Clinical outcomes and adherence to medications measured by claims data in patients with diabetes

Prevalence of adherence to oral antidiabetic drugs in patients with type 2 diabetes: A systematic review and meta-analysis

INTRODUCTION

The treatment of type 2 diabetes requires multidimensional management, with medication adherence a crucial aspect of diabetes control. However, recent rigorous estimates of adherence to oral antidiabetic drugs (OAD) are lacking. The objective of this study is to determine the prevalence of adherence to OAD in type 2 diabetes patients.

METHODS

A systematic search was performed in PubMed, EMBASE, PsycINFO, and CINAHL from July 2013 to April 2023. Cross-sectional studies published in English were included if they met the following criteria: (1) reported the adherence to OAD using a validated measure; and (2) had a sample size of at least 385 patients with type 2 diabetes. The Joanna Briggs Institute critical appraisal for studies reporting prevalence data was used to assess the quality of the included studies. Pooled estimates of the prevalence of adherence to OAD were calculated as a percentage together with 95% confidence interval (95% CI) using a random-effect model. All analyses were conducted using STATA 17.0; PROSPERO (CRD42023414264).

RESULTS

Twenty-six studies involving a total of 69,366 patients met the selection criteria and were included in the meta-analysis. The overall estimated prevalence of adherence to OAD was 55.53% (95%CI: 44.22%-66.85%). Among the included studies, nine were deemed to be of high quality. A sensitivity analysis conducted using only the high-quality studies revealed a prevalence of adherence to OAD at 52.24% (95% CI: 39.63%-64.85%).

CONCLUSIONS

The overall prevalence of adherence to OAD was remarkably low among type 2 diabetes patients worldwide. Healthcare practitioners and policy makers should employ appropriate approaches to improve adherence to OAD.

A consensus statement from the Japan Diabetes Society: A proposed algorithm for pharmacotherapy in people with type 2 diabetes - 2nd edition (English version)

This algorithm was issued for the appropriate use of drugs for the treatment of type 2 diabetes mellitus in Japan. The revisions include safety considerations, fatty liver disease as a comorbidity to be taken into account and the position of tirzepatide.

A consensus statement from the Japan Diabetes Society (JDS): a proposed algorithm for pharmacotherapy in people with type 2 diabetes-2nd Edition (English version)

The Japan Diabetes Society (JDS) adopted a sweeping decision to release consensus statements on relevant issues in diabetes management that require updating from time to time and launched a "JDS Committee on Consensus Statement Development." In March 2020, the committee's first consensus statement on "Medical Nutrition Therapy and Dietary Counseling for People with Diabetes" was published. In September 2022, a second consensus "algorithm for pharmacotherapy in people with type 2 diabetes" was proposed. In developing an algorithm for diabetes pharmacotherapy in people with type 2 diabetes, the working concept was that priority should be given to selecting such medications as would appropriately address the diabetes pathology in each patient while simultaneously weighing the available evidence for these medications and the prescribing patterns in clinical practice in Japan. These consensus statements are intended to present the committee's take on diabetes management in Japan, based on the evidence currently available for each of the issues addressed. It is thus hoped that practicing diabetologists will not fail to consult these statements to provide the best available practice in their respective clinical settings. Given that the persistent dual GIP/GLP-1 receptor agonist tirzepatide was approved in April 2023, these consensus statements have been revised1). In this revision, specifically, tirzepatide was added to the end of [likely involving insulin resistance] of "Obese patients" in Step 1: "Select medications to address the diabetes pathology involved" in Fig. 2. While the sentence, "Insulin insufficiency and resistance can be assessed by referring to the various indices listed in the JDS 'Guide to Diabetes Management.' was mentioned in the previous edition as well, "While insulin resistance is analogized based on BMI, abdominal obesity, and visceral fat accumulation, an assessment of indicators (e.g., HOMA-IR) is desirable" was added as information in order to more accurately recognize the pathology. Regarding Step 2: "Give due consideration to safety," "For renal excretion" was added to the "Rule of thumb 2: Avoid glinides in patients with renal impairment." The order of the medications in "rule of thumb 3: Avoid thiazolidinediones and biguanides in patients with heart failure (in whom they are contraindicated)." to thiazolidinediones then biguanides. In the description of the lowest part of Fig. 2, for each patient failing to achieve his/her HbA1c control goal, "while reverting to step 1" was changed to "while reverting to the opening" and "including reassessment if the patient is indicated for insulin therapy" was added. In the separate table, the column for tirzepatides was added, while the two items, "Characteristic side effects" and "Persistence of effect" were added to the area of interest. The revision also carried additional descriptions of the figure and table such as tirzepatides and "Characteristic side effects" in the statement, and while not mentioned in the proposed algorithm figure, nonalcoholic fatty liver disease (NAFLD) is covered from this revision for patients with comorbidities calling for medical attention. Moreover, detailed information was added to the relative/absolute indication for insulin therapy, the Kumamoto Declaration 2013 for glycemic targets, and glycemic targets for older people with diabetes. Again, in this revision, it is hoped that the algorithm presented here will not only contribute to improved diabetes management in Japan, but will continue to evolve into a better algorithm over time, reflecting new evidence as it becomes available.

Investigating the effect of prescribing status and patient characteristics on the therapeutic outcomes in patients with diabetes using a leftover drug adjustment protocol

Treatment for diabetes includes anti-diabetic medication in addition to lifestyle improvements through diet and exercise. In Japan, protocol-based pharmacotherapy management allows drug treatment to be provided through cooperation between physicians and pharmacists, based on a protocol that is prepared and agreed upon in advance. However, there are no studies to clarify the relationship between patient characteristics and therapeutic effects after pharmacist intervention in protocol-based pharmacotherapy management for patients with diabetes. Therefore, this study aimed to use protocol-based reports from pharmacies to understand the status of outpatient diabetes medication compliance. We classified patients with diabetes on the basis of patient characteristics that can be collected in pharmacies and investigated the characteristics that impacted diabetes treatment. Patients were prescribed oral anti-diabetic drugs at outpatient clinics of Hitachinaka General Hospital, Hitachi, Ltd., from April 2016 to March 2021. Survey items included patient characteristics (sex, age, number of drugs used, observed number of years of anti-diabetic drug prescription, number of anti-diabetic drug prescription days, and presence or absence of leftover anti-diabetic drugs) and HbA1c levels. Graphical analyses indicated the relationship between each categorised patient characteristic using multiple correspondence analyses. Subsequently, the patients were clustered using K-means cluster analysis based on the coordinates obtained for each patient. Patient characteristics and HbA1c values were compared between the groups for each cluster. A total of 1,910 patients were included and classified into three clusters, with clusters 1, 2, and 3 containing 625, 703, and 582 patients, respectively. Patient characteristics strongly associated with Cluster 1 were ages between 65 and 74 years, use of three or more anti-diabetic drugs, use of 3 years or more of anti-diabetic drugs, and leftover anti-diabetic drugs. Furthermore, Cluster 1 had the highest number of patients with worsening HbA1c levels compared with other clusters. Using the leftover drug adjustment protocol, we clarified the patient characteristics that affected the treatment course. We anticipate that through targeted interventions in patients exhibiting these characteristics, we can identify those who are irresponsibly continuing with drug treatment, are not responding well to therapy, or both. This could substantially improve the efficacy of their anti-diabetic care.

Genome-Wide Association Study Identifies Pharmacogenomic Variants Associated With Metformin Glycemic Response in African American Patients With Type 2 Diabetes

OBJECTIVE

Metformin is the most common treatment for type 2 diabetes (T2D). However, there have been no pharmacogenomic studies for T2D in which a population of color was used in the discovery analysis. This study sought to identify genomic variants associated with metformin response in African American patients with diabetes.

RESEARCH DESIGN AND METHODS

Patients in the discovery set were adult, African American participants from the Diabetes Multi-omic Investigation of Drug Response (DIAMOND), a cohort study of patients with T2D from a health system serving southeast Michigan. DIAMOND participants had genome-wide genotype data and longitudinal electronic records of laboratory results and medication fills. The genome-wide discovery analysis identified polymorphisms correlated to changes in glycated hemoglobin (HbA1c) levels among individuals on metformin monotherapy. Lead associations were assessed for replication in an independent cohort of African American participants from Kaiser Permanente Northern California (KPNC) and in European American participants from DIAMOND.

RESULTS

The discovery set consisted of 447 African American participants, whereas the replication sets included 353 African American KPNC participants and 466 European American DIAMOND participants. The primary analysis identified a variant, rs143276236, in the gene ARFGEF3, which met the threshold for genome-wide significance, replicated in KPNC African Americans, and was still significant in the meta-analysis (P = 1.17 × 10-9). None of the significant discovery variants replicated in European Americans DIAMOND participants.

CONCLUSIONS

We identified a novel and biologically plausible genetic variant associated with a change in HbA1c levels among African American patients on metformin monotherapy. These results highlight the importance of diversity in pharmacogenomic studies.

Communicative Pathways Predicting Adherence in Type II Diabetic Patients: A Mediation Analysis

Type II diabetes is a chronic health condition and its successful management requires effective patient-provider communication. Responding to a call to model pathways between provider communication and patient health outcomes, this study tested four models of type II diabetic patient adherence with four mediators. Given the complex nature of type II diabetic care, patient adherence was conceptualized as wellness, screening, medication, and treatment adherence. Mediators included patient understanding, agreement, trust, and motivation. A sample of U.S. patients with type II diabetes patients who were both under the care of a medical provider and taking medication for their type II diabetes completed online surveys (n = 793). Findings indicated that the relationships between patient-centered communication and adherence outcomes were mediated by proximal outcomes. The results contribute to the understanding of patient-centered communication, adherence behaviors, and proximal outcomes of patient understanding, agreement, trust, and motivation. Findings indicate that relationships between patient-centered communication and wellness adherence is mediated by patient motivation, patient-centered communication and screening adherence is mediated by patient agreement, trust, and motivation, and patient-centered communication and treatment adherence is mediated by patient agreement, trust, and motivation. The discussion addresses theoretical and practical implications and directions for future research.

Medication adherence reporting in pivotal clinical trials: overview of oral oncological drugs

OBJECTIVES

To assess how and to what extent adherence to medication is reported in pivotal clinical trials of oral cancer drugs.

METHODS

All drugs authorised by the European Medicines Agency from 1 January 2014 to 31 December 2019 were considered for analysis. For each pivotal trial we extracted the journal of publication, phase of the study, posology, mention of adherence within the main text of the published article or additional material and the terms in which the adherence was reported.

RESULTS

Thirty drugs were included in the analysis from 56 clinical trials. Eleven articles (19.6%) contained a mention of medication adherence in the main document, 26 (46.4%) in the supplementary material and 19 (33.9%) did not contain any reference to adherence. Seven studies reported medication adherence between the results, expressed as number of patients discontinuing treatment for non-compliance and mean or median percentage.

CONCLUSIONS

Medication adherence in pivotal clinical trials of oral oncological drugs is poorly represented. There should be a greater level of reporting in the results and it should be included among the minimum set of recommendations in reporting health research.

Impact of COVID-19 Lockdown on Glycemic, Weight, Blood Pressure Control and Medication Adherence in Patients with Type 2 Diabetes

Medication adherence profoundly affects blood glucose management in patients with type 2 diabetes. Measures to contain the COVID-19 pandemic have affected disease management and medication adherence, owing to limited access to healthcare facilities. This study aimed to examine the impact of the COVID-19 lockdown on adherence to glucose-lowering and lipid-lowering therapies (statins), and glycemic, weight, and systolic blood pressure control measures. A retrospective chart review was conducted one year pre- and post- March 18, 2020, for patients receiving glucose-lowering medications and lipid-lowering therapies (statins) in two major public hospitals in Malaysia. We compared the proportion of days covered by medication, HbA1c level, weight, and systolic blood pressure (SBP) values pre- and after the index date. A total of 1985 patients were included in this study. The adherence rate significantly increased for metformin, sulfonylureas dipeptidyl peptidase 4 inhibitors (DPP4i) and statin after the index date (metformin (PDC: 0.985 vs 0.978, p < 0.001), sulfonylureas (PDC: 0.988 vs 0.979, p < 0.01), DPP4i (PDC: 0.987 vs 0.98, p < 0.001), and statins (PDC: 0.983 vs 0.978, p < 0.05)). HbA1c levels were significantly reduced after the index follow-up (Mean difference: -0.43%, p < 0.001), while there was a 2.5 mmHg (p = 0.03) significant increase in SBP post-index follow-up. No significant changes in weight were observed during the post-index follow-up period. In this study, we observed better medication adherence and glycemic control among patients during the lockdown, but not for weight and systolic blood pressure control.

Assessment of medication adherence after enrollment in a health system funded medication assistance program for patients with diabetes

BACKGROUND

High costs for patients' medications decrease medication access and adherence which contributes to poor clinical outcomes. Numerous medication assistance programs exist, but many patients needing assistance, particularly insured patients, do not receive assistance due to eligibility criteria.

OBJECTIVE

To determine if there is an association between medication adherence to antihyperglycemic therapy and patient access to Nebraska Medicine Charity Care (NMCC).

PRACTICE DESCRIPTION

NMCC covers up to 100% of medication out-of-pocket costs for patients in financial need who do not qualify for other programs.

PRACTICE INNOVATION

There is no published information about a long-term health system-led financial medication assistance program being utilized to improve patient medication adherence and clinical outcomes.

EVALUATION METHODS

A retrospective cohort analysis was conducted to assess adherence in patients who initiated NMCC between July 1, 2018 and June 30, 2020, with a focus on diabetes for feasibility. Adherence was assessed using a modified medication possession ratio (mMPR) for 6 months after initiating NMCC based on health system dispensing data. Overall population adherence analyses were conducted in all available data, while pre-post analyses were conducted in those with antihyperglycemic medication fills during the prior 6 months.

RESULTS

Of 2758 unique patients receiving NMCC support, 656 patients with diabetes medication use were included. Of these, 71% had prescription insurance and 28% had prescription fills in the baseline period. Mean (SD) adherence to noninsulin antihyperglycemic medications in the follow-up period was 0.80 (0.25) with 63% adherent per mMPR ≥0.80. In the prepost analysis, mMPR was significantly higher during the follow-up period at 0.83 (0.23) than during the preindex period at 0.34 (0.17), as was the proportion who were adherent (66% vs. 2%) (P < 0.001).

CONCLUSION

This practice innovation observed an improvement in adherence and A1C outcomes in patients with diabetes who received medication financial assistance through a health system.

Metformin Sustained-Release and Vildagliptin Fixed-Dose Combination for Optimizing Glycemic Control: A Review with Real-World Case Reports

(1) Background: There is a high burden of poor glycemic control in the Indian population with type 2 diabetes mellitus (T2DM). Currently, the use of metformin sustained-release (SR)–vildagliptin fixed-dose combination (FDC) is very low as compared to metformin immediate-release (IR)–vildagliptin FDC which is associated with higher adverse events (AEs). Here, we present real-world effectiveness of metformin SR–vildagliptin FDC treatment in patients with T2DM; (2) Methods: This retrospective analysis was carried out from the medical records of adult T2DM patients visiting a single study center in India (December 2020–February 2021). A total of 10 patients (aged ≥20 years) were treated with vildagliptin 50 mg and metformin SR 500 mg FDC for 15 days. The treatment response was assessed by the percentage of time spent in the target glucose range (TIR at baseline and 15 days after treatment); (3) Results: The glycated hemoglobin (HbA1c) levels at baseline varied between 6.5% to 12%. The glycemic control improved in 70% of patients (mean increase in TIR: 18.9%). Treatment adherence was 100%. No gastrointestinal symptoms or AEs were reported; (4) Conclusions: Early intervention with metformin SR–vildagliptin FDC in patients with T2DM can ensure therapy compliance in terms of superior efficacy along with safety and tolerability. Key summary points: Early initiation of combination therapy helps in early achievement of glycemic goals; Early initiation of metformin and vildagliptin FDC results in significant glycemic control with good tolerability and compliance; Metformin SR–vildagliptin FDC has lower adverse events, compared to metformin IR–vildagliptin FDC; A case series of ten patients with T2DM treated with metformin SR–vildagliptin FDC is presented to assess the real-world effectiveness of this combination.

Changes in racial and ethnic disparities in glucose-lowering drug utilization and glycated haemoglobin A1c in US adults with diabetes: 2005-2018

AIM

To examine changes in racial and ethnic disparities in glucose-lowering drugs (GLD) use and glycated haemoglobin A1c in US adults with diabetes from 2005 to 2018.

METHODS

We conducted pooled cross-sectional analysis using data from the 2005-2018 Medical Expenditure Panel Surveys, and the 2005-2018 National Health and Nutrition Examination Survey. Individuals ≥18 years with diabetes were included. Racial and ethnic disparities were measured in (a) newer non-insulin GLD use; (b) insulin analogue use; (c) non-insulin GLDs adherence; (d) insulin adherence; and (e) glucose management, along with (f) the proportion of the disparities explained by potential contributing factors.

RESULTS

From 2005 to 2018, racial and ethnic disparities persisted in newer GLD use, non-insulin GLDs adherence, insulin analogue use and glucose management. In 2018, compared with non-Hispanic white adults, non-Hispanic black, Hispanic and other race/ethnicity groups had lower rates of using newer GLDs (adjusted risk ratio: 0.44, 0.52, 0.64, respectively; p < .05 for all) and insulin analogues (adjusted risk ratio: 0.93, 0.89, 0.95, respectively; p < .05 for all except other groups), lower non-insulin GLD adherence (proportion of days covered: -4.5%, -5.6%, -4.3%, respectively; p < .05 for all), higher glycated haemoglobin A1c (0.29%, 0.32%, 0.02%, respectively; p < .05 for all except other group), and similar insulin adherences. Socioeconomic and health status were the main contributors to these disparities.

CONCLUSIONS

Our findings provide evidence of racial and ethnic disparities in newer GLD use and quality of care in glucose management. Our study results can inform decision-makers of the status of racial and ethnic disparities and identify ways to reduce these disparities.

Ethnic disparities in medication adherence? A systematic review examining the association between ethnicity and antidiabetic medication adherence

OBJECTIVES

Adherence to prescribed medication is an essential component of diabetes management to obtain optimal outcomes. Understanding the relationship between medication adherence and ethnicity is key to optimising treatment for all people with different chronic illnesses, including those with diabetes. The aim of this review is to examine whether the adherence to antidiabetic medications differed by ethnicity among people with diabetes.

METHODS

A systematic review was conducted of studies reporting adherence to antidiabetic medication amongst people from different ethnic groups. MEDLINE, Embase, CINAHL, and PsycINFO were searched from their inception to June 2022 for quantitative studies with a specific focus on studies assessing adherence to antidiabetic medications (PROSPERO: CRD42021278392). The Joanna Briggs Institute critical appraisal checklist and a second checklist designed for studies using retrospective databases were used to assess study quality. A narrative synthesis approach was used to summarize the results based on the medication adherence measures.

RESULTS

Of 17,410 citations screened, 41 studies that included observational retrospective database research and cross-sectional studies were selected, each of which involved diverse ethnic groups from different settings. This review identified a difference in the adherence to antidiabetic medications by ethnicity in 38 studies, despite adjustment for several confounding variables that may otherwise explain these differences.

CONCLUSION

This review revealed that adherence to antidiabetic medication differed by ethnicity. Further research is needed to explore the ethnicity-related factors that may provide an explanation for these disparities.

The diabetes health plan and medication adherence among individuals with low incomes

OBJECTIVE

To test the impact of the Diabetes Health Plan (DHP), a diabetes-specific insurance plan that lowers out-of-pocket costs for diabetes-related medications and clinical visits, on adherence to oral hypoglycemic medications among low-income adults with Type 2 Diabetes (T2DM).

DATA SOURCES AND STUDY SETTING

Cohort of adults (18-64) with T2DM, an annual household income

STUDY DESIGN

We employed a linear regression Difference-In-Differences (DID) approach with a matched comparison group. To assess for differential DHP effects across adherent versus non-adherent patients, we ran a Difference-in-Difference-in-Differences (DDD) analysis by including an interaction term that included indicators for DHP exposure status and time, and low versus high baseline medication adherence.

DATA COLLECTION

The analytic data set is limited to employer groups that purchased the DHP and standard benefit plans from UnitedHealthcare, had internal pharmacy contracts; complete pharmacy claims data, and sufficient medical claims and lab data to identify employees and their dependents with T2DM.

PRINCIPAL FINDINGS

Our DID analysis did not show improved medication adherence associated with employer DHP adoption. However, the DDD model suggested a difference between DHP-exposed and comparison beneficiaries when comparing the relative effect on individuals who were adherent versus non-adherent at baseline, as suggested by the significant three-way interaction term (10.2,p = 0.028). This effect was driven by the 8.2 percentage point increase in medication adherence for the DHP subsample that was non-adherent at baseline.

CONCLUSIONS

The DHP may benefit low-income patients with low baseline medication adherence. Value-based insurance design may be an important strategy for mitigating income disparities in T2DM outcomes.

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Key Words

• diabetes
• health disparities
• health equity
• low-income
• medication non-adherence
• value based insurance design

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MESH Headings

• Adult
• Humans
• Diabetes Mellitus, Type 2/drug therapy
• Hypoglycemic Agents/therapeutic use
• Medication Adherence
• Pharmaceutical Services
• Cohort Studies
• Retrospective Studies

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Grants

• P30 AG021684 NIA NIH HHS
• U58 DP002722 NCCDPHP CDC HHS
• K08 AG068372 NIA NIH HHS
• U18 DP006128 NCCDPHP CDC HHS
• Centers for Disease Control and Prevention
• National Institute on Aging

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Affiliation(s)

Kimberly Danae Cauley Narain Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of MedicineUniversity of CaliforniaLos AngelesCaliforniaUSA Center for Health AdvancementFielding School of Public Health, University of California Los AngelesLos AngelesCaliforniaUSA Center for the Study of RacismSocial Justice, and Health Los AngelesLos AngelesCaliforniaUSA
Norman Turk Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of MedicineUniversity of CaliforniaLos AngelesCaliforniaUSA
O. Kenrik Duru Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of MedicineUniversity of CaliforniaLos AngelesCaliforniaUSA
Tannaz Moin Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of MedicineUniversity of CaliforniaLos AngelesCaliforniaUSA HSR&D Center for the Study of Healthcare Innovation, Implementation & PolicyVA Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA
Sam Ho UnitedHealthcareMinnetonkaMinnesotaUSA
Carol M. Mangione Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of MedicineUniversity of CaliforniaLos AngelesCaliforniaUSA Fielding School of Public HealthUniversity of CaliforniaLos AngelesCaliforniaUSA

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The Diabetes Health Plan and Healthcare Utilization Among Beneficiaries with Low Incomes

BACKGROUND

The socioeconomic status (SES) gradient in hospital and emergency room utilization among adults with type 2 diabetes (T2DM) is partially driven by cost-related non-adherence.

OBJECTIVE

To test the impact of the Diabetes Health Plan (DHP), a diabetes-specific health plan incorporating value-based insurance design principles on healthcare utilization among low-income adults with T2DM.

DESIGN

To examine the impact of the DHP on healthcare utilization, we employed a difference-in-differences (DID) study design with a propensity-matched comparison group. We modeled count and dichotomous outcomes using Poisson and logit models, respectively.

PARTICIPANTS

Cohort of adults (18-64) with T2DM, with an annual household income <$ 30,000, and who were continuously enrolled in an employer-sponsored UnitedHealthcare plan for at least 2 years between 2009 and 2014.

INTERVENTIONS

The DHP reduces or eliminates out-of-pocket costs for disease management visits, diabetes-related medicines, and diabetes self-monitoring supplies. The DHP also provides access to diabetes-specific telephone case management as well as other online resources.

MAIN MEASURES

Number of disease management visits (N = 1732), any emergency room utilization (N = 1758), and any hospitalization (N = 1733), within the year.

KEY RESULTS

DID models predicting disease management visits suggested that DHP-exposed beneficiaries had 1.7 fewer in-person disease management visits per year (- 1.70 [95% CI: - 2.19, - 1.20], p < 0.001), on average, than comparison beneficiaries. Models for emergency room (0.00 [95% CI: - 0.06, 0.06], p = 0.966) and hospital utilization (- 0.03 [95% CI: - 0.08, - 0.01], p = 0.164) did not demonstrate statistically significant changes associated with DHP exposure.

CONCLUSIONS

While no relationship between DHP exposure and high-cost utilization was observed in the short term, fewer in-person disease management visits were observed. Future studies are needed to determine the clinical implications of these findings.

Cognitive Behavioral Therapy (CBT) Telehealth Augmented With a CBT Smartphone Application to Address Type 2 Diabetes Self-Management: A Randomized Pilot Trial

Purpose:

The purpose of the study was to investigate the feasibility and acceptability of phone-delivered cognitive behavioral therapy (CBT) combined with an adjunctive smartphone application CBT MobileWork-DM© to improve self-management of type 2 diabetes mellitus (T2DM).

Methods:

Participants were 12 patients with T2DM on antihyperglycemic medication and had an A1C level of 8 or greater. A randomized controlled pilot study assessed treatment as usual (TAU) T2DM care versus a phone-delivered CBT (6, 8, or 12 weekly sessions) augmented with a CBT skills practice smartphone application. The CBT telehealth intervention addressed T2DM self-management and diabetes distress. Electronic and self-report medication taking, diabetes-related distress, and A1C were assessed at baseline and post-intervention.

Results:

After 16 weeks, a decrease in A1C and distress levels was observed in all 3 CBT phone groups and TAU group. The group with the most improvement was the 12-week CBT group, which had the greatest mean decrease in A1C (−2.33) and diabetes distress (−31.67). The TAU group exhibited a mean decrease of −2.15 and −21 for A1C and diabetes distress, respectively. The overall rate of completion for phone CBT sessions across the 3 CBT groups was 83%.

Conclusion:

This study demonstrates that telehealth CBT augmented with a smartphone application is feasible and acceptable. Patients demonstrated improvements in both T2DM management and distress.

Drug therapy and medication adherence in type 2 diabetes in a care facility: A cross sectional survey

Background

Adherence to medications improves glycaemic control and reduces diabetes-related morbidity and mortality.

Objectives

The study assessed drug therapy for type 2 diabetes, glycaemic control and association of medication adherence with socio-demographic and clinical data, among adult diabetic patients attending a healthcare facility.

Methods

Cross-sectional survey and hospital records were used to obtain data. The study included 200 adults with type 2 diabetes mellitus in a Nigerian healthcare facility. Data on patients clinical characteristics, diabetes drug therapy and medication adherence were collected, entered and anlaysed using SPSS version 24 (P <0.05). Primary outcome measure was medication adherence among the patients, while secondary outcome measures was glycaemic control.

Results

A total of 200 (100%) respondents participated in the study and the majority 141(70.5%) were over 60 years old. Oral medications were mostly used 187(93.5%), particularly, metformin 199(99.5%) and pioglitazone 100(50.0%), while dipeptidyl peptidase-4 inhibitors were not used at all. Patients mostly had poor glycaemic control 159 (79.5%) and majority 152(76.0%) did not practice self-blood glucose monitoring. Moderate medication adherence was predominant in the population. Class of medicine and socio-demographics were not significantly associated with medication adherence (P>0.05), unlike results of blood glucose self-tests (p=0.001).

Conclusion

Oral antidiabetics, particularly metformin and pioglitazone were mostly used. Poor glycaemic control and moderate adherence were found in the patients, and medication adherence was associated with self-glucose monitoring. This emphasises the need for regular diabetes education on medication adherence.

Comparison of Glucose-Lowering Drugs as Second-Line Treatment for Type 2 Diabetes: A Systematic Review and Meta-Analysis

Background: Multiple glucose-lowering drugs are available as add-ons to metformin for a second-line treatment for type 2 diabetes. However, no systematic and comparative data are available for them in China. We aimed to compare the effects of glucose-lowering drugs added to metformin in China. Methods: PubMed, Embase, Web of Science, CNKI, WanFang Data, and Chongqing VIP from 1 January 2000 until 31 December 2020 were systematically searched for randomized controlled trials comparing a glucose-lowering drug added to metformin with metformin in Chinese type 2 diabetes patients. Drug classes included sulfonylureas (SUs), glinides (NIDEs), thiazolidinediones (TZDs), α-glucosidase inhibitors (AGIs), dipeptidyl peptidase-4 inhibitors (DPP-4is), sodium-glucose cotransporter-2 inhibitors (SGLT2is), glucagon-like peptide-1 receptor agonists (GLP-1RAs), and insulins (INSs). Two reviewers independently screened studies, extracted data, and appraised the risk of bias. Results: 315 trials were included. In patients receiving metformin alone, the addition of NIDEs produced the greatest additional HbA1c reductions (1.29%; 95% CI 0.97, 1.60); while INSs yielded both the largest additional FPG reductions (1.58 mmol/L; 95% CI 1.22, 1.94) and 2 hPG reductions (2.52 mmol/L; 95% CI 1.83, 3.20). INS add-ons also conferred the largest additional HDL-C increases (0.40 mmol/L; 95% CI 0.16, 0.64), whereas AGI add-ons generated the greatest TC reductions (1.08 mmol/L; 95% CI 0.78, 1.37). The greatest incremental SBP reductions (6.65 mmHg; 95% CI 4.13, 9.18) were evident with SGLT2i add-ons. GLP-1RA add-ons had the greatest BMI reductions (1.96 kg/m2, 95% CI 1.57, 2.36), meanwhile with the lowest (0.54 time) hypoglycemia risk. Overall, only the GLP-1RA add-ons demonstrated a comprehensive beneficial effect on all outcomes. Furthermore, our results corroborated intraclass differences among therapies. Given the limited evidence, we could not reach a conclusion about the optimal therapies regarding mortality and vascular outcomes. Conclusion: The results suggested a potential treatment hierarchy for clinicians and patients, with the GLP-1RA add-ons being most preferred based on their favorable efficacy and safety profiles; and provided a unified hierarchy of evidence for conducting country-specific cost-effectiveness analyses.

DM management in HIV patients: the adoption of population health management to transform the chronic management of HIV

BACKGROUND

The success of antiretroviral therapies has made human immunodeficiency virus (HIV) a chronic disease, changing the care scenario dramatically. This study aimed to measure adherence to diabetes mellitus standards of care provided for people living with HIV (PLWH). Diabetes represents a paradigmatic case for tackling chronic care management in this target group.

METHODS

This retrospective observational study was performed on administrative health data retrieved from 2014 to 2016, with a validated algorithm to identify patients with HIV using: (i) hospital discharge records (ICD9-CM codes); (ii) drug dispensing records (with ATC codes); and (iii) disease-specific exemptions from co-payments for healthcare services. HIV-related treatments, comorbidities and health service utilization were measured, as was adherence to clinical guidelines-recommended standards of care for diabetes.

RESULTS

A population of 738 cases were identified in two Local Health Authorities in Italy, representing a prevalence of 0.14% of the general population, in line with the expected prevalence. Thirty-one cases of HIV patients diagnosed with diabetes were identified, a prevalence ratio of 4.2% compared to the 8% in the overall population. Adherence to diabetes standards of care tested within the same population was low, with the exception of those tests commonly administered for standard HIV follow-up care.

CONCLUSIONS

The use of administrative data, combined with a Population Health Management approach represents a powerful tool for evaluating system capacity to manage HIV comorbidities. Study findings prove that it is time to design new care models for PLWH, affected by one or more chronic conditions, both to prevent their onset and to manage their comorbidities.

Association Between High Deductible Health Plans and Cost-Related Non-adherence to Medications Among Americans with Diabetes: an Observational Study

BACKGROUND

For people with diabetes, adherence to prescribed medications is essential. However, the rising prevalence of high-deductible health plans (HDHPs), and prices of diabetes medications such as insulin, could deter adherence.

OBJECTIVE

To assess the impact of HDHP on cost-related medication non-adherence (CRN) among non-elderly adults with diabetes in the US.

DESIGN

Repeated cross-sectional survey.

SETTING

National Health Interview Survey, 2011-2018.

PARTICIPANTS

A total of 7469 privately insured adults ages 18-64 with diabetes who were prescribed medications and enrolled in a HDHP or a traditional commercial health plan (TCP).

MAIN MEASURES

Self-reported measures of CRN were compared between enrollees in HDHPs and TCPs overall and among the subset using insulin. Analyses were adjusted for demographic and clinical characteristics using multivariable linear regression models.

KEY RESULTS

HDHP enrollees were more likely than TCP enrollees to not fill a prescription (13.4% vs 9.9%; adjusted percentage point difference (AD) 3.4 [95% CI 1.5 to 5.4]); skip medication doses (11.4% vs 8.5%; AD 2.8 [CI 1.0 to 4.7]); take less medication (11.1% vs 8.8%; AD 2.3 [CI 0.5 to 4.0]); delay filling a prescription to save money (14.4% vs 10.8%; AD 3.0 [CI 1.1 to 4.9]); and to have any form of CRN (20.4% vs 15.5%; AD 4.4 [CI 2.2 to 6.7]). Among those taking insulin, HDHP enrollees were more likely to have any CRN (25.1% vs 18.9%; AD 5.9 [CI 1.1 to 10.8]).

CONCLUSION

HDHPs are associated with greater CRN among people with diabetes, particularly those prescribed insulin. For people with diabetes, enrollment in non-HDHPs might reduce CRN to prescribed medications.

Impact of Variation in Pill/Package Appearance of Drugs on Patients' Behavior: A Systematic Review

OBJECTIVE

This systematic review aims to identify and critically evaluate the available evidence on the impact of switches in pill appearance/packaging on patient's behavior.

METHODS

Studies from inception to March 2021 were searched across MEDLINE through PubMed, the Cochrane Library, Embase, and Scopus. Included studies carried out an original evaluation in English or Spanish language that evaluated the impact of switches in pill appearance/packaging on patient's behavior. Two authors independently extracted study data and evaluated studies for methodological quality according to the STROBE guidelines.

RESULTS

Ten studies were included, and the mean (SD) number of STROBE criteria satisfied was 17.2 (3.9). Three of 5 studies found a significant association between change in pill appearance and persistence to treatment; the 3 studies that evaluated the impact of a change on adherence to treatment found a significant association; 1 of the 2 studies that evaluated the relationship between a change a clinical outcome found a significant association with the prevalence of uncontrolled blood pressure; and 1 study showed lower rates of switchbacks to the branded product compared with patients who switched to generic drug products, with different appearance.

CONCLUSIONS

This systematic review showed an impact of the change in pill/package appearance on patients' behavior in 7 of the 10 studies included. Generic switching may lead to unintended consequences on patients' behavior, mainly regarding adherence to treatment.

Self-care practice and glycemic Control among type 2 diabetes patients on follow up in a developing country: a prospective observational study

Purpose

The main goal of managing diabetes is to achieve glycemic control. However, the glycemic level of most diabetic patients is shown to be poorly controlled mainly due to poor adherence to self-care practices. This study aims to assess the level of self-care practice and glycemic control among type 2 diabetes patients on follow up in a resource limited country.

Methods

A four-month prospective observational study was conducted among type 2 diabetes patients from February 1 to May 30, 2021. Data was collected using a data abstraction checklist and structured questionnaire. The data was entered into Epidata version 4.4.6 and analyzed with SPSS version 26. Glycemic control and its predictors were determined using binary logistic regression. P-value less than 0.05 was considered as statistically significant.

Results

A total of 138 patients were included in the study. Nearly three-fourths (74.6%) of patients had poor glycemic control and the majority of patients had poor self-care practice. 78.3%, 98.6%, 96.4%, and 55.8% of patients had poor adherence to diet, exercise, self-monitoring of blood glucose, and medications respectively. Importantly, 85(79%), 102(75%), 99(74.4%), and 65(84.4%) patients with poor adherence to diet, physical activity, self-monitoring of blood glucose, and antidiabetic medications had poor glycemic control. On multivariate logistic regression, BMI (AOR 4.1, CI:1.20-14.11, p = 0.024) and drug adherence (AOR 3.08, CI:1.22-7.08, p = 0.017) were factors associated with poor glycemic control.

Conclusions

A higher proportion of patients had low-level of self-care practice and poor glycemic control. This highlights the need to improve patients' awareness about the importance of self-care practice to maintain good glycemic control and prevent adverse outcomes associated with the disease.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-022-00995-4.

Real-World Evidence of Treatment with Teneligliptin/Canagliflozin Combination Tablets for Type 2 Diabetes Mellitus: A Post-Marketing Surveillance in Japan

Introduction

Teneligliptin/canagliflozin combination tablets, which combine a dipeptidyl peptidase-4 (DPP-4) inhibitor (teneligliptin) and a sodium-glucose cotransporter 2 (SGLT2) inhibitor (canagliflozin), are a treatment option for type 2 diabetes mellitus (T2DM) in Japan. This post-marketing surveillance evaluated the real-world safety and effectiveness of teneligliptin/canagliflozin combination tablets, and changes in self-reported adherence to oral antihyperglycaemic agents.

Methods

Japanese patients with T2DM who were prescribed the combination tablets for the first time between December 2017 and June 2018 were registered and followed up for 12 months. Safety and effectiveness were assessed in terms of adverse drug reactions (ADRs) and the changes in haemoglobin A1c (HbA1c) and body weight from baseline to 12 months with the last observation carried forward, respectively. Adherence was assessed using the Morisky Medication Adherence Scale 8.

Results

Overall, 821 patients were eligible for the analyses, including 733 who were prescribed the combination tablets for 12 months. ADRs and serious ADRs were reported in 4.38% and 0.85% of patients, respectively. Gastrointestinal disorders (0.97%) were the most common class of ADRs. No new safety concerns were identified beyond those described in the Japanese package insert. The changes in HbA1c and body weight from baseline to 12 months were − 0.43 ± 0.93% and − 1.29 ± 5.57 kg, respectively. The reductions in HbA1c at 12 months tended to be greater among patients who switched from either DPP-4 inhibitors (− 0.71 ± 0.89%) or SGLT2 inhibitors (− 0.51 ± 1.00%) relative to patients who switched from both (− 0.22 ± 0.88%). The decrease in body weight was greatest among patients who switched from DPP-4 inhibitors. An improvement in self-reported adherence to oral antihyperglycaemic agents occurred after switching to the combination tablets.

Conclusion

Teneligliptin/canagliflozin combination tablets were effective and associated with an improvement in adherence without new safety concerns in Japanese patients with T2DM in real-world clinical practice.

Trial Registration

JapicCTI-173778.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-021-02038-5.

Teneligliptin/canagliflozin combination tablets are used as an option for the treatment of type 2 diabetes mellitus in Japan. We performed this surveillance to obtain data on the frequency of side effects (adverse drug reactions) and effectiveness (in terms of changes in haemoglobin A1c and body weight) in Japanese patients treated with teneligliptin/canagliflozin combination tablets in real-world clinical practice. We also asked patients to evaluate their adherence to oral antihyperglycaemic agents as part of their prescribed therapies. We collected data for up to 12 months. We detected no new safety concerns, other than those already described in the Japanese package insert for the combination tablets. In terms of effectiveness, we observed improvements in both haemoglobin A1c and body weight over 12 months of treatment. Furthermore, self-reported adherence to oral antihyperglycaemic agents improved after treatment with the combination tablets.

The effect of Patient's Own Medication use on patient's self-reported medication knowledge during hospitalisation: a pre-post intervention study

Background

Improving patient’s medication knowledge and consequently medication use is essential for optimal treatment outcomes. As patient knowledge about medication is currently suboptimal, interventions to optimise medication knowledge are necessary. Implementation of Patient’s Own Medication (POM) in which patients bring their outpatient medication to the hospital, and nurses administer these during admission, may increase medication knowledge. The aim of this study is to explore the impact of POM use on self-reported medication knowledge of hospitalised patients compared to standard care. Patient’s sense of medication safety, attitude to the provision of information, and to inpatient medication use were studied in both standard care and during POM use too.

Method

In this nationwide intervention study perceived medication knowledge was assessed with a questionnaire pre and post implementing POM use. The questionnaire assessed perceived medication knowledge at admission and discharge, medication safety during hospitalisation, the provision of information during hospitalisation and at discharge, and inpatient medication use during hospitalisation. Patients’ answers were categorised into positive and negative/neutral. The proportion of patients with adequate medication knowledge, in the standard care and POM use group at hospital admission and discharge, were calculated and compared with adjustment for potential confounders.

Results

Among the 731 patients (393 received standard care and 338 POM) who completed the questionnaire (80.2%), POM use seemed to be positively associated with self-reported knowledge on how to use medication at discharge (adjusted OR: 3.22 [95% CI 2.01–5.16]). However, for the other two knowledge related statements POM use was not associated. Medication knowledge at admission was the most important variable associated with perceived medication knowledge at discharge. The majority perceived POM use to be safer (52.9% of standard care patients versus 74.0% POM users; P <  0.01), POM users knew better which medicines they still used during hospitalisation (85.8% versus 92.3% resp.; P = 0.01), and most patients preferred POM use regardless of having experienced it (68.2% versus 82.2% resp.; P <  0.01).

Conclusion

POM use positively affects patient’s medication knowledge about how to use medication and patients’ perception of medication safety. With POM use more patients have a positive attitude towards the provision of information. The majority of patients prefer POM use. In conclusion, POM use seems a valuable intervention and requires further investigation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07752-6.

Adherence, control of cardiometabolic factors and therapeutic inertia in patients with type 2 diabetes in the primary care setting

Introduction

Studies on treatment adherence to glucose‐lowering drugs among patients with type 2 diabetes (T2D) including concomitant treatment for other cardiovascular risk factors are scarce. We aimed to estimate the prevalence of good adherence to all medications used to control diabetes, hypertension and dyslipidemia and to analyse cardiometabolic control and its associated factors in T2D patients in the primary care (PC) setting.

Methods

Observational, retrospective study conducted in adult patients with T2D who were followed in the PC setting in Spain. Patients were classified as adherent in a particular category if the summary of the proportion of days covered (PDC) for a particular medication category was ≥80% and were considered globally adherent if the PDC was ≥80% for each of the 3 medication categories.

Results

A total of 457 evaluable patients were recruited, among which 321 patients (70.3%, 95% CI 65.8 to 74.4) were adherent to the three drug categories. The proportion of patients controlled for the 3 cardiometabolic risk factors was 31% according to the contemporary clinical practice guideline criteria, 58% according to investigator judgment and 36% when the objective for HbA1c was individualized. In a multivariate analysis, presenting comorbidities was associated with a lower likelihood of showing adequate control of dyslipidemia (odds ratio [OR] 0.25, 95% CI, 0.16–0.40) and the three cardiometabolic factors as a whole (OR 0.43, 95% CI 0.26–0.70). In a post hoc analysis, therapeutic inertia was found to be greater for dyslipidemia and hypertension than for T2D.

Conclusions

Despite a relatively high adherence to all medications for treating diabetes, hypertension and dyslipidemia in patients with T2D in the PC setting in Spain, the control of cardiometabolic risk factors as a whole is far from optimal. This could be related, at least in part, to the high frequency of comorbidity of these patients.

The role of integrated medical and prescription drug plans in addressing racial and ethnic disparities in medication adherence

Medication nonadherence in the United States contributes to 125,000 deaths and 10% of hospitalizations annually. The pain of preventable deaths and the personal costs of nonadherence are borne disproportionately by Black, Latino, and other minority groups because nonadherence is higher in these groups due to a variety of factors. These factors include socioeconomic challenges, issues with prescription affordability and convenience of filling and refilling them, lack of access to pharmacies and primary care services, difficulty taking advantage of patient engagement opportunities, health literacy limitations, and lack of trust due to historical and structural discrimination outside of and within the medical system. Solutions to address the drivers of lower medication adherence, specifically in minority populations, are needed to improve population outcomes and reduce inequities. While various solutions have shown some traction, these solutions have tended to be challenging to scale for wider impact. We propose that integrated medical and pharmacy plans are well positioned to address racial and ethnic health disparities related to medication adherence. DISCLOSURES: This study was not supported by any funding sources other than employment of all authors by Humana Inc. Humana products and programs are referred to in this article.

Anti-Hyperglycemic Medication Adherence and Health Services Utilization in People with Diabetes: A Longitudinal Study of Alberta's Tomorrow Project

BACKGROUND

Little is known about the long-term (>2 years) relationship between the time-varying drug adherence and healthcare utilization for patients with diabetes.

OBJECTIVE

To characterize the relationship between time-varying anti-hyperglycemic medication adherence and healthcare utilization in patients with diabetes, using data from Alberta's Tomorrow Project, a population-based cohort study in Alberta, Canada.

METHODS

Incident cases of diabetes with at least 24 months of follow-up were included in the study. Anti-hyperglycemic drug adherence was measured by proportion of days covered (PDC) in the past 12 months for each year after diagnosis. The rate of healthcare utilization was assessed for the subsequent 12 months, 36 months and 60 months. A time-varying, negative binomial generalized estimating equation model was used to examine the association between medication adherence and healthcare utilization.

RESULTS

Among 2155 incident cases of diabetes, average age at diagnosis was 59.6±9.3, 51.0% were female and average duration of follow-up was 7.3±3.7 (range, 2.0-16.2) years. The proportion of patients taking anti-hyperglycemic medications was 47.6% during the first year of diagnosis, which increased to 77.3% by the end of follow-up. Compared to adherent patients (PDC≥0.8), non-adherent patients (PDC<0.8) had substantially higher rate of all-cause hospitalization [incident rate ratio, IRR=1.48 (1.22-1.79), ED visits [1.30 (1.15-1.47)] and GP visits [1.17 (1.08-1.27)] in the subsequent 12 months. However, these associations became weaker with longer follow-up [eg, IRR=1.18 (0.98-1.39) and 1.05 (0.94-1.18) for all-cause hospitalization in the subsequent 36 and 60 months, respectively].

CONCLUSION

Poor adherence among diabetic patients was associated with substantially higher rate of healthcare utilization in the short term (eg, 12 months); however, this association weakened over a longer period (eg, 36-60 months).

The impact of the COVID-19 pandemic on medical conditions and medication adherence in people with chronic diseases

Background

The coronavirus disease 2019 (COVID-19) pandemic has drastically disrupted primary health care and pharmacy services, posing a challenge in people with chronic diseases who receive routine care. Currently, there exists limited literature on the indirect impact of the pandemic on chronic disease management, particularly related to accessibility to medications and health care resources.

Objectives

To determine the prevalence of medical- and medication-related problems reported by people with chronic diseases during the pandemic. The secondary objective was to identify the barriers and contributing factors related to these medical- and medication-related problems.

Methods

The anonymous and voluntary, Web-based survey was filled out by interested adult respondents with chronic disease(s) across Michigan between September 1, 2020, and January 1, 2021. The primary outcome included self-reported medical- and medication-related problems during the pandemic. Secondary outcomes included potential risk factors for medical- and medication-related problems. Descriptive statistics was used to describe respondents’ demographics, chronic disease characteristics, medication adherence, medical- and medication-related problems, and COVID-19–related factors. The multivariable Firth logistic regression was used to analyze correlations between potential risk factors associated with medical- and medication-related problems.

Results

A total of 1103 respondents completed the survey and were included in the analysis. Approximately, 51% of respondents reported a medication-related problem with 19.6% reported problems obtaining medication(s) and 31.7% reported forgetting or not taking their medication(s). The top reason for problems obtaining medication(s) was doctor’s office being closed for in-person visit(s). In addition, of all responses, more than half reported worsening symptoms of their chronic disease(s) during the pandemic especially with psychiatric disorders (79.5%) and inflammatory bowel disease (60%). Respondents with a significantly higher risk of medication-related problems included those who were younger, were female, and had psychiatric disorder(s), diabetes, arthritis, or lupus, and respondents with a significantly higher risk of medical-related problems included those with multiple chronic diseases, psychiatric disorder(s), and heart failure.

Conclusion

Understanding the consequences of the pandemic, such as medical- and medication-related problems, in this population is critical to improving health care accessibility and resources through potential outpatient pharmacy services during this and future pandemics.

Digital messaging to support control for type 2 diabetes (StAR2D): a multicentre randomised controlled trial

BACKGROUND

Failure to take medicines for diabetes as prescribed contributes to poor outcomes from the condition. Mobile phones are ubiquitous and short message service (SMS) texts have shown promise as a low-cost intervention. We tested the effectiveness of SMS-text messaging in improving outcomes in adults with type 2 diabetes.

METHODS

StAR2D was a 12-month two-arm randomised trial of SMS-text messaging and usual care in Cape Town, South Africa and Lilongwe, Malawi. Messages used behaviour change theory and were developed with patients and staff. The intervention group received four messages each week. The primary outcome was change in HbA1c. Secondary outcomes were the proportion of patients who collected > 80% medication and changes in systolic blood pressure, lipids, cardiovascular risk, and the proportion of the participants reaching treatment goals.

RESULTS

The trial took place between 1 October, 2016 and 1 October 2018, 1186 participants were randomised to intervention (593) and control (593) groups. 91% of participants completed follow-up. There was a reduction in HbA1c (DCCT) in both groups but not in mean change (95% CI) between groups (- 0.08% (- 0.31 to 0.16) (IFCC - 0.82 mmol/mol (- 3.44 to 1.79). There was a small but not significant increase in the proportions of participants likely to have collected 80% or more of medication (Relative risk 1.11 (0.84 to 1.47; P = 0.47). There was a significant difference between groups in change in systolic blood pressure from baseline of 3.46 mmHg (1.48 to 5.44, P = 0.001) in favour of the intervention group. The between group difference in change in 10-year risk of coronary heart disease was - 0.71% (- 1.46 to 0.04, P = 0.064). The proportion of participants meeting treatment goals in the intervention group was 36.0% and in the control group 26.8% (Relative risk 1.36 (1.13 to 1.63, P = 0.001). Participants reported many challenges to adherence despite finding messages acceptable and useful.

CONCLUSIONS

Whilst SMS text messages do not lead to improved glycaemia in these low-resource settings there appeared to be an impact on blood pressure and achievement of treatment goals but the mechanisms for this are unclear. Text messages alone, may be unsuccessful unless accompanied by health system strengthening and other forms of self-management support for type 2 diabetes.

TRIAL REGISTRATION

Trial registration: ISRCTN, ISRCTN70768808. Registered 1 July 2015, http://www.isrctn.com/I ISRCTN70768808.

Validation of EHR medication fill data obtained through electronic linkage with pharmacies

BACKGROUND: Recent linkages between electronic health records (EHRs) and pharmacy data hold opportunity for up-to-date assessment of medication adherence at the point of care. OBJECTIVE: To validate linked EHR-pharmacy data, which can be used for point-of-care interventions for concordance with insurance claims data for patients in a large health care delivery system. METHODS: We performed a retrospective cohort study of adult patients with an active antihypertensive medication order and seen as outpatients between August 25, 2019, and August 31, 2019. Pharmacy fill information was obtained from the EHR via linkages with Surescripts pharmacy and pharmacy benefit manager data, as well as from insurance claims available at our institution. We matched antihypertensive medication fills observed in the linked EHR-pharmacy database with available fills in the insurance claims database and calculated the percentage of medication fills that were available in each database. We estimated medication adherence using proportion of days covered in the linked EHR-pharmacy database and in the insurance claims database. RESULTS: Of 26,679 patients with hypertension, 23,348 (87.5%) had at least 1 antihypertensive medication fill recorded in the linked EHR-pharmacy database. Of 1,501 patients matched with the insurance database and with a documented medication fill, a fill was present for 1,484 (98.9%) and 1,259 (83.9%) patients in the linked EHR-pharmacy and insurance databases, respectively. Of 12,109 medication fills recorded in the insurance data, we found an overlap of 11,060 (91.3%) fills with the linked EHR-pharmacy database. The linked EHR-pharmacy database also contained 18,232 of 19,281 (94.6%) medication fills present in either database. Measured medication adherence was higher for patients when based on linked EHR-pharmacy data compared with insurance claims data (42% vs 30%, P < 0.001). CONCLUSIONS: Linked EHR-pharmacy data captured medication fills for the vast majority of patients and resulted in higher estimates of adherence than insurance claims. Our results suggest that pharmacy fill data available in the EHR have sufficient reliability to be used for point-of-care assessment of medication adherence. DISCLOSURES: This study was supported by grant R01HL155149 from the National Heart, Lung, and Blood Institute. Allen Thorpe provided funding for the NYU Langone Health Learning Health System Program, which helped fund this project. The authors have nothing to disclose.

Health-related quality of life in patients with type 2 diabetes initiating a second-line glucose-lowering therapy: The DISCOVER study

AIM

To investigate factors associated with health-related quality of life (HRQoL) in patients with type 2 diabetes mellitus (T2D) at initiation of second-line glucose-lowering therapy.

METHODS

DISCOVER is a 3-year, prospective observational study of patients with T2D initiating second-line glucose-lowering therapy, conducted in 38 countries. HRQoL at baseline was assessed using the physical and mental component summary (PCS; MCS) scores of the 36-Item Short Form Health Survey version 2 (SF-36v2) in 31 countries (n = 8309) and the Hypoglycaemia Fear Survey-II (HFS-II) in 23 countries (n = 6516). Factors associated with differences in HRQoL were assessed using multivariable hierarchical regression models.

RESULTS

Mean PCS and MCS scores were 48.0 (standard deviation [SD]: 7.8) and 45.5 (SD: 10.4), respectively. Factors associated with significantly lower SF-36v2 scores included being female, having a history of macrovascular complications and first-line treatment with oral combinations (vs metformin monotherapy). Mean HFS-II behaviour and worry scores were 8.2 (SD: 9.9) and 7.3 (SD: 11.8), respectively. Increased fear of hypoglycaemia was significantly associated with lower SF-36v2 scores.

CONCLUSIONS

Several patient-, disease- and treatment-related characteristics correlated with HRQoL, indicating that a multifactorial approach is needed to maintain HRQoL in patients with T2D.

Pharmacist-led intervention in treatment non-adherence and associated direct costs of management among ambulatory patients with type 2 diabetes in southwestern Nigeria

BACKGROUND

Non-adherence to recommended therapy remains a challenge to achieving optimal clinical outcome with resultant economic implications.

OBJECTIVE

To evaluate the effect of a pharmacist-led intervention on treatment non-adherence and direct costs of management among patients with type 2 diabetes (T2D).

METHOD

A quasi-experimental study among 201-patients with T2D recruited from two-tertiary healthcare facilities in southwestern Nigeria using semi-structured interview. Patients were assigned into control (HbA1c < 7%, n = 95) and intervention (HbA1c ≥ 7%, n = 106) groups. Baseline questionnaire comprised modified 4-item Medication Adherence Questions (MAQ), Perceived Dietary Adherence Questionnaire (PDAQ) and International Physical Activity Questionnaire, to assess participants' adherence to medications, diet and physical activity, respectively. Post-baseline, participants were followed-up for 6-month with patient-specific educational intervention provided to resolve adherence discrepancies in the intervention group only, while control group continued to receive usual care. Subsequently, direct costs of management for 6-month pre-baseline and 6-month post-baseline were estimated for both groups. Data were summarized using descriptive statistics. Chi-square, McNemar and paired t-test were used to evaluate categorical and continuous variables at p < 0.05.

RESULTS

Mean age was 62.9 ± 11.6 years, and 160(79.6%) were females. Glycated haemoglobin (HbA1c) was 6.1 ± 0.6% (baseline) and 6.1 ± 0.8% at 6-month post-baseline (p = 0.094) for control group, and 8.7 ± 1.5% (baseline) versus 7.8 ± 2.0% (6-month), p < 0.001, for the intervention. Post-baseline, response to MAQ items 1 (p = 0.017) and 2 (p < 0.001) improved significantly for the intervention. PDAQ score increased significantly from 51.8 ± 8.8 at baseline to 56.5 ± 3.9 at 6-month (p < 0.001) for intervention, and from 56.3 ± 4.0 to 56.5 ± 3.9 (p = 0.094) for the control group. Physical activity increased from 775.2 ± 700.5 Metabolic Equivalent Task (MET) to 829.3 ± 695.5MET(p < 0.001) and from 901.4 ± 743.5MET to 911.7 ± 752.6MET (p = 0.327) for intervention and control groups, respectively. Direct costs of management per patient increased from USD 327.3 ± 114.4 to USD 333.0 ± 118.4 (p = 0.449) for the intervention, while it decreased from USD 290.1 ± 116.97 to USD289.1 ± 120.0 (p = 0.89) for control group, at baseline and 6-month post-baseline, respectively.

CONCLUSION

Pharmacist-led intervention enhanced adherence to recommended medications, diet and physical activity among the intervention patients, with a corresponding significant improvement in glycaemic outcome and an insignificant increase in direct costs of management. There is a need for active engagement of pharmacists in management of patients with diabetes in clinical practice.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04712916 . Retrospectively-registered.

Prevalence and associated factors of premature discontinuation of antiplatelet therapy after ischemic stroke: a nationwide population-based study

BACKGROUND

We tried to evaluate the prevalence of premature discontinuation of antiplatelets and its affecting factors after ischemic stroke using large-sized representative national claims data.

METHODS

Patients aged 20 years or older with newly confirmed ischemic stroke who started aspirin or clopidogrel for the first time were selected from 2003 to 2010 National Health Insurance Service-National Sample Cohort (NHIS-NSC) of South Korea (n = 4621), a randomly collected sample which accounts for 2.2% (n = 1,017,468) of total population (n = 46,605,433). The prevalence of discontinuation of antiplatelets was measured every 6 months until the 24 months since the first prescription. Then we classified the participants into 2 groups according to the discontinuation status at 12 months and assessed the factors influencing premature discontinuation of antiplatelets within 12 months.

RESULTS

Among total participants, 35.5% (n = 1640) discontinued antiplatelets within 12 months and 58.5% (n = 2704) discontinued them within 24 months. The remaining 41.5% (n = 1917) continued them for 24 months or more. In the multivariate logistic regression analysis, initiating treatment with aspirin monotherapy [adjusted OR (aOR), 2.66, 95% CI 2.17-3.25] was the most prominent determinant of premature discontinuation within 12 months followed by CCI score ≥ 6 (aOR 1.50, 95% CI 1.31-1.98), and beginning treatment with clopidogrel monotherapy (aOR 1.41, 95% CI 1.15-1.72). Rural residency (aOR 1.36, 95% CI 1.14-1.62), < 4 total prescribed drugs (aOR 1.24, 95% CI 1.05-1.47), lower income (aOR 1.20, 95% CI 1.03-1.40 for middle income class and OR 1.21, 95% CI 1.02-1.45 for low income class), and ages ≥70 years (aOR 1.15, 95% CI 1.00-1.31) were also significantly associated with premature discontinuation of antiplatelets within 12 months.

CONCLUSIONS

The prevalence of premature discontinuation of antiplatelets after ischemic stroke was quite high. Thus, by understanding factors associated with premature discontinuation, a more strategic approach is required for the physicians to improve persistence with antiplatelets.

Forgone care in patients with type 2 diabetes: a cross-sectional study

BACKGROUND AND OBJECTIVE

Diabetes mellitus is a complex chronic disease requiring appropriate continuous medical care and delayed, or forgone care may exacerbate the severity of the disease. This study aimed to investigate the factors affecting forgone care in patients with type2 diabetes.

MATERIALS AND METHODS

This was a cross-sectional study involving 1139 patients with type 2 diabetes aged> 18 years in 2019 in Tabriz, Iran. The researcher-made questionnaire was used for data collection. Data were analyzed using IBM SPSS software version 22 and IBM AMOS 22. Exploratory Factor Analysis (EFA) was performed for dimension reduction of the questionnaire, and Confirmatory Factor Analysis (CFA) used to verify the result of EFA. We applied the binary logistic regression model to assess the factors affecting forgone care.

RESULTS

Of the 1139 patients, 510 patients (45%) reported forgone care during the last year. The percentage of forgoing care was higher in patients without supplementary insurance coverage (P = 0.01), those with complications (P = 0.01) and those with a history of hospitalization (P = 0.006). The majority of patients (41.5%) reported that the most important reason for forgoing care is financial barriers resulting from disease treatment costs. Of the main four factors affecting, quality of care had the highest impact on forgone care at 61.28 (of 100), followed by accessibility (37.01 of 100), awareness and attitude towards disease (18.52 of 100) and social support (17.22 of 100).

CONCLUSION

The results showed that, despite the implementation of the Islamic Republic of Iran on a fast-track to beating non-communicable diseases (IraPEN), a considerable number of patients with type2 diabetes had a history of forgoing care, and the most important reasons for forgoing care were related to the financial pressure and dissatisfaction with the quality of care. Therefore, not only more financial support programs should be carried out, but the quality of care should be improved.

Process evaluation of a brief messaging intervention to improve diabetes treatment adherence in sub-Saharan Africa

Background

The SMS text Adherence suppoRt for people with type 2 diabetes (StAR2D) intervention is a pragmatic randomised controlled trial, testing the effectiveness of brief text messaging for improving clinical outcomes and medication adherence. The intervention did not impact glycaemic control. We conducted a pre-and post-trial process evaluation alongside the StAR2D study in Malawi and South Africa, exploring the experiences and perceptions of patient participants, to better understand potential underlying reasons for the trial outcomes.

Methods

We employed a qualitative research design, including conducting semi structured in-depth interviews and focus groups at both trial sites. Purposive sampling was used to ensure representation of a wide range of patients with type 2 diabetes with regards to age, gender, ethnicity, language, and duration of diabetes. We interviewed the same participants at baseline and at the end of the trial. We used within-case and across-case thematic analysis to identify key themes.

Results

Brief messages delivered by text were acceptable and useful for addressing informational and support needs for participants. Some participants reported behaviour changes because of the text reminders and advice on a healthy lifestyle. Both participating in the trial and the messages were experienced as a source of support, caring, and motivation. Participants’ ability to act on the messages was limited. A common theme was frustration over the lack of ability to effectively control one’s blood glucose level. They reported a range of routinised, partial diabetes care adherence behaviours, shaped by complex and interacting individual, social, and health service factors. Participant responses and intervention impact were similar across sites, despite differences in health services.

Conclusion

This process evaluation provided context and insight into the factors influencing participants’ engagement with the text messaging intervention. The complex context in which patients take their diabetes medication, may explain in part, why brief text messaging may have been insufficient to bring about changes in health outcomes. The scale of need for self-management and health service support, suggests that health system strengthening, and other forms of self-management support should accompany digital communication interventions. (Current Controlled Trials ISRCTN70768808, registered 03/08/2015.)

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11552-8.

Comparison of measures of medication adherence from pharmacy dispensing and insurer claims data

OBJECTIVE

Medication nonadherence is linked to worsened clinical outcomes and increased costs. Existing system-level adherence interventions rely on insurer claims for patient identification and outcome measurement, yet suffer from incomplete capture and lags in data acquisition. Data from pharmacies regarding prescription filling, captured in retail dispensing, may be more efficient.

DATA SOURCES

Pharmacy fill and insurer claims data.

STUDY DESIGN

We compared adherence measured using pharmacy fill data to adherence using insurer claims data, expressed as proportion of days covered (PDC) over 12 months. Agreement was evaluated using correlation/validation metrics. We also explored the relationship between adherence in both sources and disease control using prediction modeling.

DATA EXTRACTION METHODS

Large pragmatic trial of cardiometabolic disease in an integrated delivery network.

PRINCIPAL FINDINGS

Among 1113 patients, adherence was higher in pharmacy fill (mean = 50.0%) versus claims data (mean = 47.4%), although they had moderately high correlation (R = 0.57, 95% CI: 0.53-0.61) with most patients (86.9%) being similarly classified as adherent or nonadherent. Sensitivity and specificity of pharmacy fill versus claims data were high (0.89, 95% CI: 0.86-0.91 and 0.80, 95% CI: 0.75-0.85). Pharmacy fill-based PDC predicted better disease control slightly more than claims-based PDC, although the difference was nonsignificant.

CONCLUSIONS

Pharmacy fill data may be an alternative to insurer claims for adherence measurement.

Association between Medication Non-Adherence and Increases in Hypertension and Type 2 Diabetes Medications

Importance: Medication non-adherence is highly costly and leads to worse disease control and outcomes. However, knowledge about medication adherence is often disconnected from prescribing decisions, and this disconnect may lead to inappropriate increases in medications and higher risks of adverse events. Objectives: To evaluate the association between medication non-adherence and the likelihood of increases in the intensity of medication regimens for two chronic conditions, hypertension and type 2 diabetes. Design: Cohort Study. Setting and Participants: This study used US national pharmacy claims data for Medicare Part D (ages ≥ 65) and commercial (ages 50-64) plans to evaluate medication adherence and its association with the likelihood of receiving an increase in medication intensity for patients with hypertension and/or oral diabetes medication fills. Patients had an index fill for hypertension (N = 2,536,638) and/or oral diabetes (N = 701,376) medications in January 2015. Medication fills in the follow-up period from August 2015 to December 2016 were assessed for increases in medication regimen intensity. Main Outcome(s) and Measure(s): The proportion of days covered (PDC) over 181 days was used as a measure for patient's medication adherence before a medication addition, medication increase, or dosage increase. Differences in the likelihood of experiencing an escalation in medication intensity was considered between patients with a PDC < 80% vs. PDC ≥ 80%. Results: Among Medicare Part D and commercial plan patients filling hypertension and/or oral diabetes medications, non-adherent patients were significantly more likely to experience an intensification of their medication regimens (p < 0.001). Conclusions and Relevance: This study found a significant association between non-adherence to medications and a higher likelihood of patients experiencing potentially inappropriate increases in treatment intensity. Sharing of objective patient refill data between retail pharmacies and prescribers can enable prescribers to have more targeted discussions with patients about their adherence and overall treatment plan. Additionally, it can increase safe medication prescribing and plausibly reduce adverse drug events and healthcare costs while improving patient health outcomes.

Impact of a motivational interviewing intervention targeting statins on adherence to concurrent hypertension or diabetes medications

OBJECTIVE

This study explored if a motivational interviewing intervention customized for statins impacted adherence to concomitantly used antidiabetic/antihypertensive medications.

METHODS

The intervention was conducted among patients with a history of suboptimal adherence to statins and included 152 patients in intervention and 304 controls. This retrospective study design identified patients with claims for statins and either antidiabetic/antihypertensive medications. The outcome variable was adherence, measured as proportion of days covered ≥ 0.80, to antidiabetic/antihypertensive medications. Multivariable linear and logistic regression evaluated the effect of intervention on adherence to antidiabetic/antihypertensive medications during the 6 months post-intervention.

RESULTS

The antidiabetic group had 53 intervention patients and 102 controls. The antihypertensive group had 80 intervention patients and 159 controls. There was no significant improvement in adherence for antidiabetic/antihypertensive medications following the intervention. Adherence at baseline was a significant predictor of adherence post-intervention in the antidiabetic (OR = 6.5;P < 0.0001) and antihypertensive (OR = 4.1; P = 0.0001 & β = 0.09; P = 0.008) users. Physician specialty (OR = 3.902; P = 0.01& β = 0.09; P = 0.015) among antidiabetic users and age >70 years (OR = 2.148; P = 0.025) among antihypertensive users were predictors of adherence.

CONCLUSION

The intervention targeting statin did not significantly improve antihypertensive/antidiabetic adherence.

PRACTICE IMPLICATIONS

Targeted interventions tailored to patient past adherence and specific medications should be explored.

A study protocol for a feasibility trial of telephone-delivered Adherence Therapy for adults with type 2 diabetes

AIMS

Adherence therapy is a candidate intervention to improve medication adherence and clinical outcomes in patients with type 2 diabetes. The feasibility of conducting a trial of adherence therapy in this population has not been established. The objective of this study is therefore to test the feasibility of conducting a randomized controlled trial of adherence therapy in a Middle Eastern context.

DESIGN

A single-centre randomized controlled feasibility trial of adherence therapy in patients with type 2 diabetes.

METHODS

We will undertake an initial cultural adaptation of a telephone-delivered form of adherence therapy in four patients in a Middle Eastern context. Our subsequent feasibility trial will aim to recruit 40 non-adherent diabetic patients that will be randomly allocated to receive eight weekly 30-min telephone adherence therapy sessions delivered by a diabetes educator versus treatment as usual. Key outcomes of interest include the number of patients invited to take part in the trial that consent to participate and then go on to complete treatment.

RESULT

The findings of this study will determine the feasibility of undertaking a full randomized controlled trial of adherence therapy in patients with type 2 diabetes.

Peer coach delivered storytelling program improved diabetes medication adherence: A cluster randomized trial

BACKGROUND

Because medication adherence is linked to better diabetes outcomes, numerous interventions have aimed to improve adherence. However, suboptimal adherence persists and necessitate continued research into intervention strategies. This study evaluated the effectiveness of an intervention that combined storytelling and peer support to improve medication adherence and health outcomes in adults with diabetes.

METHODS

Living Well with Diabetes was a cluster randomized controlled trial. Intervention participants received a six-month, 11-session peer-delivered behavioral diabetes self-care program over the phone. Control participants received a self-paced general health program. Outcomes were changes in medication adherence and physiologic measures (hemoglobin A1c, systolic blood pressure, low-density lipoprotein cholesterol, body mass index).

RESULTS

Of the 403 participants with follow-up data, mean age was 57 (±SD 11), 78% were female, 91% were African American, 56.4% had high school education or less, and 70% had an annual income of < $20,000. At follow-up, compared to controls, intervention participants had greater improvement in medication adherence (β = -0.25 [95% CI -0.35, -0.15]). Physiologic measures did not change significantly in either group. Intervention participants had significant improvements in beliefs about the necessity of medications (β = 0.87 [95% CI 0.27, 1.47]) concerns about the negative effects of medication (β = -0.91 [95% CI -1.35, -0.47]), and beliefs that medications are harmful (β = -0.50 [95% CI -0.89, -0.10]). In addition, medication use self-efficacy significantly improved in intervention participants (β = 1.0 [95% CI 0.23, 1.76]). 473 individuals were enrolled in the study and randomized.

DISCUSSION

Living Well intervention resulted in improved medication adherence, medication beliefs, and medication use self-efficacy but not improved risk factor levels.

Non-persistence with anti-platelet therapy and long-term mortality after ischemic stroke: A nationwide study

Background

We tried to investigate the effect of non-persistence with antiplatelets after ischemic stroke on long-term all-cause mortality (ACM).

Methods and findings

We selected newly diagnosed ischemic stroke patients aged ≥20years who were newly treated with aspirin or clopidogrel from 2003–2010 Korean National Health Insurance Service-National Sample Cohort, a random sample of 2.2% of total population. Subjects were divided into two pairs of groups according to persistence with antiplatelets at 6 and 12 months: those who discontinued antiplatelets within 6 months (DA6M) and those who continued them for 6 or months or more (CA6M); and those who discontinued antiplatelets within 12 months (DA12M) and those who continued them for 12 months or more (CA12M). Those who died within 6 months among DA6M and those who died within 12 months among DA12M were excluded along with those with medication possession ratio<80% among CA6M and CA12M. Subjects were followed-up until death or December 31, 2013. Among 3,559 total subjects, DA6M were 1,080 and CA6M were 2,479 while, out of 3,628 total patients, DA12M were 1,434 and CA12M were 2,194. The risks of ACM [adjusted hazard ratio (aHR), 2.25; 95% confidence interval (CI), 1.94–2.61], cerebro-cardiovascular disease (CVD) death (aHR, 2.52; 95% CI, 1.96–3.24) and non-CVD death (aHR, 2.11; 95% CI, 1.76–2.64) of DA6M were all significantly increased compared to CA6M. DA12M also had significantly higher risks of ACM (aHR, 1.93; 95% CI, 1.65–2.25), CVD mortality (aHR, 2.13; 95% CI; 1.63–2.77) and non-CVD mortality (aHR, 1.83;95% CI 1.51–2.22) than DA12M but aHRs were lower than that between DA6M and CA6M. The difference rates of ACM, CVD death, and non-CVD death between non-persistent and persistent groups all continuously widened over time but the degree of difference was gradually decreased.

Conclusions

Maintaining antiplatelets for the first 12 months after ischemic stroke reduces long-term risks of both CVD death and non-CVD death.

Depression and antecedent medication adherence in a cohort of new metformin users

AIMS

The association between depression and poor medication adherence is based on cross-sectional studies and cohort studies that measure adherence rates after depression status is determined. However, depressive symptoms occur well before diagnosis. This study examined adherence patterns in the year before a depressive episode.

METHODS

This retrospective cohort study followed new metformin users identified in Alberta Health's administrative data between 2008 and 2018. Depressive episodes starting ≥1 year after metformin initiation were identified using a validated case definition. Controls were randomly assigned a pseudo depression date. Adherence to oral antihyperglycemic medications was estimated using proportion of days covered (PDC) and group-based trajectory models to explore the association between depression and poor adherence (PDC<0.8).

RESULTS

A depressive episode occurred in 17,418 (10.6%) of 165,056 new metformin users. Individuals with depression were more likely to have poor adherence compared to controls (adjusted odds ratio 1.21; 95% CI 1.17, 1.26). Five trajectories were identified: nearly perfect adherence (PDC >0.95 [34.8% of cohort]), discontinued (PDC=0 [18.3% of cohort], poor initial adherence (PDC 0.75) that declined either rapidly (9.2% of cohort) or gradually (30.1% of cohort), and poor initial adherence (PDC 0.26) that increased gradually (7.6% of cohort). Individuals with depression were more likely to be in one of the four trajectories of poor adherence compared to controls (adjusted odds ratio 1.24; 95% CI 1.19-1.29).

CONCLUSIONS

Poor medication adherence occurs in the year before a depressive episode; therefore, poor medication use patterns could be used as an early warning sign for depression.

The Clinical Utility and Ecological Validity of the Medication Management Ability Assessment in Older Adults with and without Dementia

OBJECTIVE

Older adults are susceptible to medication nonadherence, which may signify functional decline. Thus, performance-based proxies of medication-taking behavior may help diagnose dementia. We assessed the Medication Management Ability Assessment's (MMAA) clinical utility and ecological validity.

METHOD

This was a retrospective chart review of 180 outpatients (age = 72 ± 8 years) who completed the MMAA during clinical evaluations. Forty-seven were cognitively normal (CN), 103 had mild cognitive impairment (MCI), and 30 had dementia. Most (136) were independent in medication management, whereas 28 were assisted and 16 were dependent. Kruskal-Wallis tests assessed whether MMAA scores differed by diagnosis and independence. Receiver operating characteristic (ROC) analyses identified diagnostic cut-offs. Classification accuracy estimates were derived.

RESULTS

MMAA performance differed across diagnosis as expected (p's < .001). Those who were independent in medication management outperformed assisted and dependent counterparts (p's < .001). Assisted and dependent cases were no different. At a cut-off = 23, the MMAA was good-to-strong in distinguishing dementia from CN cases (Sn = 0.96, Sp = 0.83), dementia from MCI (Sn = 0.70, Sp = 0.83), and dementia from functionally unimpaired cases (Sn = 0.78, Sp = 0.83). At a cut-off = 27, it had good sensitivity but weaker specificity when distinguishing both MCI and all cognitively impaired patients (MCI and dementia) from CN cases (Sn = 0.81, Sp = 0.66 and Sn = 0.81, Sp = 0.72, respectively).

CONCLUSIONS

The MMAA has ecological validity and clinical utility in identifying dementia. Its inclusion in neuropsychological practice may be especially useful when medication mismanagement is suspected.

Choice across 10 pharmacologic combination strategies for type 2 diabetes: a cost-effectiveness analysis

BACKGROUND

Clinical guidelines recommend a stepped-escalation treatment strategy for type 2 diabetes (T2DM). Across multiple treatment strategies varying in efficacy and costs, no clinical or economic studies directly compared them. This study aims to estimate and compare the cost-effectiveness of 10 commonly used pharmacologic combination strategies for T2DM.

METHODS

Based on Chinese guideline and practice, 10 three-stepwise add-on strategies were identified, which start with metformin, then switch to metformin plus one oral drug (i.e., sulfonylurea, thiazolidinedione, α-glucosidase inhibitor, glinide, or DPP-4 inhibitor) as second line, and finally switch to metformin plus one injection (i.e., insulin or GLP-1 receptor agonist) as third line. A cohort of 10,000 Chinese patients with newly diagnosed T2DM was established. From a healthcare system perspective, the Cardiff model was used to estimate the cost-effectiveness of the strategies, with clinical data sourced from a systematic review and indirect treatment comparison of 324 trials, costs from claims data of 1164 T2DM patients, and utilities from an EQ-5D study. Outcome measures include costs, quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios (ICERs), and net monetary benefits (NMBs).

RESULTS

Over 40-year simulation, the costs accumulated for a patient ranged from $7661 with strategy 1 to $14,273 with strategy 10, while the QALY gains ranged from 13.965 with strategy 1 to 14.117 with strategy 8. Strategy 7 was dominant over seven strategies (strategies 2~6, 9~10) with higher QALYs but lower costs. Additionally, at a willingness-to-pay threshold of $30,787/QALY (i.e., 3 times GDP/capita for China), strategy 7 was cost-effective compared with strategy 1 (ICER of strategy 7 vs. 1, $3371/QALY) and strategy 8 (ICER of strategy 8 vs. 7, $132,790/QALY). Ranking the strategies by ICERs and NMBs, strategy 7 provided the best value for money when compared to all other strategies, followed by strategies 5, 9, 8, 1, 3, 6, 10, 2, and 4. Scenario analyses showed that patients insist on pharmacologic treatments increased their QALYs (0.456~0.653) at an acceptable range of cost increase (ICERs, $1450/QALY~$12,360/QALY) or even at cost saving compared with those not receive treatments.

CONCLUSIONS

This study provides evidence-based references for diabetes management. Our findings can be used to design the essential drug formulary, infer clinical practice, and help the decision-maker design reimbursement policy.

Lasting Effects of a Community-Based Self-Management Intervention for Patients With Type 2 Diabetes in China: Outcomes at 2-Year Follow-up of a Randomized Trial

This research is to evaluate the lasting effects of a community-based self-management intervention for patients with type 2 diabetes at 2-year follow-up in China. Five hundred patients with diabetes were recruited and randomly divided into intervention group and control group. Eight times standardized self-management intervention group activities were conducted. The results of physical examination, biochemical laboratory examination, health behavior, and self-efficacy information were collected before intervention, 3 months after intervention, and 2 years after intervention. The total score for self-efficacy in the intervention group increased from 96.12 ± 17.48 to 112.90 ± 14.58 after intervention and decreased after 2 years (106.98 ± 18.03; F = 6.64, P = .0014). The number of days of self-blood glucose monitoring in the intervention group was increased from 1 day per week to 2 days per week after intervention, and 2 days per week at 2-year follow-up (F = 8.02, P = .0003). The frequency of average number of aerobic exercises in the intervention group increased from 6 days per week to 7 days per week after intervention and was 7 days per week at 2-year follow-up (F = 3.63, P = .0269). Community-based self-management group intervention for patients with diabetes has long-term effects.

Everyday objects and spaces: How they afford resilience in diabetes routines

Thirty million Americans currently have diabetes, and a substantial portion do not reach the goals of clinical treatment. This is in part due to the complex barriers to effective self-care faced by people with diabetes. This study uses a patient work perspective, focusing on the everyday, lived experience of managing diabetes. Our primary research goal was to explore how the work of self-care is embedded in the other routines of everyday living. We found that everyday objects and spaces were instrumental in the incorporation of diabetes work into daily routines. Objects anchored diabetes tasks by linking illness-specific artifacts to space and time (e.g. a morning routine), and by enabling the performance on diabetes tasks while on the move in either planned or unplanned ways.