self-administered medication. Dose administration aids (DAAs) are a simple and common solution to improve unintentional non-adherence for oral tablets. DAAs can be in the form of compartmentalised pill boxes, automated medication dispensing devices, blister packs and sachets packets. This protocol aims to outline the methods that will be used in a systematic review of the current literature to assess the impact of DAAs on adherence to medications and health outcomes.

METHODS AND ANALYSIS

Randomised controlled trials will be identified through electronic searches in databases including EMBASE, MEDLINE, CINAHL and the Cochrane Library, from the beginning of each database until January 2020. Two reviewers will independently screen studies and extract data using the standardised forms. Data extracted will include general study information, characteristics of the study, participant characteristics, intervention characteristics and outcomes. Primary outcome is to assess the effects of DAAs on medication adherence. Secondary outcome is to evaluate the changes in health outcomes. The risk of bias will be ascertained by two reviewers in parallel using The Cochrane Risk of Bias Tool. A meta-analysis will be performed if data are homogenous.

ETHICS AND DISSEMINATION

Ethics approval will not be required for this study. The results of the review described within this protocol will be disseminated through publication in a peer-reviewed journal and relevant conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42018096087.

Assessment of Smart Watches for Management of Non-Communicable Diseases in the Ageing Population: A Systematic Review

Advancement in wearable technologies is providing promising new ways to monitor and improve patient care to the ageing population. With the global demographic transition of developed countries to an ageing population, implementation of these technologies could benefit patients and clinicians. This systematic review assesses experimental studies performed utilizing these technologies. A systematic review of peer-reviewed literature was performed on the application of wearable technologies in the patients 60 years old or greater or what is considered ageing population. Search results were reviewed and synthesized to attempt to ascertain its possible clinical application and impact. A total of 422 papers were identified for review. Eight papers were relevant to the ageing population. The majority of papers identified were experimental studies. This was because the technology is still new to the field of medicine. The studies were performed in North America, United Kingdom, Germany and Indonesia. All showed promise that wearable technologies can benefit the management of non-communicable diseases in the ageing population. Current studies focus on the experimental nature of wearable technology. Further clinical trials are needed to assess the benefit in the management of ageing populations in the clinical setting.

Mood, cognitive structuring and medication adherence

A study with a placebo was conducted. Healthy university students were given a placebo and were told to make one pill every day for a week. Participants were informed that the medicine improved mood. The extent to which they conformed to this instruction was treated as an index of compliance. Our results show that for women, but not for men, positive mood and cognitive structuring or negative mood and lack of cognitive structuring significantly predicted participants' compliance. A new model of medication adherence, based on the role of the patient's mood and cognitive structuring processes in decision making is presented in the paper.

Active ageing, emotional care and the threat of stigma: Identity management in older adults using sleeping medication long-term

Amid fears about the medicalisation of old age, the high prevalence of sleeping medication use in older cohorts is a significant public health concern. Long-term use is associated with a plethora of negative effects, such as cognitive impairment and risk of addiction. However, little is known about the lived experience of older adults using sleeping medication longer term. Episodic interviews lasting approximately 90 minutes were conducted with 15 independently living adults, aged 65-88 years, who were using sedative-hypnotic or tricyclic sleeping medication for more than 11 years on average. Thematic analysis shows that participants divided their rationale for use into two temporal periods: (1) to ensure physical ability in the daytime and (2) to ensure emotional stability at night. Long-term sleeping medication was thus characterised as a form of 'emotional self-management' of the negative emotions associated with later life, blotting out feelings of loss and loneliness by inducing sleep. Participants feared loss of access to their medication 'supply', employing strategies to ensure its continuity, while expressing shame about their dependence. However, identity management, in the form of explanations, minimisations and social comparisons, functioned to downplay their addiction. Through this, long-term sleeping medication users were able to elude the spoiled identities and multiple stigmas of both the 'out of control' addict and the unsuccessful older adult by asserting a positive identity; that of the 'new' older adult, actively medicating for success both day and night.

Guidelines for the Treatment of Elderly Cancer Patients

BACKGROUND

The management of elderly patients with cancer is influenced by several factors that can vary widely among aging individuals. As the proportion of elderly individuals increases, the need for specific care guidelines for this population is critical. The National Comprehensive Cancer Network (NCCN) has developed guidelines to address these factors when formulating optimal treatment regimens for elderly patients and to avoid significant toxicity and maintain their quality of life.

METHODS

Factors that influence the appropriate treatment choices for the elderly, such as functional status, comorbidity, polypharmacy, and the presence of anemia, are reviewed, and the guidelines developed by the NCCN for treatment elderly patients are discussed.

RESULTS

The guidelines address these factors when defining the goal of therapy and formulating individualized treatment approaches for the elderly to provide optimal care for these patients, avoid significant toxicity, and maintain their quality of life.

CONCLUSIONS

The goal of therapy must be clearly defined, whether survival, remission, cure, or palliation of symptoms. Enrollment of elderly cancer patients onto clinical trials is encouraged so the guidelines can be validated.

Intentional and Unintentional Medication Non-Adherence in Hypertension: The Role of Health Literacy, Empowerment and Medication Beliefs

Background

Medication non-adherence is a major public health issue, creating obstacles to effective treatment of hypertension. Examining the underlying factors of deliberate and non-deliberate non-adherence is crucial to address this problem. Thus, the goal of the present study is to assess the socio-demographic, clinical and psychological determinants of intentional and unintentional non-adherence.

Design and methods

A cross-sectional survey was conducted between March, 2015 and April, 2016. The sample consisted of hypertension patients holding at least one medical prescription (N=109). Measurements assessed patients’ medication adherence, health literacy, empowerment, self-efficacy, medication beliefs, and patients’ acceptance of their doctor’s advice, socio-demographic and clinical characteristics.

Results

Patients who occasionally engaged in either intentional or unintentional non-adherence reported to have lower adherence selfefficacy, higher medication concern beliefs, lower meaningfulness scores and were less likely to accept the doctor’s treatment recommendations. Patients who occasionally engaged in unintentional nonadherence were younger and had experienced more side effects compared to completely adherent patients. Adherence self-efficacy was a mediator of the effect of health literacy on patients’ medication adherence and acceptance of the doctor’s advice was a covariate.

Conclusions

Regarding the research implications, health literacy and adherence self-efficacy should be assessed simultaneously when investigating the factors of non-adherence. Regarding the practical implications, adherence could be increased if physicians i) doublecheck whether their patients accept the treatment advice given and ii) if they address patients’ concerns about medications. These steps could be especially important for patients characterized with lower self-efficacy, as they are more likely to engage in occasional nonadherence.

Development and Test of a Model to Predict Adherence to a Medical Regimen

Objective:

To develop a predictive model that projects patient adherence to new and existing medication regimens.

Methods:

A panel of adherence experts was convened to develop a decision theoretic model to predict and explain patient medication adherence behavior. Two predictive models were developed: one for patients new to their regimen and one for patients on an existing regimen. The models have 12 and 13 predictive factors of adherence, respectively. The panel developed levels for each factor and diagnostic value estimates for each level.

Results:

Both models were tested by having randomly generated hypothetical patient medication adherence profiles scored by the model developers and a separate panel of healthcare practitioners. These scores were then compared with predictions made by the model. For the new-to-regimen model, the correlations were 0.86 for the development panel and 0.68 for the healthcare practitioner panel. Only the practitioner panel scored the existing medication model. The model's correlation with their scores was 0.88.

Conclusions:

The medication adherence model seems to have promise as an approach to predicting the likelihood of medication adherence. The model has the benefit of considering many factors of adherence simultaneously. It can also highlight areas that may result in patient nonadherence and suggest potential intervention strategies to enhance patient adherence to a medication regimen.

Ergonomics for the inclusion of older workers in the knowledge workforce and a guidance tool for designers

The ageing of the population and the inverted population pyramid is bringing important changes to society as a whole. These changes are associated with the inclusion of an older workforce in knowledge work and the challenge they represent in adapting the work environment accordingly. In order to approach a more universal design of the work environment, industrial designers need support from user-sensitive inclusive design studies. While there are plenty of guidelines and tools containing relevant information, there is a need to develop more appropriate tools for Industrial Designers that cover the initial phase of the design process. This study provides a review of the available tools and guidelines and proposes a theoretical framework intended for developing a design guidance tool for inclusive workstation design.

Stability of chronic medicines in dosage administration aids. How much have been done?

BACKGROUND

The prevalence of chronic diseases is increasing in Asia, therefore compliance to the medications is of utmost importance to slow disease progression and improve outcomes. Dosage administration aids (DAAs) serve as important tool to improve the compliance of patients. However, there is a dearth of data on the stability of chronic medications in DAAs. Furthermore, data presented by our Western counterparts may not be applicable to us because of our extreme humidity and temperature. In this study, we aim to summarize the data available in the literature on the stability of chronic medications in DAA.

METHODS

We performed a literature search using electronic databases and related keywords.

RESULTS

In total, 24,336 articles were retrieved and 21 articles were found to be relevant to our topic. This commentary stratified drugs according to their treatment categories and key stability conclusions, DAA and conditions used and recommendations were presented.

CONCLUSION

Due to the lack of specific data, pharmacists have to exercise their professional judgment with the help from professional guidelines when using DAA in repackaging medication. Manufacturers and regulators can play a greater role in filling the gap needed to provide pharmacists with necessary information to fulfill their function.

Initial development of the Systems Approach to Home Medication Management (SAHMM) model

BACKGROUND

Adverse drug events and medication nonadherence are two problems associated with prescription medication use for chronic conditions. These issues often develop because patients have difficulty managing their medications at home. To guide patients and providers for achieving safe and effective medication use at home, the Systems Approach to Home Medication Management (SAHMM) model was derived from a systems engineering model for health care workplace safety.

OBJECTIVE

To explore how well concepts from the SAHMM model can represent home medication management by using patient descriptions of how they take prescription medications at home.

METHODS

Twelve patients were interviewed about home medication management using an interview guide based on the factors of the SAHMM model. Each interview was audio-taped and then transcribed verbatim. Interviews were coded to identify themes for home medication management using MAXQDA for Windows.

RESULTS

SAHMM concepts extracted from the coded interview transcripts included work system components of person, tasks, tools & technology, internal environment, external environment, and household. Concepts also addressed work processes and work outcomes for home medication management.

CONCLUSIONS

Using the SAHMM model for studying patients' home medication management is a promising approach to improving our understanding of the factors that influence patient adherence to medication and the development of adverse drug events.

Adherence to capecitabine treatment and contributing factors among cancer patients in Malaysia

Ensuring adherence to chemotherapy is important to prevent disease progression, prolong survival and sustain good quality of life. Capecitabine is a complex chemotherapeutic agent with many side effects that might affect patient adherence to treatment. This cross sectional study aimed to determine adherence to capecitabine and its contributing factors among cancer outpatients in Malaysia. One hundred and thirteen patients on single regime capecitabine were recruited from Hospital Sultan Ismail and Hospital Kuala Lumpur from October 2013 to March 2014. Adherence was determined based on adherence score using validated Medication Compliance Questionnaire. Patient socio-demographics, disease, and treatment characteristics were obtained from medical records. Satisfaction score was measured using the validated Patient Satisfaction with Healthcare questionnaire. The mean adherence score was 96.1% (standard deviation: 3.29%). The significant contributing factors of adherence to capecitabine were Malay ethnicity [β=1.3; 95% confidence interval (CI): 0.21, 2.43; p value=0.020], being female [β=1.8; 95%CI: 0.61, 2.99; p value=0.003]), satisfaction score [β=0.08; 95%CI: 0.06, 1.46; p value=0.035], presence of nausea or vomiting [β=2.3; 95%CI: 1.12, 3.48; p value <0.001] and other side effects [β=1.45; 95%CI: 0.24, 2.65; p value=0.019]. Adherence to capecitabine was generally high in our local population. Attention should be given to non-Malay males and patients having nausea, vomiting or other side effects. Sufficient information, proactive assessment and appropriate management of side effects would improve patient satisfaction and thus create motivation to adhere to treatment plans.

Multidrug punch cards in primary care: a mixed methods study on patients' preferences and impact on adherence

Background: Multidrug punch cards are frame cards with 28 plastic cavities filled with a patient's oral solid medication. They are used in primary care to facilitate medication management and to enhance adherence. Main criticism concerned handling difficulties and fading knowledge about medication of patients using them. This study aimed at exploring daily use, preferences, and adherence of primary care patients using multidrug punch cards.

Methods: Community pharmacies in Switzerland recruited primary care patients using multidrug punch cards. A mixed methods approach was applied with quantitative interviews performed by telephone and qualitative interviews face-to-face.

Results: Of 149 eligible patients from 21 community pharmacies, 22 participated 2011 in the quantitative and 11 participated 2013/14 in the qualitative interview. Patients were very satisfied with the multidrug punch cards and stated increased medication safety. All considered adherence as very important. Self-reported adherence was 10 (median) on a visual analog scale (0 = no intake, 10 = perfect adherence). The absence of package inserts and predefined handling difficulties e.g., tablets spiking at removal were not perceived as problems.

Conclusions: Patients are satisfied with the multidrug punch cards, feel safe, mostly have no handling problems and adhere to their treatment. Trust in health-care professionals and patients' experiences emerged as key variables for initiating multidrug punch card use and for medication adherence. This mixed methods study invalidates previous concerns about disadvantages of multidrug punch cards. Health-care professionals should actively recommend them for primary care patients with polypharmacy and poor adherence.

Dose-dispensing service as an intervention to improve adherence to polymedication

Given the importance of high adherence to long-term pharmacotherapy and the growing need to improve medication adherence, choosing the best intervention represents a challenge for healthcare providers. A dose-dispensing service is defined as the repackaging of solid oral medication into dose-dispensing aids by a healthcare provider, mostly in a community pharmacy or hospital pharmacy, in order to assist patients in the management of their polymedication. The personalized dose-dispensing aid organizes individual oral doses according to their prescribed intake schedule throughout the day and the week. This review aims to describe the pros and cons of different dose-dispensing services and technologies, summarizes current evidence and addresses research gaps.

Effect of drug reminder packaging on medication adherence: a systematic review revealing research gaps

BACKGROUND

This was a systematic review of the literature in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Evidence mapping was used to reveal the effect of drug reminder packaging on medication adherence, to identify research gaps and to make suggestions for future research.

METHODS

PubMed, Embase, CINAHL and PsycINFO were searched with an end date of September 2013 using the Medical Subject Headings (MeSH) term 'medication adherence' and 20 different search terms for 'drug reminder packaging', limited to the English and German languages. Additional references were identified through cross-referencing. All prospective controlled trials with an intervention using drug reminder packaging for patients taking at least one medication without the assistance of a health-care professional were included in the evidence mapping of the effect of drug reminder packaging on adherence and outcomes according to the Economic, Clinical and Humanistic Outcomes (ECHO) model.

RESULTS

A total of 30 studies met the inclusion criteria: 10 randomized controlled trials, 19 controlled clinical trials and 1 cohort study. Drug reminder packaging had a significant effect on at least one adherence parameter in 17 studies (57%). The methodological quality was strong in five studies. Two studies provided complete information. Clear research gaps emerged.

CONCLUSIONS

Overall, the studies showed a positive effect of drug reminder packaging on adherence and clinical outcomes. However, poor reporting and important gaps like missing humanistic and economic outcomes and neglected safety issues limit the drawing of firm conclusions. Suggestions are made for future research.

An informatics approach to medication adherence assessment and improvement using clinical, billing, and patient-entered data

The aim of this study was to describe an integrated informatics approach to aggregating and displaying clinically relevant data that can identify problems with medication adherence and facilitate patient-provider communication about strategies to improve medication use. We developed a clinical dashboard within an electronic health record (EHR) system that uses data from three sources: the medical record, pharmacy claims, and a personal health record. The data are integrated to inform clinician-patient discussions about medication adherence. Whereas prior research on assessing patterns of medication adherence focused on a single approach using the EHR, pharmacy data, or patient-entered data, we present an approach that integrates multiple electronic data sources increasingly found in practice. Medication adherence is a complex challenge that requires patient and provider team input, necessitating an integrated approach using advanced EHR, clinical decision support, and patient-controlled technologies. Future research should focus on integrated strategies to provide patients and providers with the right combination of informatics tools to help them adequately address the challenge of adherence to complex medication therapies.

Nurse care coordination and technology effects on health status of frail older adults via enhanced self-management of medication: randomized clinical trial to test efficacy

BACKGROUND

Self-management of complex medication regimens for chronic illness is challenging for many older adults.

OBJECTIVES

The purpose of this study was to evaluate health status outcomes of frail older adults receiving a home-based support program that emphasized self-management of medications using both care coordination and technology.

DESIGN

This study used a randomized controlled trial with three arms and longitudinal outcome measurement.

SETTING

Older adults having difficulty in self-managing medications (n = 414) were recruited at discharge from three Medicare-certified home healthcare agencies in a Midwestern urban area.

METHODS

All participants received baseline pharmacy screens. The control group received no further intervention. A team of advanced practice nurses and registered nurses coordinated care for 12 months to two intervention groups who also received either an MD.2 medication-dispensing machine or a medplanner. Health status outcomes (the Geriatric Depression Scale, Mini Mental Status Examination, Physical Performance Test, and SF-36 Physical Component Summary and Mental Component Summary) were measured at baseline and at 3, 6, 9, and 12 months.

RESULTS

After covariate and baseline health status adjustment, time × group interactions for the MD.2 and medplanner groups on health status outcomes were not significant. Time × group interactions were significant for the medplanner and control group comparisons.

DISCUSSION

Participants with care coordination had significantly better health status outcomes over time than those in the control group, but addition of the MD.2 machine to nurse care coordination did not result in better health status outcomes.

Role of Illness Perceptions and Medication Beliefs on Medication Compliance of Elderly Hypertensive Cohorts

Background:

Poor compliance with antihypertensive medications is one possible reason why its success in clinical trials has not been translated into everyday practice. In addition, medication noncompliance in elderly leads to increased hospitalizations, physician visits, and higher health care costs.

Objective:

The study assessed influence of illness perceptions and medications beliefs on medication compliance of elderly hypertensive cohorts.

Method:

A cross-sectional survey research design, utilizing self-administered health surveys, was adapted to address key study objectives. Conceptualized associations among the study variables were explored to assess their individual as well as their collective impact on the medication compliance.

Result:

A total of 78 (66%) study samples were found to be noncompliant with their medications. Analysis revealed that perceptions about illness and beliefs about medication jointly played a significant role in the prediction of medication compliance ( F = 5.966, P < .05; R2 = .212). Significant bivariate correlations were observed between Morisky’s test score versus Brief Illness Perception Questionnaire measure ( r = .332, P = .001), Beliefs of Medication Questionnaire (BMQ) differential score ( r = .301, P = .001), and BMQ components, such as specific necessity ( r = .250, P = .008), specific concern ( r = −.231, P = .001), and general overuse ( r = −.342, P = .001).

Conclusion:

The findings provide practical basis for designing interventions and programs aimed at compliance building in elderly populations having hypertension by incorporating the value and importance of patient perceptions of illness and medications in order to achieve desired patient outcomes.

Motivational Enhancement and MEMS Review to Improve Medication Adherence

Electronic caps (most often Microelectronic Monitoring Systems; MEMS) that record date and time of bottle opening have been widely used to describe medication adherence. This paper expands upon descriptions of adherence-focused therapy built around review of MEMS data with the patient, adding the application of Motivational Enhancement Therapy (MET) principles. MEMS Feedback Therapy involves (a) motivational interviewing to complement the skill-building aspects of MEMS review; (b) detailed MEMS review with discussion of patterns of missed doses, and thoughts, feelings and habits accompanying missed doses; and (c) medication-taking routines to suggest after MET and MEMS review have prepared the patient to follow advice.

Capecitabine non-adherence: exploration of magnitude, nature and contributing factors

OBJECTIVES

The prescribing of oral chemotherapy agents previously available only in the intravenous formulation, such as capecitabine, has afforded many benefits including reduced administration costs and improved patient acceptability. However, it has introduced the new challenge of ensuring patient adherence to therapy. It is therefore necessary to quantify adherence, and with a view to improving services, explore factors that may impact on medication taking behavior.

METHODS

Patients with a diagnosis of breast or colorectal cancer and prescribed capecitabine were recruited from a UK teaching hospital. Data regarding self-reported adherence, beliefs about medicines, side effects, and satisfaction with information received about capecitabine were recorded.

RESULTS

Non-adherence was reported by 23.3% of the 43 participants. Capecitabine therapy was perceived necessary by 97.6%, but almost one-third of participants had strong concerns. Side effects were reported by 80% of participants, with Palmar-Plantar erythrodysesthesia and fatigue most troubling participants. Complete satisfaction with information received was reported by 65% of participants; however, dissatisfaction about how to tell if capecitabine is working and the proposed duration of therapy was expressed by 42.9% and 37.3% of participants, respectively.

CONCLUSIONS

Adherence to capecitabine is high with a strong conviction that the therapy is necessary. However, concerns were expressed regarding the experience of side effects. Patients have unmet information needs regarding the processes involved with monitoring capecitabine efficacy and determination of therapy duration. Healthcare professionals may therefore wish to consider a greater focus on involving patients in the monitoring of their care with respect to efficacy and planned treatment schedules.

Subjects at risk of discontinuation of lipid-lowering agents: a 6-month cohort study among 12,875 patients in a chinese population

BACKGROUND

Dyslipidemia is a significant health problem, and persistent use of lipid-lowering agents among dyslipidemic patients is clinically important. However, few studies have evaluated the profiles of medication discontinuation among ethnic Chinese patients.

OBJECTIVE

The objective of this study was to evaluate the level of medication adherence among Chinese patients who were prescribed a lipid-lowering drug and to investigate factors that could help physicians identify patients at risk for discontinuing their medication.

METHODS

All patients who attended any primary care clinic in 1 territory of Hong Kong and were prescribed at least 1 lipid-lowering agent from January 2004 to June 2007 were included. The incidences of drug discontinuation within 180 days after drug prescriptions were measured, and the factors associated with discontinuation using binary logistic regression analyzes were evaluated.

RESULTS

Of the 12,875 eligible patients, the majority were prescribed fibrates (54.4%) and statins (45.1%). Among the patients, 17.0% discontinued their medication. Older patients (adjusted odds ratio [aOR] = 0.72-0.79 for patients >50 years), male subjects (aOR = 0.87; 95% CI, 0.78-0.97; P = 0.009), fee payers (aOR = 0.88; 95% CI, 0.78-0.99; P = 0.029), attendees in family medicine specialist clinics (aOR = 0.82; 95% CI, 0.70-0.96; P = 0.013), residents in rural districts (aOR = 0.52; 95% CI, 0.44-0.60; P < 0.001), follow-up visitors (aOR = 0.60; 95% CI, 0.54-0.66; P < 0.001), patients with comorbidities (aOR = 0.39; 95% CI, 0.35-0.44; P < 0.001 for 1 comorbidity and aOR = 0.28; 95% CI, 0.25-0.33; P < 0.001 for at least 2 comorbidities), and persons who use fibrates (aOR = 0.56; 95% CI, 0.49-0.64; P < 0.001) were significantly less likely to discontinue their medication.

CONCLUSIONS

The findings of these associated factors were new for ethnic Chinese patients. These findings could help physicians identify patients who had been prescribed a lipid-lowering agent who were at higher risk of discontinuing their medication. Their medication-taking behavior should be monitored more closely, and future studies should evaluate the reasons of drug discontinuation.

Factors affecting therapeutic compliance: A review from the patient's perspective

Objective

To explore and evaluate the most common factors causing therapeutic non-compliance.

Methods

A qualitative review was undertaken by a literature search of the Medline database from 1970 to 2005 to identify studies evaluating the factors contributing to therapeutic non-compliance.

Results

A total of 102 articles was retrieved and used in the review from the 2095 articles identified by the literature review process. From the literature review, it would appear that the definition of therapeutic compliance is adequately resolved. The preliminary evaluation revealed a number of factors that contributed to therapeutic non-compliance. These factors could be categorized to patient-centered factors, therapy-related factors, social and economic factors, healthcare system factors, and disease factors. For some of these factors, the impact on compliance was not unequivocal, but for other factors, the impact was inconsistent and contradictory.

Conclusion

There are numerous studies on therapeutic noncompliance over the years. The factors related to compliance may be better categorized as “soft” and “hard” factors as the approach in countering their effects may differ. The review also highlights that the interaction of the various factors has not been studied systematically. Future studies need to address this interaction issue, as this may be crucial to reducing the level of non-compliance in general, and to enhancing the possibility of achieving the desired healthcare outcomes.

Medication compliance devices in primary care: activities of community-based nurses

Objective

To investigate the workload, training and views of community-based nurses in relation to medication compliance devices.

Method

Postal questionnaires distributed to all nurse team leaders (n=57) and community-based nurses (n=327) in the Grampian region of Scotland.

Setting

Primary care.

Key findings

Responses were received from 32 team leaders (56 per cent) and 153 nurses (47 per cent). Ninety-six nurses (63 per cent) filled a total of 212 medication compliance devices per week for patients under their care — an activity which accounted for an estimated total of 121 hours per week (mean of 1.25 hours per nurse per week, range 0.5 to 7 hours) and for which they had received no formal training. One hundred devices (47 per cent) were filled to enable carers to administer medicines. Team leaders reported several areas of concern which had been raised by their staff, particularly relating to responsibility and accountability under professional body guidelines.

Conclusion

Many community-based nurses fill medication compliance devices, an activity which clearly causes much concern. There is an urgent need to develop and evaluate multidisciplinary models of care based around the needs of individual patients requiring medication compliance devices.

Designing packaging to support the safe use of medicines at home

In the light of a number of serious incidents in the UK resulting from accidental overdoses of methotrexate, this study investigated how the design of methotrexate packaging can influence patient safety, and aimed to collect evidence to provide a basis for the development of new concepts for revised designs by the pharmaceutical industry. The research found that patients using methotrexate experience a number of difficulties in using their medicines packaging, and as a result, resourcefully adopt a variety of "coping strategies" which may increase the risk of dosing errors. By investigating both the practice of methotrexate users, and the design of the system that supports methotrexate use, additional problems were observed across the healthcare system, meaning that the function of medicines packaging in ensuring safety may be even more critical than first suspected. As a result of this research the National Patient Safety Agency responded with a UK-wide programme of work to improve safety for patients, and continues to work with the pharmaceutical industry to develop more user-friendly packaging and labelling.

Pharmacoeconomics and aging

The aging of the general population in industrialized countries has brought to public attention the increasing incidence of age-related clinical conditions, because the long-term impact of diseases on functional status and on costs are greater in older people than in any other age group. With the aging of the population, it is becoming increasingly important to quantify the burden of illness in the elderly; this will be vital not only in planning for the necessary health services that will be required in coming years, but also in order to measure the benefit to be expected from interventions to prevent disability in older people. The management of multiple and chronic disorders has become a more important issue for healthcare authorities because of increasing requests for medical assistance and healthcare interventions. Among these, pharmacological treatments and drug utilization in older people are pressing issues for healthcare managers and politicians; indeed, a relatively small proportion of the population accounts for a substantial part of public drug costs. Two key sources of pressure are well known: the growing number of elderly persons, who are the highest per-capita users of medicines, and the introduction of new, often more expensive, medicines. On the other hand, the development of strategies for controlling costs, while providing the elderly with equitable access to needed pharmaceuticals, should be based on an evaluation of the economic impact of pharmacological care in older people, taking into account the burden of illness, drug utilization data, drug technology assessment evidence and results. Furthermore, there are major factors affecting pharmacological care in older people: for example inappropriate prescribing, lack of adherence and compliance, and the burden of adverse drug events. The assessment of these factors should be considered a priority in pharmacoeconomic evaluations in the aging population, and the most relevant evidence will be reviewed in this paper with examples referring to particular settings or conditions and diseases, such as the presence of cardiovascular risk factors, diabetes and chronic pain.

Enhancing adherence to capecitabine chemotherapy by means of multidisciplinary pharmaceutical care

Purpose

In this prospective multi-centre observational cohort study, we investigated the effect of an intensified multidisciplinary pharmaceutical care programme on the adherence of cancer patients treated with capecitabine, a prodrug of fluorouracil.

Patients and methods

Twenty-four colorectal and 24 breast cancer patients participated in this study. Patients of the control group (n = 24) received standard care, patients of the intervention group (n = 24) received intensified pharmaceutical care consisting of written and spoken information. Adherence to capecitabine chemotherapy was measured using an electronic medication event monitoring system (MEMS™).

Results

Patients in the intervention group exhibited an enhanced but not significantly different mean overall adherence compared to the control group (97.9% vs 90.5%, p = 0.069). Mean daily adherence was significantly higher in the intervention group (96.8% vs 87.2%, p = 0.029). Variability of both adherence parameters was considerably reduced when pharmaceutical care was provided. At the end of the observation period of 126 days, the probability of still being treated with capecitabine was found to be 48% in the control group and 83% in the intervention group (p = 0.019, log-rank test). The relative risk for a deviating drug intake interval, i.e. <10 or >14 instead of 12 h, in the intervention group was found to be 0.51 (95% CI, 0.46–0.56) compared with the control group (p < 0.05, Chi-square test).

Conclusions

The provision of intensified pharmaceutical care can enhance adherence to and prolong treatment with capecitabine. The results underline the importance of multidisciplinary care to assure the effectiveness of oral chemotherapy.

Adesão e não-adesão ao tratamento farmacológico para depressão

O presente estudo objetivou compreender aspectos relacionados à adesão e a não-adesão ao tratamento farmacológico para depressão, envolvendo usuários e ex-usuários de um serviço público de saúde mental. Foram entrevistados, individualmente, 24 pacientes (12 aderentes e 12 não aderentes ao tratamento medicamentoso para depressão). Por meio da análise de conteúdo das entrevistas, identificou-se que o fenômeno da adesão/não-adesão estaria inter-relacionado a aspectos intrapessoais, interpessoais e ao contexto do tratamento do paciente. Os resultados fomentaram reflexões acerca do papel de equipes de saúde mental no incremento da adesão ao tratamento, bem como da necessidade de uma maior consideração do indivíduo, da família e do atendimento prestado pela instituição.

Adherence to medication in patients with dementia: predictors and strategies for improvement

Measures to facilitate patient medication adherence should be considered an integral part of the comprehensive care of older patients with multiple diseases. However, impairment of cognitive functions and dementia, in particular, may substantially compromise adherence behaviour. Therefore, a literature review was performed to identify factors associated with adherence to medication in patients with cognitive impairment or dementia, and to discuss strategies for improvement of non-adherence. Evidence-based information on how to deal with adherence to medication in patients with dementia is scarce because of a lack of specific studies. However, there is increasing knowledge about factors influencing medication adherence behaviour in older age, and emerging insight into the relationships between adherence behaviour and cognitive capacity, memory and executive function, in particular. Nevertheless, understanding elderly persons' strategies for maintaining regular use of even complex drug regimens is still limited. Progress of research in this field is needed. It is notable that measures to improve adherence consist of combinations of educational interventions and cognitive support but assessment of study participants' cognitive function is rare. In clinical practice, awareness of non-adherence as a result of cognitive impairment is relatively low. The most important step is early detection of cognitive impairment when this is impacting negatively on medication management. A practical geriatric screening test is recommended to identify memory problems and further functional impairments associated with cognitive impairment. Performance-based assessments might be useful for screening medication management capacity, in addition to a careful drug history, inspection of all medicines used (including over-the-counter drugs) and proxy information. However, no feasible screening methods have as yet found their way into clinical practice. Patients with impaired executive function, lack of awareness of illness and personality traits such as independency and high self-confidence may be at particular risk of non-adherence. The question is when to switch patient medication self-management to another person's responsibility if cognitive decline progresses. Further research is needed on measures to differentiate cognitive function and the relationships between memory concerns, memory strategy use and medication management. Also, studies evaluating the influence of personal support, health status and depression on the memory strategies used are needed. It is important to assess patients' attitudes toward medication and their relationship with proxies. Strategies for facilitating medication adherence in patients with dementia include prescribing as few medicines as possible, tailoring dose regimens to personal habits, and coordinating all drug dosing schedules as much as possible. When providing medication organizers, it is important to observe the patient's ability to use devices appropriately. In addition, automated computer-based reminding aids, online medication monitoring and telemonitoring may be helpful for patients with mild dementia. The decision as to when assistance with medication self-management is needed has to be made taking into account patient independency and safety aspects. This holds true for medicines with a narrow therapeutic range, in particular. Interactions among the individual patient's cognitive status, mood, level of self-efficacy and particular living situation must also be taken into consideration when searching for the optimal medication adherence strategy. No evidence-based recommendations can be given as yet. However, comprehensive assessment of the individual patient and careful consideration of all potential drug-related problems will probably help facilitate adherence and prevent compromised health outcomes in patients with dementia.

Adherence Devices in a Community Sample: How are Pillboxes Used?

Background:

Calendar-packaging devices such as pillboxes (dosettes) and blister packaging are often recommended to seniors, and are commonly used. However, little is known about how they are used. The goal of this project was to investigate how older adults in the community use calendar-packaging adherence devices.

Methods:

A mail survey of a community sample was used. Analyses addressed 3 research questions. First, the respondents reported on what type of calendar packaging they used. Second, the characteristics of the individuals who used pillboxes and blister packs were compared. Third, the way in which calendar devices were used by these individuals was described.

Results:

Respondents were 135 community-dwelling older adults (mean age ± standard deviation = 73 ± 9 years). The majority of respondents in the survey (75%) used a pillbox at least some of the time, while a smaller number (13%) used blister packs for at least some of their medications. Respondents who used pillboxes were taking more medications than those who did not. Few of the respondents reported using pillboxes in the recommended way. Only 11% of pillbox users used boxes with multiple slots for each day and, while the majority of respondents (93%) filled their pillboxes themselves, most of these individuals (82%) depended solely on their memory for filling the pillbox and only one individual had a second person check the pillbox for errors.

Conclusion:

Although pillboxes are often recommended and are widely used, the types of pillboxes chosen and the ways in which they are used may not be optimal to ensure medication adherence. Can Pharm J 2009;142:28–35.

Persistence of atorvastatin and simvastatin among patients with and without prior cardiovascular diseases: a US managed care study

BACKGROUND

In clinical practice, persistence with statin therapy is poor. While little is known about relative persistence to specific statins, previous studies have observed greater persistence in patients who achieve greater degrees of lipid lowering. Identification of statin therapies which improve patient persistence has the potential to improve the quality of patient care and clinical outcomes. Therefore, we assessed patient persistence with atorvastatin and simvastatin in primary and secondary prevention patients enrolled in managed care.

METHODS

New statin users aged > or =18 years, both with and without prior cardiovascular (CV) events within the 12 month pre-treatment period, were identified from a large national database of managed care patients. Patients initiated atorvastatin or simvastatin therapy from January 1, 2003 to September 30, 2005 and were continuously enrolled in a covered plan for at least 12 months before and after initiation of statin therapy. Subanalyses of patients > or =65 years were also conducted. Measures of interest included demographic and clinical characteristics of the study samples and persistence of statin utilization over the 1-year follow-up period. Persistence was defined as the number of days a patient remained on treatment in the first year following their index date, measured from the date of first fill to study end or the date of discontinuation.

RESULTS

A total of 129 764 atorvastatin users and 45 558 simvastatin users without prior CV events were included in the study. For those patients with prior CV events, a total of 6888 atorvastatin users and 4443 simvastatin users were included in the study. Median persistence in patients without prior CV events was 50 days longer for patients initiating therapy with atorvastatin than simvastatin (207 vs. 157 days, p<0.0001) and after adjusting for confounding factors, those treated with atorvastatin were 15% less likely to discontinue therapy during the first year than those treated with simvastatin (HR=0.85; 95% CI 0.84, 0.86; p<0.001). In secondary prevention patients median persistence was 85 days longer in atorvastatin patients than simvastatin patients (266 vs. 181 days, p<0.0001) and atorvastatin patients were 22% less likely to discontinue therapy (HR=0.78; 95% CI 0.75, 0.82; p<0.001). Persistence was worse in the elderly patients, but the relative difference between atorvastatin and simvastatin was similar to the overall patient population.

CONCLUSIONS

In patients with and without prior CV disease, persistence is generally poor, even worse in the elderly, but significantly better for atorvastatin patients than simvastatin patients (p<0.001). Further studies are required to determine whether this is due to differences in cost, effectiveness, side-effects, or other attributes of the statins.

STUDY LIMITATIONS

Differences in persistence could be, in part, due to unmeasured confounders although all available variables were adjusted in multivariate analyses. Additionally, the claims database lacks some clinical data such as lipid levels, limiting assessments of statin efficacy, and does not include any reasons for discontinuation of therapy.

Polypharmacy in elderly patients

BACKGROUND

Polypharmacy (ie, the use of multiple medications and/or the administration of more medications than are clinically indicated, representing unnecessary drug use) is common among the elderly.

OBJECTIVE

The goal of this research was to provide a description of observational studies examining the epidemiology of polypharmacy and to review randomized controlled studies that have been published in the past 2 decades designed to reduce polypharmacy in older adults.

METHODS

Materials for this review were gathered from a search of the MEDLINE database (1986-June 2007) and International Pharmaceutical Abstracts (1986-June 2007) to identify articles in people aged >65 years. We used a combination of the following search terms: polypharmacy, multiple medications, polymedicine, elderly, geriatric, and aged. A manual search of the reference lists from identified articles and the authors' article files, book chapters, and recent reviews was conducted to identify additional articles. From these, the authors identified those studies that measured polypharmacy.

RESULTS

The literature review found that polypharmacy continues to increase and is a known risk factor for important morbidity and mortality. There are few rigorously designed intervention studies that have been shown to reduce unnecessary polypharmacy in older adults. The literature review identified 5 articles, which are included here. All studies showed an improvement in polypharmacy.

CONCLUSIONS

Many studies have found that various numbers of medications are associated with negative health outcomes, but more research is needed to further delineate the consequences associated with unnecessary drug use in elderly patients. Health care professionals should be aware of the risks and fully evaluate all medications at each patient visit to prevent polypharmacy from occurring.

Comparison of persistence rates of acetylcholine-esterase inhibitors in a state Medicaid program

OBJECTIVE

To compare levels of persistency between cholinesterase inhibitors (ChEIs) among a Medicaid patient population of older adults.

METHODS

Survival analysis was used to assess differences in discontinuation between ChEIs (donepezil versus rivastigmine and galantamine), and for difference in patient gender, age, race, and care setting.

RESULTS

Rates of discontinuation increased from 42.7% (95% CI = 39.9-45.5) at 12 months to 84.8% (95% CI = 82.3-87.3) at 24 months. In multivariate models, no significant difference in discontinuation existed prior to 365 days. However, patients dispensed donepezil were less likely to discontinue as compared with users of the other two ChEIs after the first year (RR = 0.70; CI = 0.499-0.983; p < 0.04). Patients of white race were less likely to discontinue (RR = 0.549; 95% CI = 0.43-0.82; p = 0.0015), while gender, care setting, and age were not associated with discontinuation.

CONCLUSIONS

One-year persistence rates were similar between different ChEIs. Among patients persisting with ChEI medication for at least 12 months, users of donepezil were slightly more likely to continue to persist at 24 months. Nearly half of patients failed to persist with ChEI therapy for at least 12 months. Our findings underscore the limitations of the ChEI medications and the urgent need for effective and tolerable therapeutic options for patients having dementia.

A composite screening tool for medication reviews of outpatients: general issues with specific examples

Regular performance of medication reviews is prominent among methods that have been advocated to reduce the extent and seriousness of drug-related problems, such as adverse drug reactions, drug-disease interactions, drug-drug interactions, drug ineffectiveness and cost ineffectiveness. Several screening tools have been developed to guide practising healthcare professionals and researchers in reviewing the medication patterns of elderly patients; however, each of these tools has its own limitations. This review discusses a wide range of general prescription-, treatment- and patient-related issues that should be taken into account when reviewing medication patterns by implicit screening. These include generic and therapeutic substitution; potentially superfluous or inappropriate medications; potentially inappropriate dosages or duration of treatment; drug-disease and drug-drug interactions; under-treatment; making use of laboratory test results; patient adherence, experiences and habits; appropriate dosage forms and packaging. A broad selection of specific examples and references that can be used as a basis for explicit screening of medication patterns in outpatients is also offered.

A claims database analysis of persistence with alendronate therapy and fracture risk in post-menopausal women with osteoporosis

OBJECTIVE

To explore the relationship between persistence with alendronate therapy and fracture rates in women with postmenopausal osteoporosis.

RESEARCH DESIGN AND METHODS

Claims data from a large US health plan database were used to examine persistence with therapy in postmenopausal women followed for 24 months. Persistence was defined as the time (in days) from the date of first fill to the run-out date of the last prescription with no lapses > 30 days after completion of the previous refill. A persistent cohort (length of persistence > or = 182 days) and a nonpersistent cohort (length of persistence < 182 days) were defined. The number of patients with a fracture claim in each cohort was determined. Cox-proportional hazards regression (HR) analysis was used to determine significant differences in fracture rates between the two cohorts.

RESULTS

4769 patients were followed for 24 months. Patients in the persistent cohort were significantly more likely to receive a treatment (vs. prevention) dose of alendronate (p = 0.03) and to be older than 65 years (p = 0.04). There was a trend toward more fractures in the non-persistent (4.9%) than in the persistent cohort (3.9%; p = 0.09). When controlled for other significant factors (including age and previous fractures) patients in the persistent cohort were 26% less likely to have a fracture diagnosis claim during the study period than those in the non-persistent cohort (HR = 0.74; 95% CI, 0.549-0.996; p = 0.045). Prescription fill data are an indirect measure of medication-taking behavior. The use of claims data to estimate persistence and identify fracture events prohibits the establishment of causality between these two variables.

CONCLUSION

Study results demonstrated that non-persistence with therapy, along with previous fracture and increasing age, was associated with a greater risk of fracture.

Oral Anticancer Drugs in the Elderly

The increasing number of elderly people in the world population has led to a parallel increase in the number of older cancer patients, with over 45% of all cancers in Europe occurring in patients >70 years of age. The increasing tendency to use oral chemotherapy is thus of interest in the elderly, given that both elderly patients and their physicians prefer to use less complex and toxic regimens when such treatments have equivalent efficacy to more complex regimens. However, data from studies designed to evaluate these therapies in the elderly are currently limited. Factors that must be considered before prescribing oral agents to this subset of patients include age-related physiological changes affecting clinical pharmacology, adherence, the patient's capability to self-administer medications, and safety issues concerning the older patient and his or her caregivers. The idea that elderly patients may benefit from the introduction of oral chemotherapy is very fashionable, but to date there is no proof that this approach is as effective as intravenous therapy in this age group, particularly since randomised trials are lacking. This review discusses these issues and reviews current information about the use of specific oral chemotherapeutic drugs for major neoplastic diseases in the elderly.

Patient safety, systems design and ergonomics

The complexity of the health care environments necessitates an holistic and systematic ergonomics approach to understand the potential for accidents and errors to occur. The health service is also a socio-technical system, and design needs must be met within this context. This paper aims to present the design challenges and emphasises the specialised needs of the health care sector, when dealing with patient safety. It also provides examples of approaches and methods that ergonomists can bring to help inform our knowledge of these systems and the potential towards improving their safety. Mapping workshops provide an example of such methods. Results from these are used to illustrate how the knowledge base required for better design requirements can be generated. The workshops were developed specifically to help improve the design of medication packaging and thereby reduce the probability of medication error. The issues raised are now the subject of further research, design requirements guidance and new design concepts. The paper illustrates the need to engage with the design community and, through the use of robust scientific methods, to generate appropriate design requirements.

A systematic review of the effectiveness of naltrexone in the maintenance treatment of opioid and alcohol dependence

This systematic review summarises evidence of the effectiveness of naltrexone (NTX) and the added value of psychosocial treatment in the maintenance treatment of opioid and alcohol dependence. Studies were selected through a literature search conducted in March 2004. Seven opioid and seventeen alcohol studies were identified. When possible, meta-(regression) analyses were performed. There is lack of evidence about the effectiveness of NTX in the maintenance treatment of opioid dependence. There is evidence for the effectiveness and applicability of NTX in the management of alcohol dependence. The opioid studies combined NTX with a variety of psychosocial interventions, which plagued the evaluation of their value. Concomitant psychosocial interventions used in the alcohol studies were mainly cognitive behavioural, which seems to be more effective than NTX combined with supportive therapy. Available data do not allow firm conclusions regarding the added effect of psychosocial interventions. However, the data suggest that a combination of naltrexone with cognitive behavioural relapse prevention therapy is beneficial in alcohol dependent patients.