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Schulz M, Laufs U. Not obtaining a medication the first time it is prescribed: primary non-adherence to cardiovascular pharmacotherapy. Clin Res Cardiol 2024; 113:1103-1116. [PMID: 37209148 PMCID: PMC11269373 DOI: 10.1007/s00392-023-02230-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 05/08/2023] [Indexed: 05/22/2023]
Abstract
Primary medication non-adherence describes the situation when a first prescription for a new medication is never filled. Primary non-adherence is an important, yet understudied aspect of reduced effectiveness of pharmacotherapy. This review summarizes the frequency, impact, reasons, predictors, and interventions regarding primary non-adherence to cardiovascular/cardiometabolic drugs. The current literature reveals a high prevalence of primary non-adherence. The individual risk of primary non-adherence is determined on multiple factors, e.g., primary non-adherence of lipid-lowering drugs is higher compared to antihypertensive medications. However, the overall rate of primary non-adherence is > 10%. Additionally, this review identifies specific areas for research to better understand why patients forgo evidence-based beneficial pharmacotherapy and to explore targeted interventions. At the same time, measures to reduce primary non-adherence-once proven to be effective-may represent an important new opportunity to reduce cardiovascular diseases.
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Affiliation(s)
- Martin Schulz
- Institute of Pharmacy, Freie Universität Berlin, Kelchstraße 31, 12169, Berlin, Germany.
- Drug Commission of German Pharmacists (AMK), Heidestraße 7, 10557, Berlin, Germany.
- German Institute for Drug Use Evaluation (DAPI), Heidestraße 7, 10557, Berlin, Germany.
| | - Ulrich Laufs
- Department of Cardiology, University of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
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Fiorini G, Pellegrini G, Franchi M, Rigamonti AE, Marazzi N, Sartorio A, Corrao G, Cella SG. Evaluation of adherence to pharmacological treatments by undocumented migrants with chronic diseases: a 10-year retrospective cohort study. BMJ Open 2024; 14:e078431. [PMID: 38724060 PMCID: PMC11086564 DOI: 10.1136/bmjopen-2023-078431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 04/19/2024] [Indexed: 05/12/2024] Open
Abstract
OBJECTIVES To investigate the time course of medication adherence and some of the factors involved in this process in undocumented migrants with chronic diseases. DESIGN Retrospective cohort study. SETTING A big non-governmental organisation in Milano, Italy, giving medical assistance to undocumented migrants. PARTICIPANTS 1918 patients, 998 females and 920 males, with at least one chronic condition (diabetes, cardiovascular diseases (CVDs), mental health disorders) seen over a period of 10 years (2011-2020). Their mean age was 49.2±13 years. RESULTS Adherence to medications decreased over 1 year in all patients. This was more evident during the first 2 months of treatment. Patients on only one medication were less adherent than those on more than one medication; at 6 months the percentage of patients with high adherence was 33% vs 57% (p<0.0001) for diabetes, 15% vs 46% (p<0.0001) for mental disorders and 35% vs 59% (p<0.0001) for CVDs. Patients with mental disorders had the lowest adherence: 25% at 6 months and 3% at 1 year. Mental disorders, when present as comorbidities, greatly reduced the probability of being highly adherent: risk ratio (RR) 0.72 (95% CI 0.57 to 0.91; p=0.006) at 3 months, RR 0.77, (95% CI 0.59 to 1.01; p=0.06) at 6 months, RR 0.35 (95% CI 0.13 to 0.94; p=0.04) at 1 year. This was especially evident for patients with CVDs, whose percentage of high adherents decreased to 30% (p=0.0008) at 6 months and to 3% (p=0.01) at 1 year. We also noted that highly adherent patients usually were those most frequently seen by a doctor. CONCLUSIONS Interventions to increase medication adherence of undocumented migrants with chronic diseases are necessary, particularly in the first 2 months after beginning treatment. These should be aimed at people-centred care and include more outpatient consultations. Educational interventions should especially be taken into consideration for patients on monotherapy.
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Affiliation(s)
- Gianfrancesco Fiorini
- Istituti Clinici Zucchi Spa, Monza, Italy
- Università degli Studi di Milano, Milano, Italy
| | | | | | | | - Nicoletta Marazzi
- Istituto Auxologico Italiano Istituto di Ricovero e Cura a Carattere Scientifico, Milano, Italy
| | - Alessandro Sartorio
- Istituto Auxologico Italiano Istituto di Ricovero e Cura a Carattere Scientifico, Milano, Italy
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Corral-Partearroyo C, Sánchez-Viñas A, Gil-Girbau M, Peñarrubia-María MT, Aznar-Lou I, Gallardo-González C, Olmos-Palenzuela MDC, Rubio-Valera M. Complex multidisciplinary intervention to improve Initial Medication Adherence to cardiovascular disease and diabetes treatments in primary care (the IMA-cRCT study): mixed-methods process evaluation protocol. BMJ Open 2022; 12:e067468. [PMID: 36316078 PMCID: PMC9628671 DOI: 10.1136/bmjopen-2022-067468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Medication non-initiation, or primary non-adherence, is a persistent public health problem that increases the risk of adverse clinical outcomes. The initial medication adherence (IMA) intervention is a complex multidisciplinary intervention to improve adherence to cardiovascular and diabetes treatments in primary care by empowering the patient and promoting informed prescriptions based on shared decision-making. This paper presents the development and implementation strategy of the IMA intervention and the process evaluation protocol embedded in a cluster randomised controlled trial (the IMA-cRCT) to understand and interpret the outcomes of the trial and comprehend the extent of implementation and fidelity, the active mechanisms of the IMA intervention and in what context the intervention is implemented and works. METHODS AND ANALYSIS We present the protocol for a mixed-methods process evaluation including quantitative and qualitative methods to measure implementation and fidelity and to explore the active mechanisms and the interactions between the intervention, participants and its context. The process evaluation will be conducted in primary care centres and community pharmacies from the IMA-cRCT, and participants include healthcare professionals (general practitioners, nurses and community pharmacists) as well as patients. Quantitative data collection methods include data extraction from the intervention operative records, patient clinical records and participant feedback questionnaires, whereas qualitative data collection involves semistructured interviews, focus groups and field diaries. Quantitative and qualitative data will be analysed separately and triangulated to produce deeper insights and robust results. ETHICS AND DISSEMINATION Ethical approval has been obtained from the Research Ethics Comittee (CEIm) at IDIAP Jordi Gol (codeCEIm 21/051 P). Findings will be disseminated through publications and conferences, as well as presentations to healthcare professionals and stakeholders from healthcare organisations. TRIAL REGISTRATION NUMBER NCT05026775.
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Affiliation(s)
- Carmen Corral-Partearroyo
- Health Technology Assessment in Primary Care and Mental Health (PRISMA) Research Group, Parc Sanitari Sant Joan de Deu, Institut de Recerca Sant Joan de Deu, St Boi de Llobregat, Catalunya, Spain
- Department of Paediatrics, Obstetrics, Gynaecology and Preventive Medicine, Universitat Autonoma de Barcelona, Bellaterra, Catalunya, Spain
| | - Alba Sánchez-Viñas
- Health Technology Assessment in Primary Care and Mental Health (PRISMA) Research Group, Parc Sanitari Sant Joan de Deu, Institut de Recerca Sant Joan de Deu, St Boi de Llobregat, Catalunya, Spain
- Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Catalunya, Spain
| | - Montserrat Gil-Girbau
- Health Technology Assessment in Primary Care and Mental Health (PRISMA) Research Group, Parc Sanitari Sant Joan de Deu, Institut de Recerca Sant Joan de Deu, St Boi de Llobregat, Catalunya, Spain
- Research Network on Chronicity, Primary Care and Health Promotion (RICAPPS), Barcelona, Spain
| | - Maria Teresa Peñarrubia-María
- Health Technology Assessment in Primary Care and Mental Health (PRISMA) Research Group, Parc Sanitari Sant Joan de Deu, Institut de Recerca Sant Joan de Deu, St Boi de Llobregat, Catalunya, Spain
- Unitat de Suport a la Recerca Regió Metropolitana Sud, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Catalunya, Spain
| | - Ignacio Aznar-Lou
- Health Technology Assessment in Primary Care and Mental Health (PRISMA) Research Group, Parc Sanitari Sant Joan de Deu, Institut de Recerca Sant Joan de Deu, St Boi de Llobregat, Catalunya, Spain
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Comunidad de Madrid, Spain
| | - Carmen Gallardo-González
- Health Technology Assessment in Primary Care and Mental Health (PRISMA) Research Group, Parc Sanitari Sant Joan de Deu, Institut de Recerca Sant Joan de Deu, St Boi de Llobregat, Catalunya, Spain
- Unitat de Suport a la Recerca Regió Metropolitana Sud, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Catalunya, Spain
| | - María Del Carmen Olmos-Palenzuela
- Primary Care Centre Bartomeu Fabrés Anglada, Institut Català de la Salut Gerència Territorial Metropolitana Sud, Barcelona, Catalunya, Spain
| | - Maria Rubio-Valera
- Health Technology Assessment in Primary Care and Mental Health (PRISMA) Research Group, Parc Sanitari Sant Joan de Deu, Institut de Recerca Sant Joan de Deu, St Boi de Llobregat, Catalunya, Spain
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Comunidad de Madrid, Spain
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Sánchez-Viñas A, Corral-Partearroyo C, Gil-Girbau M, Peñarrubia-María MT, Gallardo-González C, Olmos-Palenzuela MDC, Aznar-Lou I, Serrano-Blanco A, Rubio-Valera M. Effectiveness and cost-effectiveness of an intervention to improve Initial Medication Adherence to treatments for cardiovascular diseases and diabetes in primary care: study protocol for a pragmatic cluster randomised controlled trial and economic model (the IMA-cRCT study). BMC PRIMARY CARE 2022; 23:170. [PMID: 35790915 PMCID: PMC9255541 DOI: 10.1186/s12875-022-01727-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 05/04/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Between 2 and 43% of patients who receive a new prescription in PC do not initiate their treatments. Non-initiation is associated with poorer clinical outcomes, more sick leave and higher costs to the healthcare system. Existing evidence suggests that shared decision-making positively impacts medication initiation. The IMA-cRCT assesses the effectiveness of the IMA intervention in improving adherence and clinical parameters compared to usual care in patients with a new treatment for cardiovascular disease and diabetes prescribed in PC, and its cost-effectiveness, through a cRCT and economic modelling. METHODS The IMA intervention is a shared decision-making intervention based on the Theoretical Model of Non-initiation. A cRCT will be conducted in 24 PC teams in Catalonia (Spain), randomly assigned to the intervention group (1:1), and community pharmacies in the catchment areas of the intervention PC teams. Healthcare professionals in the intervention group will apply the intervention to all patients who receive a new prescription for cardiovascular disease or diabetes treatment (no other prescription from the same pharmacological group in the previous 6 months). All the study variables will be collected from real-world databases for the 12 months before and after receiving a new prescription. Effectiveness analyses will assess impact on initiation, secondary adherence, cardiovascular risk, clinical parameters and cardiovascular events. Cost-effectiveness analyses will be conducted as part of the cRCT from a healthcare and societal perspective in terms of extra cost per cardiovascular risk reduction and improved adherence; all analyses will be clustered. Economic models will be built to assess the long-term cost-effectiveness of the IMA intervention, in terms of extra cost for gains in QALY and life expectancy, using clinical trial data and data from previous studies. DISCUSSION The IMA-cRCT represents an innovative approach to the design and evaluation of behavioural interventions that use the principles of complex interventions, pragmatic trials and implementation research. This study will provide evidence on the IMA intervention and on a new methodology for developing and evaluating complex interventions. The results of the study will be disseminated among stakeholders to facilitate its transferability to clinical practice. TRIAL REGISTRATION ClinicalTrials.gov, NCT05026775 . Registered 30th August 2021.
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Affiliation(s)
- Alba Sánchez-Viñas
- Health Technology Assessment in Primary Care and Mental Health (PRISMA) Research Group, Institut de Recerca Sant Joan de Déu, Santa Rosa 39-57, 08950, Esplugues de Llobregat, Spain
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, c. Casanova 143, 08036, Barcelona, Spain
| | - Carmen Corral-Partearroyo
- Health Technology Assessment in Primary Care and Mental Health (PRISMA) Research Group, Institut de Recerca Sant Joan de Déu, Santa Rosa 39-57, 08950, Esplugues de Llobregat, Spain
- Department of Paediatrics, Obstetrics, Gynaecology and Preventive Medicine, Univ Autonoma de Barcelona, Bellaterra, Spain
| | - Montserrat Gil-Girbau
- Health Technology Assessment in Primary Care and Mental Health (PRISMA) Research Group, Institut de Recerca Sant Joan de Déu, Santa Rosa 39-57, 08950, Esplugues de Llobregat, Spain
- Parc Sanitari Sant Joan de Déu, Doctor Antoni Pujadas 42, 08830, Sant Boi de Llobregat, Spain
| | - M Teresa Peñarrubia-María
- Health Technology Assessment in Primary Care and Mental Health (PRISMA) Research Group, Institut de Recerca Sant Joan de Déu, Santa Rosa 39-57, 08950, Esplugues de Llobregat, Spain
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- Centre d'Atenció Primària Bartomeu Fabrés Anglada, Direcció D'Atenció Primària Regió Metropolitana Sud, Institut Català de la Salut, Barcelona, Spain
- Unitat de Suport a la Recerca Regió Metropolitana Sud, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Carmen Gallardo-González
- Health Technology Assessment in Primary Care and Mental Health (PRISMA) Research Group, Institut de Recerca Sant Joan de Déu, Santa Rosa 39-57, 08950, Esplugues de Llobregat, Spain
- Centre d'Atenció Primària Bartomeu Fabrés Anglada, Direcció D'Atenció Primària Regió Metropolitana Sud, Institut Català de la Salut, Barcelona, Spain
- Unitat de Suport a la Recerca Regió Metropolitana Sud, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - María-Del-Carmen Olmos-Palenzuela
- Health Technology Assessment in Primary Care and Mental Health (PRISMA) Research Group, Institut de Recerca Sant Joan de Déu, Santa Rosa 39-57, 08950, Esplugues de Llobregat, Spain
- Centre d'Atenció Primària Bartomeu Fabrés Anglada, Direcció D'Atenció Primària Regió Metropolitana Sud, Institut Català de la Salut, Barcelona, Spain
| | - Ignacio Aznar-Lou
- Health Technology Assessment in Primary Care and Mental Health (PRISMA) Research Group, Institut de Recerca Sant Joan de Déu, Santa Rosa 39-57, 08950, Esplugues de Llobregat, Spain.
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain.
| | - Antoni Serrano-Blanco
- Health Technology Assessment in Primary Care and Mental Health (PRISMA) Research Group, Institut de Recerca Sant Joan de Déu, Santa Rosa 39-57, 08950, Esplugues de Llobregat, Spain
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- Parc Sanitari Sant Joan de Déu, Doctor Antoni Pujadas 42, 08830, Sant Boi de Llobregat, Spain
| | - Maria Rubio-Valera
- Health Technology Assessment in Primary Care and Mental Health (PRISMA) Research Group, Institut de Recerca Sant Joan de Déu, Santa Rosa 39-57, 08950, Esplugues de Llobregat, Spain
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- Parc Sanitari Sant Joan de Déu, Doctor Antoni Pujadas 42, 08830, Sant Boi de Llobregat, Spain
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Thirunavukkarasu A, Naser Abdullah Alshahrani A, Mazen Abdel-Salam D, Homoud Al-Hazmi A, Farhan ALruwaili B, Awad Alsaidan A, Narapureddy BR, Muteb AL-Ruwaili A, Ghuwayli aljabri F, Khalaf Albalawi R, Alanazi KAF. Medication Adherence Among Hypertensive Patients Attending Different Primary Health Centers in Abha, Saudi Arabia: A Cross-Sectional Study. Patient Prefer Adherence 2022; 16:2835-2844. [PMID: 36303595 PMCID: PMC9592733 DOI: 10.2147/ppa.s388365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 10/12/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Optimal blood pressure control is achieved by medication adherence. This will reduce the risk of associated morbidities and mortalities. The present study aimed to determine medication adherence and its associated factors among hypertensive patients attending different primary health centers (PHC) in Abha, Saudi Arabia (KSA). METHODS A cross-sectional study was conducted among ten different PHCs in Abha, KSA. Simple random sampling procedure was utilized to choose 400 participants. A structured anonymous questionnaire was used in the present study. Analysis of the data was done using the SPSS program, version 23. A logistic regression statistical test was applied to identify the independent associated factors of medication adherence. Furthermore, we have applied Spearman's test to find the correlation between overall B-IPQ score and medication adherence score. RESULTS A total of 400 hypertensive patients responded in the present survey. More than one-third of the participants (36.3%) were in the high adherence category group, while the remaining participants (63.7%) were either low or medium adherence category. The binary logistic regression analysis revealed that low and medium adherence category is significantly associated with age (adjusted odds ratio [AOR] = 0.96, 95% CI =0.93-0.99, p = 0.021), married participants (AOR = 0.42, 95% CI =0.33-0.58, p = 0.001), residing at village (AOR = 1.49, 95% CI =1.14-1.73, p = 0.038), and participants with monthly family income of 5000 to 7000 SAR (AOR = 3.06, 95% CI =1.62-5.79, p = 0.001). A negligible positive correlation was revealed between illness perception and medication adherence. CONCLUSION The present study revealed that hypertensive patients poorly adhere to their antihypertensive medications. This low adherence is significantly associated with the age, monthly income, people living in rural areas, and married participants. The present study results recommend sustained efforts to implement health education programs and awareness-raising interventions targeted at hypertensive patients.
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Affiliation(s)
- Ashokkumar Thirunavukkarasu
- Department of Community and Family Medicine, College of Medicine, Jouf University, Sakaka, Saudi Arabia
- Correspondence: Ashokkumar Thirunavukkarasu, Email
| | - Abdullah Naser Abdullah Alshahrani
- Department of Community and Family Medicine, College of Medicine, Jouf University, Sakaka, Saudi Arabia
- Department of Public Health, Asir Health Affairs, Asir Region, Saudi Arabia
| | - Doaa Mazen Abdel-Salam
- Department of Public Health and Community Medicine, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmad Homoud Al-Hazmi
- Department of Community and Family Medicine, College of Medicine, Jouf University, Sakaka, Saudi Arabia
| | - Bashayer Farhan ALruwaili
- Department of Community and Family Medicine, College of Medicine, Jouf University, Sakaka, Saudi Arabia
| | - Aseel Awad Alsaidan
- Department of Community and Family Medicine, College of Medicine, Jouf University, Sakaka, Saudi Arabia
| | - Bayapa Reddy Narapureddy
- Department of Public Health and Community Medicine, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Aliyah Muteb AL-Ruwaili
- Department of Public Health, Ministry of Health, Jouf Health Affairs, Sakaka, Aljouf, Saudi Arabia
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Carbonell-Duacastella C, Rubio-Valera M, Marqués-Ercilla S, Peñarrubia-María MT, Gil-Girbau M, Garcia-Cardenas V, Pasarín MI, Parody-Rúa E, Aznar-Lou I. Pediatric Medication Noninitiation in Spain. Pediatrics 2022; 149:184034. [PMID: 34957504 PMCID: PMC9647521 DOI: 10.1542/peds.2020-034371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/06/2021] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES To estimate medication noninitiation prevalence in the pediatric population and identify the explanatory factors underlying this behavior. METHODS Observational study of patients (<18 years old) receiving at least 1 new prescription (28 pharmaceutical subgroups; July 2017 to June 2018) in Catalonia, Spain. A prescription was considered new when there was no prescription for the same pharmaceutical subgroup in the previous 6 months. Noninitiation occurred when a prescription was not filled within 1 month or 6 months (sensitivity analysis). Prevalence was estimated as the proportion of total prescriptions not initiated. To identify explanatory factors, a multivariable multilevel logistic regression model was used, and adjusted odds ratios were reported. RESULTS Overall, 1 539 003 new prescriptions were issued to 715 895 children. The overall prevalence of 1-month noninitiation was 9.0% (ranging from 2.6% [oral antibiotics] to 21.5% [proton pump inhibitors]), and the prevalence of 6-month noninitiation was 8.5%. Noninitiation was higher in the youngest and oldest population groups, in children from families with a 0% copayment rate (vulnerable populations) and those with conditions from external causes. Out-of-pocket costs of drugs increased the odds of noninitiation. The odds of noninitiation were lower when the prescription was issued by a pediatrician (compared with a primary or secondary care clinician). CONCLUSIONS The prevalence of noninitiation of medical treatments in pediatrics is high and varies according to patients' ages and medical groups. Results suggest that there are inequities in access to pharmacologic treatments in this population that must be taken into account by health care planners and providers.
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Affiliation(s)
- Cristina Carbonell-Duacastella
- Institut de Recerca Sant Joan de Déu (IRSJD), Esplugues de Llobregat, Spain,Teaching, Research & Innovation Unit, Parc Sanitari Sant Joan de Déu, Barcelona, Spain,Center for Biomedical Research in Epidemiology and Public Health Network (CIBERESP), Madrid, Spain,School of Pharmacy, University of Barcelona, Barcelona, Spain
| | - Maria Rubio-Valera
- Institut de Recerca Sant Joan de Déu (IRSJD), Esplugues de Llobregat, Spain,Teaching, Research & Innovation Unit, Parc Sanitari Sant Joan de Déu, Barcelona, Spain,Center for Biomedical Research in Epidemiology and Public Health Network (CIBERESP), Madrid, Spain,Address correspondence to Maria Rubio-Valera, Parc Sanitari Sant Joan de Deu, Carrer Pablo Picasso 12, 08830, Sant Boi de Llobregat, Barcelona, Spain. E-mail:
| | - Sílvia Marqués-Ercilla
- Basic Health Area (ABS) Bartomeu Fabrés Anglada, Direcció d'Atenció Primària Costa Ponent, Institut Català de la Salut, Gavà, Spain,Unitat de Suport a la Recerca Costa Ponent, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAP JGol), Barcelona, Spain
| | - Maria Teresa Peñarrubia-María
- Center for Biomedical Research in Epidemiology and Public Health Network (CIBERESP), Madrid, Spain,Basic Health Area (ABS) Bartomeu Fabrés Anglada, Direcció d'Atenció Primària Costa Ponent, Institut Català de la Salut, Gavà, Spain,Unitat de Suport a la Recerca Costa Ponent, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAP JGol), Barcelona, Spain
| | - Montserrat Gil-Girbau
- Institut de Recerca Sant Joan de Déu (IRSJD), Esplugues de Llobregat, Spain,Teaching, Research & Innovation Unit, Parc Sanitari Sant Joan de Déu, Barcelona, Spain,Primary Care Prevention and Health Promotion Network (redIAPP), Barcelona, Spain
| | - Victoria Garcia-Cardenas
- Graduate School of Health, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Maria Isabel Pasarín
- Center for Biomedical Research in Epidemiology and Public Health Network (CIBERESP), Madrid, Spain,Barcelona Public Health Agency (ASPB), Barcelona, Spain,Sant Pau Biomedical Research Institute, Barcelona, Spain,Department of Experimental and Health Sciences, Pompeu Fabra University, Barcelona, Spain
| | - Elizabeth Parody-Rúa
- Institut de Recerca Sant Joan de Déu (IRSJD), Esplugues de Llobregat, Spain,Teaching, Research & Innovation Unit, Parc Sanitari Sant Joan de Déu, Barcelona, Spain,Primary Care Prevention and Health Promotion Network (redIAPP), Barcelona, Spain
| | - Ignacio Aznar-Lou
- Institut de Recerca Sant Joan de Déu (IRSJD), Esplugues de Llobregat, Spain,Teaching, Research & Innovation Unit, Parc Sanitari Sant Joan de Déu, Barcelona, Spain,Center for Biomedical Research in Epidemiology and Public Health Network (CIBERESP), Madrid, Spain
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Peñarrubia-María MT, Gil-Girbau M, Gallardo-González MC, Aznar-Lou I, Serrano-Blanco A, Mendive Arbeloa JM, Garcia-Cardenas V, Sánchez-Viñas A, Rubio-Valera M. Non-initiation of prescribed medication from a Spanish health professionals' perspective: A qualitative exploration based on Grounded Theory. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:e213-e221. [PMID: 34080746 DOI: 10.1111/hsc.13431] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 02/24/2021] [Accepted: 04/13/2021] [Indexed: 06/12/2023]
Abstract
We explore, from the perspective of primary care health professionals, the motivations that lead patients to not initiate prescribed treatments, by developing a qualitative study in Spanish primary care. Six focus groups (N = 46) were conducted with general practitioners, nurse practitioners, social workers and community pharmacists and carried out in primary care (PC) of Barcelona Province, from April to July of 2018. The 46 participants were identified by three general practitioners and two pharmacists. In the interviews, the reasons for non-initiation of PC patients' medication were explored. Triangulated content analysis was performed. Patients' perspective, analysed in a previous study, and professionals' perspective agree on most of the factors that affect non-initiation. New factors were categorized into existent categories, confirming, and supplementing the model developed with patients. Health professionals identified some new factors which were not present in the patients' discourse, such as stigma related to the drug, hidden reasons for consultation, the role of nurses in prescription and support, the role of the pharmacy technician, illiteracy and lack of social support. The professionals confirm and expand on the Theoretical Model of Medication Non-Initiation. Primary care professionals should consider the factors described when prescribing a new medication. Knowledge contributed by the model should guide the design of interventions to improve initiation.
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Affiliation(s)
- Maria Teresa Peñarrubia-María
- Primary Care Centre Bartomeu Fabrés Anglada, Catalan Institute of Health, Primary Care Research Institute (IDIAP Jordi Gol), Barcelona, Spain
- Consortium for Biomedical Research in Epidemiology & Public Health (CIBERESP), Madrid, Spain
| | - Montserrat Gil-Girbau
- Sant Joan de Déu Research Institute, Esplugues de Llobregat, Spain
- Primary Care Prevention and Health Promotion Research Network (redIAPP), Madrid, Spain
| | - Mari Carmen Gallardo-González
- Primary Care Centre Bartomeu Fabrés Anglada, Catalan Institute of Health, Primary Care Research Institute (IDIAP Jordi Gol), Barcelona, Spain
- Primary Care Prevention and Health Promotion Research Network (redIAPP), Madrid, Spain
| | - Ignacio Aznar-Lou
- Consortium for Biomedical Research in Epidemiology & Public Health (CIBERESP), Madrid, Spain
- Sant Joan de Déu Research Institute, Esplugues de Llobregat, Spain
| | - Antoni Serrano-Blanco
- Consortium for Biomedical Research in Epidemiology & Public Health (CIBERESP), Madrid, Spain
- Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Spain
| | - Juan Manuel Mendive Arbeloa
- Primary Care Prevention and Health Promotion Research Network (redIAPP), Madrid, Spain
- Catalan Institute of Health, Barcelona, Spain
| | | | - Alba Sánchez-Viñas
- Consortium for Biomedical Research in Epidemiology & Public Health (CIBERESP), Madrid, Spain
- Sant Joan de Déu Research Institute, Esplugues de Llobregat, Spain
| | - Maria Rubio-Valera
- Consortium for Biomedical Research in Epidemiology & Public Health (CIBERESP), Madrid, Spain
- Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Spain
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8
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Yang C, Zhu S, Lee DTF, Chair SY. Interventions for improving medication adherence in community-dwelling older people with multimorbidity: A systematic review and meta-analysis. Int J Nurs Stud 2021; 126:104154. [PMID: 34953373 DOI: 10.1016/j.ijnurstu.2021.104154] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 11/29/2021] [Accepted: 12/01/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Multimorbidity is highly prevalent amongst older people. Compared with those with a single disease, older people with multimorbidity are more susceptible to medication nonadherence, which causes adverse health outcomes and increased health care costs. The effectiveness of interventions for improving medication adherence in this population is still unclear. OBJECTIVE To evaluate the effectiveness of interventions to improve medication adherence for community-dwelling older people with multimorbidity. DESIGN Systematic review and meta-analysis. DATA SOURCES Ten databases: Airiti Library, China National Knowledge Infrastructure, Cochrane CENTRAL, EBSCO CINAHL, OVID EMBASE, OVID MEDLINE, Proquest Central, PsycINFO, Wanfang Database and Web of Science Core Collection. REVIEW METHODS Studies evaluating the effects of interventions on medication adherence in community-dwelling older people with multimorbidity were included. Two researchers independently performed the study selection, data extraction and risk assessment. Intervention effects were pooled by random-effects meta-analysis. RESULTS A total of nine studies with 3,292 participants were included. Studies on self-management interventions revealed a significant and modest improvement in medication adherence (n = 3 studies; SMD 0.52; 95% CI 0.04 to 0.99; p = 0.03, I2 = 43%). Studies using electronic health interventions demonstrated a small yet significant benefit for medication adherence (n = 2 studies; SMD 0.22; 95% CI 0.02 to 0.42; p = 0.03, I2 = 0%). There was no pooled significant effect of medication review on medication adherence (n = 4 studies; SMD -0.03; 95% CI -0.21 to 0.15; p = 0.74, I2 = 68%). Most of the studies failed to yield a significant improvement in patients' health outcomes. CONCLUSIONS Self-management interventions and electronic health interventions might be effective in improving medication adherence for older people with multimorbidity. Future adherence interventions are needed to demonstrate improvements in medication adherence and health outcomes. PROSPERO REGISTRATION NUMBER CRD42020150500.
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Affiliation(s)
- Chen Yang
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China.
| | - Song Zhu
- Department of Thoracic Surgery, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Diana Tze Fan Lee
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Sek Ying Chair
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
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9
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Rzewuska M, Carolina Guidorizzi Zanetti A, Skea ZC, Moscovici L, Almeida de Oliveira C, Mazzoncini de Azevedo-Marques J. Mental-physical multimorbidity treatment adherence challenges in Brazilian primary care: A qualitative study with patients and their healthcare providers. PLoS One 2021; 16:e0251320. [PMID: 33983998 PMCID: PMC8118469 DOI: 10.1371/journal.pone.0251320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 04/26/2021] [Indexed: 11/26/2022] Open
Abstract
Improved understanding of multimorbidity (MM) treatment adherence in primary health care (PHC) in Brazil is needed to achieve better healthcare and service outcomes. This study explored experiences of healthcare providers (HCP) and primary care patients (PCP) with mental-physical MM treatment adherence. Adults PCP with mental-physical MM and their primary care and community mental health care providers were recruited through maximum variation sampling from nine cities in São Paulo State, Southeast of Brazil. Experiences across quality domains of the Primary Care Assessment Tool-Brazil were explored through semi-structured in-depth interviews with 19 PCP and 62 HCP, conducted between April 2016 and April 2017. Through thematic conent analysis ten meta-themes concerning treatment adherence were developed: 1) variability and accessibility of treatment options available through PHC; 2) importance of coming to terms with a disease for treatment initation; 3) importance of person-centred communication for treatment initiation and maintenance; 4) information sources about received medication; 5) monitoring medication adherence; 6) taking medication unsafely; 7) perceived reasons for medication non-adherence; 8) most challenging health behavior change goals; 9) main motives for initiation or maintenance of treatment; 10) methods deployed to improve treatment adherence. Our analysis has advanced the understanding of complexity inherent to treatment adherence in mental-physical MM and revealed opportunities for improvement and specific solutions to effect adherence in Brazil. Our findings can inform research efforts to transform MM care through optimization.
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Affiliation(s)
- Magdalena Rzewuska
- Health Services Research Unit, University of Aberdeen, Scotland, United Kingdom
- Public Health Postgraduate Program, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Ana Carolina Guidorizzi Zanetti
- Department of Psychiatric Nursing and Human Sciences, University of São Paulo at Ribeirão Preto College of Nursing, WHO Collaborating Centre for Nursing Research Development, São Paulo, Brazil
| | - Zoë C. Skea
- Health Services Research Unit, University of Aberdeen, Scotland, United Kingdom
| | - Leonardo Moscovici
- Department of Social Medicine, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
- Primary Health Care, Academic Health Services Complex at Ribeirão Preto Medical School of the São Paulo University, XIII Regional Health Department, Unified Health System, São Paulo State, Brazil
| | - Camila Almeida de Oliveira
- Public Health Postgraduate Program, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - João Mazzoncini de Azevedo-Marques
- Public Health Postgraduate Program, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
- Department of Social Medicine, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
- Primary Health Care, Academic Health Services Complex at Ribeirão Preto Medical School of the São Paulo University, XIII Regional Health Department, Unified Health System, São Paulo State, Brazil
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10
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Rubio-Valera M, Marqués-Ercilla S, Peñarrubia-María MT, Urbanos-Garrido RM, Borrell C, Bosch J, Sánchez-Viñas A, Aznar-Lou I. Who Suffers From Pharmaceutical Poverty and What Are Their Needs? Evidence From a Spanish Region. Front Pharmacol 2021; 12:617687. [PMID: 33959003 PMCID: PMC8093809 DOI: 10.3389/fphar.2021.617687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 02/08/2021] [Indexed: 11/18/2022] Open
Abstract
Background: Pharmaceutical poverty occurs when a patient cannot afford the cost of prescribed medication and/or medical products. Nonprofit organizations are covering the cost of medication to those patients in some contexts. The aim of the study was to describe the population of beneficiaries of the PB, a nongovernmental organization based on the primary healthcare system, which provides free-of-charge access to medicines and their utilization pattern of medicines and healthcare products. Methods: This was an observational study using PB beneficiary data collected between November 2017 and December 2018 in Catalonia. The Catalan Health Service provided information from the general population. A descriptive analysis of the beneficiaries' characteristics was conducted and compared to the general population. Results: The beneficiaries (N = 1,206) were mainly adults with a low level of education, unemployed, with functional disability, and with ≥1 child. Compared with the general population, the beneficiaries were older, had a lower level of education, showed a higher prevalence of functional disability, were less likely to be Spanish, and were more likely to be divorced and unemployed. The beneficiaries were polymedicated, and most were using medication related to the nervous (79%), musculoskeletal (68%), and cardiovascular system (56%) and alimentary tract and metabolism (68%). Almost 19% of beneficiaries used healthcare products. Female beneficiaries were older and more likely to be divorced or widowed, employed, and with children. Compared to men, women were more likely to use medicines for pain and mental disorders. The pediatric group used medications for severe, chronic conditions (heart diseases, autoimmune diseases, conduct disorders, and attention deficit hyperactivity disorder). Conclusion: Patients with severe, chronic, and disabling conditions are affected by pharmaceutical poverty. While the system of copayment remains unchanged, family physicians and pediatricians should explore economic barriers to treatment and direct their patients to resources that help to cover the cost of treatment.
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Affiliation(s)
- Maria Rubio-Valera
- Research and Teaching Unit, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Spain
- The Biomedical Research Centre Network for Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Silvia Marqués-Ercilla
- Centre d’Atenció Primària Bartomeu Fabrés Anglada, Direcció d'Atenció Primària Costa de Ponent, Institut Català de la Salut, Gavà, Spain
- Unitat de Suport a la Recerca Costa de Ponent, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Cornellà de Llobregat, Spain
| | - M Teresa Peñarrubia-María
- The Biomedical Research Centre Network for Epidemiology and Public Health (CIBERESP), Madrid, Spain
- Centre d’Atenció Primària Bartomeu Fabrés Anglada, Direcció d'Atenció Primària Costa de Ponent, Institut Català de la Salut, Gavà, Spain
- Unitat de Suport a la Recerca Costa de Ponent, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Cornellà de Llobregat, Spain
| | - Rosa M. Urbanos-Garrido
- Department of Applied Economics, Public Economics and Political Economy, The Complutense University of Madrid, Madrid, Spain
| | - Carme Borrell
- The Biomedical Research Centre Network for Epidemiology and Public Health (CIBERESP), Madrid, Spain
- Agència de Salut Pública de Barcelona, Barcelona, Spain
| | | | - Alba Sánchez-Viñas
- Research and Teaching Unit, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Spain
- The Biomedical Research Centre Network for Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Ignacio Aznar-Lou
- Research and Teaching Unit, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Spain
- The Biomedical Research Centre Network for Epidemiology and Public Health (CIBERESP), Madrid, Spain
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11
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Yang C, Hui Z, Zeng D, Zhu S, Wang X, Lee DTF, Chair SY. A community-based nurse-led medication self-management intervention in the improvement of medication adherence in older patients with multimorbidity: protocol for a randomised controlled trial. BMC Geriatr 2021; 21:152. [PMID: 33653300 PMCID: PMC7923480 DOI: 10.1186/s12877-021-02097-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 02/17/2021] [Indexed: 11/23/2022] Open
Abstract
Background Older patients suffering from multimorbidity are at high risk of medication nonadherence. It has been well established that self-management support is an effective strategy to enhance medication adherence for patients with chronic conditions. However, little is known about the effect of the medication self-management intervention in older patients with multimorbidity. This paper presents the protocol for a study that aims to evaluate the effectiveness of a nurse-led medication self-management intervention in improving medication adherence and health outcomes for community-dwelling older patients with multimorbidity. Methods The study protocol follows the recommendations of the Standard Protocol Items: Recommendations for Interventional Trials 2013 statement. This study is a multicentre, single-blind, two-arm randomised controlled trial. Older patients with multimorbidity will be recruited from three community health centres in Changsha, China. A total of 136 participants will be randomly allocated to receive usual care or usual care plus the medication self-management intervention. The intervention will be delivered by community nurses. The 6-week intervention includes three face-to-face education sessions and two weekly follow-up phone calls. Participants in the control group continue to receive all respects of usual care offered by community healthcare providers, including chronic disease management, drug prescription, referral to hospital specialists, health education and consultations regarding patients’ diseases and treatments during centre visits. The primary outcome is medication adherence as measured by the 5-item Medication Adherence Report Scale. Secondary outcomes include medication self-management capacity (medication knowledge, medication beliefs, medication social support, medication skills, and medication self-efficacy), treatment experiences (medication treatment satisfaction and treatment burden), quality of life, and utilisation of healthcare services. All outcomes will be measured at baseline, immediately post-intervention, and at 3-month post-intervention. Discussion This study will provide evidence about the effectiveness of a medication self-management intervention, delivered by nurses, for older patients with multimorbidity and adherence problems. It is expected that the results of the study, if proven effective in improving patients’ adherence and health outcomes, will provide evidence-based self-management support strategies for healthcare providers in routine chronic disease management in community settings. Trial registration The trial is registered at ChiCTR.org.cn (ChiCTR2000030011; date February 19, 2020). Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02097-x.
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Affiliation(s)
- Chen Yang
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, 6/F, Esther Lee Building, Shatin, Hong Kong SAR, China.
| | - Zhaozhao Hui
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, 6/F, Esther Lee Building, Shatin, Hong Kong SAR, China
| | - Dejian Zeng
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, 6/F, Esther Lee Building, Shatin, Hong Kong SAR, China
| | - Song Zhu
- Department of Thoracic Surgery, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Xiuhua Wang
- Xiang Ya Nursing School, Central South University, Changsha, China
| | - Diana Tze Fan Lee
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, 6/F, Esther Lee Building, Shatin, Hong Kong SAR, China
| | - Sek Ying Chair
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, 6/F, Esther Lee Building, Shatin, Hong Kong SAR, China
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12
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Malo S, Rabanaque MJ, Maldonado L, Moreno-Franco B, Chaure-Pardos A, Lallana MJ, Rodrigo MP, Aguilar-Palacio I. Identifying Clusters of Adherence to Cardiovascular Risk Reduction Behaviors and Persistence with Medication in New Lipid-Lowering Drug Users. Impact on Healthcare Utilization. Nutrients 2021; 13:723. [PMID: 33668726 PMCID: PMC7996322 DOI: 10.3390/nu13030723] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/15/2021] [Accepted: 02/20/2021] [Indexed: 12/22/2022] Open
Abstract
We sought to identify specific profiles of new lipid-lowering drug users based on adherence to a healthy lifestyle and persistence with medication, and to characterize co-morbidities, co-treatments, and healthcare utilization for each of the profiles identified. Observational study in 517 participants in the Aragon Workers' Health Study (AWHS) without previous cardiovascular disease (CVD) and who initiated lipid-lowering therapy. Data were collected from workplace medical examinations and administrative health databases (2010-2018). Using cluster analysis, we identified distinct patient profiles based on persistence with therapy and lifestyle. We then compared characteristics, morbidity, and healthcare utilization across clusters. Participants were aggregated into four clusters based on persistence with therapy, smoking status, adherence to Mediterranean diet, and physical activity. In cluster 1 (n = 113), comprising those with a healthiest lifestyle (14.2% smokers, 84.0% with medium-high adherence to Mediterranean diet, high physical activity), 16.8% were persistent. In cluster 3 (n = 108), comprising patients with the least healthy lifestyle (100% smokers, poor adherence to the Mediterranean diet, low level of physical activity), all were non-persistent. Clusters 2 (n = 150) and 4 (n = 146) both comprised patients with intermediate lifestyle behaviors, but differed in terms of persistence (100 and 0%, respectively). Compared with other clusters, the burden of morbidity, cardiovascular score, and healthcare utilization were lower in cluster 1. The healthy adherer effect was only observed in new lipid-lowering drug users of certain profiles. Furthermore, we found that differences in adherence to lifestyle and medication recommendations for CVD prevention influenced morbidity burden and healthcare utilization.
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Affiliation(s)
- Sara Malo
- Department of Preventive Medicine and Public Health, University of Zaragoza, 50009 Zaragoza, Spain; (M.J.R.); (B.M.-F.); (A.C.-P.); (I.A.-P.)
- Fundación Instituto de Investigación Sanitaria de Aragón (IIS Aragón), 50009 Zaragoza, Spain; (L.M.); (M.J.L.)
- Grupo de Investigación en Servicios Sanitarios de Aragón (GRISSA), Spain;
| | - María José Rabanaque
- Department of Preventive Medicine and Public Health, University of Zaragoza, 50009 Zaragoza, Spain; (M.J.R.); (B.M.-F.); (A.C.-P.); (I.A.-P.)
- Fundación Instituto de Investigación Sanitaria de Aragón (IIS Aragón), 50009 Zaragoza, Spain; (L.M.); (M.J.L.)
- Grupo de Investigación en Servicios Sanitarios de Aragón (GRISSA), Spain;
| | - Lina Maldonado
- Fundación Instituto de Investigación Sanitaria de Aragón (IIS Aragón), 50009 Zaragoza, Spain; (L.M.); (M.J.L.)
- Department of Structure and Economic History and Public Economy, University of Zaragoza, 50009 Zaragoza, Spain
| | - Belén Moreno-Franco
- Department of Preventive Medicine and Public Health, University of Zaragoza, 50009 Zaragoza, Spain; (M.J.R.); (B.M.-F.); (A.C.-P.); (I.A.-P.)
- Fundación Instituto de Investigación Sanitaria de Aragón (IIS Aragón), 50009 Zaragoza, Spain; (L.M.); (M.J.L.)
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Armando Chaure-Pardos
- Department of Preventive Medicine and Public Health, University of Zaragoza, 50009 Zaragoza, Spain; (M.J.R.); (B.M.-F.); (A.C.-P.); (I.A.-P.)
- Fundación Instituto de Investigación Sanitaria de Aragón (IIS Aragón), 50009 Zaragoza, Spain; (L.M.); (M.J.L.)
- Grupo de Investigación en Servicios Sanitarios de Aragón (GRISSA), Spain;
| | - María Jesús Lallana
- Fundación Instituto de Investigación Sanitaria de Aragón (IIS Aragón), 50009 Zaragoza, Spain; (L.M.); (M.J.L.)
- Grupo de Investigación en Servicios Sanitarios de Aragón (GRISSA), Spain;
- Aragon Healthcare Service, 50017 Zaragoza, Spain
| | - María Pilar Rodrigo
- Grupo de Investigación en Servicios Sanitarios de Aragón (GRISSA), Spain;
- Aragon Department of Health, 50017 Zaragoza, Spain
| | - Isabel Aguilar-Palacio
- Department of Preventive Medicine and Public Health, University of Zaragoza, 50009 Zaragoza, Spain; (M.J.R.); (B.M.-F.); (A.C.-P.); (I.A.-P.)
- Fundación Instituto de Investigación Sanitaria de Aragón (IIS Aragón), 50009 Zaragoza, Spain; (L.M.); (M.J.L.)
- Grupo de Investigación en Servicios Sanitarios de Aragón (GRISSA), Spain;
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13
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Health Outcomes and Primary Adherence to Secondary Prevention Treatment after St-Elevation Myocardial Infarction: a Spanish Cohort Study. J Cardiovasc Transl Res 2020; 14:308-316. [PMID: 32557320 DOI: 10.1007/s12265-020-10045-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 06/03/2020] [Indexed: 01/13/2023]
Abstract
This retrospective observational study aimed to establish the first prescription and its dispensation (primary adherence) in the first 30 days of the four pharmacotherapeutic classes recommended after a type 1 STEMI episode, determine the potential risk factors for lack of primary adherence, and evaluate the potential impact of primary adherence on cardiovascular outcomes. Of the 613 patients analyzed, 576 were included (64.7 ± 13.8 years, 73.8% men) between January 2008 and December 2013. Primary adherence exceeded 90% in all groups. Complete primary adherence was higher in high-drug coverage patients and was lower in patients with cardiovascular or neuropsychiatric diseases. According to competing risk analysis, 1-year cardiovascular mortality was significantly lower in patients with complete primary adherence than in those without complete prescription or adherence, 1.8% versus 5.6% (HR = 0.286; p = 0.012). Complete primary adherence did not prevent a 1-year cardiovascular event, 5.6% versus 5.5% (p = 0.904).
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14
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Vilaplana-Carnerero C, Aznar-Lou I, Peñarrubia-María MT, Serrano-Blanco A, Fernández-Vergel R, Petitbò-Antúnez D, Gil-Girbau M, March-Pujol M, Mendive JM, Sánchez-Viñas A, Carbonell-Duacastella C, Rubio-Valera M. Initiation and Single Dispensing in Cardiovascular and Insulin Medications: Prevalence and Explanatory Factors. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E3358. [PMID: 32408626 PMCID: PMC7277594 DOI: 10.3390/ijerph17103358] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/08/2020] [Accepted: 05/10/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Adherence problems have negative effects on health, but there is little information on the magnitude of non-initiation and single dispensing. OBJECTIVE The aim of this study was to estimate the prevalence of non-initiation and single dispensation and identify associated predictive factors for the main treatments prescribed in Primary Care (PC) for cardiovascular disease (CVD) and diabetes. METHODS Cohort study with real-world data. Patients who received a first prescription (2013-2014) for insulins, platelet aggregation inhibitors, angiotensin-converting enzyme inhibitors (ACEI) or statins in Catalan PC were included. The prevalence of non-initiation and single dispensation was calculated. Factors that explained these behaviours were explored. RESULTS At three months, between 5.7% (ACEI) and 9.1% (antiplatelets) of patients did not initiate their treatment and between 10.6% (statins) and 18.4% (ACEI) filled a single prescription. Body mass index, previous CVD, place of origin and having a substitute prescriber, among others, influenced the risk of non-initiation and single dispensation. CONCLUSIONS The prevalence of non-initiation and single dispensation of CVD medications and insulin prescribed in PC in is high. Patient and health-system factors, such as place of origin and type of prescriber, should be taken into consideration when prescribing new medications for CVD and diabetes.
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Affiliation(s)
- Carles Vilaplana-Carnerero
- Research and Development Unit, Institut de Recerca Sant Joan de Déu, 08830 Barcelona, Catalonia, Spain; (C.V.-C.); (I.A.-L.); (M.G.-G.); (A.S.-V.); (C.C.-D.)
- School of Pharmacy, University of Barcelona, 08028 Barcelona, Catalonia, Spain;
| | - Ignacio Aznar-Lou
- Research and Development Unit, Institut de Recerca Sant Joan de Déu, 08830 Barcelona, Catalonia, Spain; (C.V.-C.); (I.A.-L.); (M.G.-G.); (A.S.-V.); (C.C.-D.)
- Consortium for Biomedical Research in Epidemiology & Public Health (CIBER en Epidemiología y Salud Pública—CIBERESP), 28029 Madrid, Spain; (M.T.P.-M.); (A.S.-B.)
| | - María Teresa Peñarrubia-María
- Consortium for Biomedical Research in Epidemiology & Public Health (CIBER en Epidemiología y Salud Pública—CIBERESP), 28029 Madrid, Spain; (M.T.P.-M.); (A.S.-B.)
- Primary Care Research Institute (IDIAP Jordi Gol), 08007 Barcelona, Spain; (R.F.-V.); (J.M.M.)
- Catalan Institute of Health, 08028 Barcelona, Spain;
| | - Antoni Serrano-Blanco
- Consortium for Biomedical Research in Epidemiology & Public Health (CIBER en Epidemiología y Salud Pública—CIBERESP), 28029 Madrid, Spain; (M.T.P.-M.); (A.S.-B.)
- Parc Sanitari Sant Joan de Déu, 08830 Sant Boi de Llobregat, Catalonia, Spain
| | - Rita Fernández-Vergel
- Primary Care Research Institute (IDIAP Jordi Gol), 08007 Barcelona, Spain; (R.F.-V.); (J.M.M.)
- Catalan Institute of Health, 08028 Barcelona, Spain;
| | | | - Montserrat Gil-Girbau
- Research and Development Unit, Institut de Recerca Sant Joan de Déu, 08830 Barcelona, Catalonia, Spain; (C.V.-C.); (I.A.-L.); (M.G.-G.); (A.S.-V.); (C.C.-D.)
- School of Pharmacy, University of Barcelona, 08028 Barcelona, Catalonia, Spain;
- Primary Care Prevention and Health Promotion Research Network, 08007 Barcelona, Catalonia, Spain
| | - Marian March-Pujol
- School of Pharmacy, University of Barcelona, 08028 Barcelona, Catalonia, Spain;
- Consortium for Biomedical Research in Epidemiology & Public Health (CIBER en Epidemiología y Salud Pública—CIBERESP), 28029 Madrid, Spain; (M.T.P.-M.); (A.S.-B.)
| | - Juan Manuel Mendive
- Primary Care Research Institute (IDIAP Jordi Gol), 08007 Barcelona, Spain; (R.F.-V.); (J.M.M.)
- Catalan Institute of Health, 08028 Barcelona, Spain;
- Primary Care Prevention and Health Promotion Research Network, 08007 Barcelona, Catalonia, Spain
| | - Alba Sánchez-Viñas
- Research and Development Unit, Institut de Recerca Sant Joan de Déu, 08830 Barcelona, Catalonia, Spain; (C.V.-C.); (I.A.-L.); (M.G.-G.); (A.S.-V.); (C.C.-D.)
| | - Cristina Carbonell-Duacastella
- Research and Development Unit, Institut de Recerca Sant Joan de Déu, 08830 Barcelona, Catalonia, Spain; (C.V.-C.); (I.A.-L.); (M.G.-G.); (A.S.-V.); (C.C.-D.)
- Consortium for Biomedical Research in Epidemiology & Public Health (CIBER en Epidemiología y Salud Pública—CIBERESP), 28029 Madrid, Spain; (M.T.P.-M.); (A.S.-B.)
| | - Maria Rubio-Valera
- Consortium for Biomedical Research in Epidemiology & Public Health (CIBER en Epidemiología y Salud Pública—CIBERESP), 28029 Madrid, Spain; (M.T.P.-M.); (A.S.-B.)
- Parc Sanitari Sant Joan de Déu, 08830 Sant Boi de Llobregat, Catalonia, Spain
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15
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Parody-Rúa E, Rubio-Valera M, Guevara-Cuellar C, Gómez-Lumbreras A, Casajuana-Closas M, Carbonell-Duacastella C, Aznar-Lou I. Economic Evaluations Informed Exclusively by Real World Data: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E1171. [PMID: 32059593 PMCID: PMC7068655 DOI: 10.3390/ijerph17041171] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 02/03/2020] [Accepted: 02/08/2020] [Indexed: 12/28/2022]
Abstract
Economic evaluations using Real World Data (RWD) has been increasing in the very recent years, however, this source of information has several advantages and limitations. The aim of this review was to assess the quality of full economic evaluations (EE) developed using RWD. A systematic review was carried out through articles from the following databases: PubMed, Embase, Web of Science and Centre for Reviews and Dissemination. Included were studies that employed RWD for both costs and effectiveness. Methodological quality of the studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Of the 14,011 studies identified, 93 were included. Roughly half of the studies were carried out in a hospital setting. The most frequently assessed illnesses were neoplasms while the most evaluated interventions were pharmacological. The main source of costs and effects of RWD were information systems. The most frequent clinical outcome was survival. Some 47% of studies met at least 80% of CHEERS criteria. Studies were conducted with samples of 100-1000 patients or more, were randomized, and those that reported bias controls were those that fulfilled most CHEERS criteria. In conclusion, fewer than half the studies met 80% of the CHEERS checklist criteria.
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Affiliation(s)
- Elizabeth Parody-Rúa
- Teaching, Research & Innovation Unit, Parc Sanitari Sant Joan de Déu–Institut de Recerca Sant Joan de Déu, 08830 Barcelona, Spain; (M.R.-V.); (C.C.-D.); (I.A.-L.)
- Primary Care Prevention and Health Promotion Network (redIAPP), 08007 Barcelona, Spain
| | - Maria Rubio-Valera
- Teaching, Research & Innovation Unit, Parc Sanitari Sant Joan de Déu–Institut de Recerca Sant Joan de Déu, 08830 Barcelona, Spain; (M.R.-V.); (C.C.-D.); (I.A.-L.)
- CIBER of Epidemiology and Public Health (CIBERESP), 28029 Madrid, Spain
| | | | - Ainhoa Gómez-Lumbreras
- Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAPJGol), 08007 Barcelona, Spain; (A.G.-L.); (M.C.-C.)
- Universitat Autònoma de Barcelona, 08193 Bellaterra (Cerdanyola del Vallès), Spain
- Health Science School, Universitat de Girona, 17071 Girona, Spain
| | - Marc Casajuana-Closas
- Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAPJGol), 08007 Barcelona, Spain; (A.G.-L.); (M.C.-C.)
- Universitat Autònoma de Barcelona, 08193 Bellaterra (Cerdanyola del Vallès), Spain
| | - Cristina Carbonell-Duacastella
- Teaching, Research & Innovation Unit, Parc Sanitari Sant Joan de Déu–Institut de Recerca Sant Joan de Déu, 08830 Barcelona, Spain; (M.R.-V.); (C.C.-D.); (I.A.-L.)
- CIBER of Epidemiology and Public Health (CIBERESP), 28029 Madrid, Spain
| | - Ignacio Aznar-Lou
- Teaching, Research & Innovation Unit, Parc Sanitari Sant Joan de Déu–Institut de Recerca Sant Joan de Déu, 08830 Barcelona, Spain; (M.R.-V.); (C.C.-D.); (I.A.-L.)
- CIBER of Epidemiology and Public Health (CIBERESP), 28029 Madrid, Spain
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Zaini S, Manivanna Bharathy HA, Sulaiman AH, Singh Gill J, Ong Hui K, Zaman Huri H, Shamsudin SH, Chong Guan N. Development of a Strategic Tool for Shared Decision-Making in the Use of Antidepressants among Patients with Major Depressive Disorder: A Focus Group Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15071402. [PMID: 29970848 PMCID: PMC6068982 DOI: 10.3390/ijerph15071402] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 06/26/2018] [Accepted: 06/28/2018] [Indexed: 01/22/2023]
Abstract
Shared decision-making (SDM) has been recognized as an important tool in the mental health field and considered as a crucial component of patient-centered care. Therefore, the purpose of this study was to develop a strategic tool towards the promotion and implementation of SDM in the use of antidepressants among patients with major depressive disorder. Nineteen doctors and 11 major depressive disorder patients who are involved in psychiatric outpatient clinic appointments were purposively selected and recruited to participate in one of six focus groups in a large teaching hospital in Malaysia. Focus groups were transcribed verbatim and analyzed using a thematic approach to identify current views on providing information needed for SDM practice towards its implementation in near future. Patients’ and doctors’ views were organized into six major themes, which are; summary of treatment options, correct ways of taking medication, potential side effects of treatments related to patients, sharing of case study related to the treatment options, cost of treatment options, and input from pharmacist. The information may be included in the SDM tool which can be useful to inform further research efforts and developments that contribute towards the successful implementation of SDM into clinical practice.
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Affiliation(s)
- Syahrir Zaini
- Department of Psychological Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia.
- Department of Pharmacy Practice, Kulliyyah of Pharmacy, International Islamic University Malaysia, Kuantan 25200, Malaysia.
| | | | - Ahmad Hatim Sulaiman
- Department of Psychological Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia.
| | - Jesjeet Singh Gill
- Department of Psychological Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia.
| | - Koh Ong Hui
- Department of Psychological Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia.
| | - Hasniza Zaman Huri
- Department of Pharmacy, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia.
| | - Siti Hadijah Shamsudin
- Department of Pharmacy Practice, Kulliyyah of Pharmacy, International Islamic University Malaysia, Kuantan 25200, Malaysia.
| | - Ng Chong Guan
- Department of Psychological Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia.
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Aznar-Lou I, Pottegård A, Fernández A, Peñarrubia-María MT, Serrano-Blanco A, Sabés-Figuera R, Gil-Girbau M, Fajó-Pascual M, Moreno-Peral P, Rubio-Valera M. Effect of copayment policies on initial medication non-adherence according to income: a population-based study. BMJ Qual Saf 2018; 27:878-891. [DOI: 10.1136/bmjqs-2017-007416] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 02/06/2018] [Accepted: 02/11/2018] [Indexed: 01/03/2023]
Abstract
ObjectiveCopayment policies aim to reduce the burden of medication expenditure but may affect adherence and generate inequities in access to healthcare. The objective was to evaluate the impact of two copayment measures on initial medication non-adherence (IMNA) in several medication groups and by income level.DesignA population-based study was conducted using real-world evidence.SettingPrimary care in Catalonia (Spain) where two separate copayment measures (fixed copayment and coinsurance) were introduced between 2011 and 2013.ParticipantEvery patient with a new prescription issued between 2011 and 2014 (3 million patients and 10 million prescriptions).OutcomesIMNA was estimated throughout dispensing and invoicing information. Changes in IMNA prevalence after the introduction of copayment policies (immediate level change and trend changes) were estimated through segmented logistic regression. The regression models were stratified by economic status and medication groups.ResultsBefore changes to copayment policies, IMNA prevalence remained stable. The introduction of a fixed copayment was followed by a statistically significant increase in IMNA in poor population, low/middle-income pensioners and low-income non-pensioners (OR from 1.047 to 1.370). In high-income populations, there was a large statistically non-significant increase. IMNA decreased in the low-income population after suspension of the fixed copayment and the introduction of a coinsurance policy that granted this population free access to medications (OR=0.676). Penicillins were least affected while analgesics were affected to the greatest extent. IMNA to medications for chronic conditions increased in low/middle-income pensioners.ConclusionEven nominal charge fixed copayment may generate inequities in access to health services. An anticipation effect and expenses associated with IMNA may have generated short-term costs. A reduction in copayment can protect from non-adherence and have positive, long-term effects. Copayment scenarios could have considerable long-term consequences for health and costs due to increased IMNA in medication for chronic physical conditions.
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Aznar-Lou I, Iglesias-González M, Gil-Girbau M, Serrano-Blanco A, Fernández A, Peñarrubia-María MT, Sabés-Figuera R, Murrugarra-Centurión AG, March-Pujol M, Bolívar-Prados M, Rubio-Valera M. Impact of initial medication non-adherence to SSRIs on medical visits and sick leaves. J Affect Disord 2018; 226:282-286. [PMID: 29024901 DOI: 10.1016/j.jad.2017.09.057] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 05/30/2017] [Accepted: 09/29/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Initial medication non-adherence (IMNA) to antidepressants, which are commonly used to treat depression in primary care (PC), is around 6-12%. Although it is well known that post-initial non-adherence to antidepressants increases the cost of depression, the impact of IMNA on cost is unknown. The aim of this study is to assess the impact of IMNA to Selective Serotonin Reuptake Inhibitors (SSRI) on medical visits and sick leave in patients with depression treated in PC in Catalonia (Spain). METHODS This was a four-year retrospective register-based study (2011-2014). All PC patients of working age who received a new SSRI prescription and had a diagnosis of depression were included (N = 79,642). Treatment initiation, number of visits and days on sick leave were gathered from the database. We assessed the impact of IMNA on costs with ordered logistic regressions. RESULTS The 3-year incidence of IMNA was 15%. Initially non-adherent patients made a lesser number of GP visits (OR = 0.82; 95% CI = 0.79-0.84) but had more days on sick leave (OR = 1.25; 95% CI = 1.20-1.31). There were no differences in the number of specialist visits (OR = 1.04; 95% CI = 0.99-1.08). LIMITATIONS Differences between adherent and non-adherent patients could be explained by non-observed variables. GP recognition and documentation of depression might be inaccurate. Costs of unpaid work and use of hospital services were not considered. CONCLUSIONS Although IMNA decreases the use of medical PC services, it increases the number of days on sick leave. This could also indicate worse health status. These consequences are currently overlooked when considering post-initial medication non-adherence.
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Affiliation(s)
- Ignacio Aznar-Lou
- Teaching, Research & Innovation Unit, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain; Centro de Investigación Biomédica en Red en Epidemiología y Salud Pública, CIBERESP, Madrid, Spain; School of Pharmacy, University of Barcelona, Barcelona, Spain
| | | | - Montserrat Gil-Girbau
- Teaching, Research & Innovation Unit, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain; School of Pharmacy, University of Barcelona, Barcelona, Spain; Primary Care Prevention and Health Promotion Research Network (redIAPP), Spain
| | - Antoni Serrano-Blanco
- Centro de Investigación Biomédica en Red en Epidemiología y Salud Pública, CIBERESP, Madrid, Spain; Parc Sanitari Sant Joan de Déu, University of Barcelona, Sant Boi de Llobregat, Spain
| | - Ana Fernández
- Centro de Investigación Biomédica en Red en Epidemiología y Salud Pública, CIBERESP, Madrid, Spain; Community Health Service, Public Health Agency of Barcelona, Barcelona, Spain
| | - María Teresa Peñarrubia-María
- Centro de Investigación Biomédica en Red en Epidemiología y Salud Pública, CIBERESP, Madrid, Spain; Fundació Idiap Jordi Gol i Gurina, Barcelona, Spain
| | - Ramón Sabés-Figuera
- Centro de Investigación Biomédica en Red en Epidemiología y Salud Pública, CIBERESP, Madrid, Spain; Faculty of Economic and Business Science, Universitat Pompeu Fabra, Barcelona, Spain
| | | | - Marian March-Pujol
- Centro de Investigación Biomédica en Red en Epidemiología y Salud Pública, CIBERESP, Madrid, Spain; School of Pharmacy, University of Barcelona, Barcelona, Spain
| | | | - Maria Rubio-Valera
- Teaching, Research & Innovation Unit, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain; Centro de Investigación Biomédica en Red en Epidemiología y Salud Pública, CIBERESP, Madrid, Spain; School of Pharmacy, University of Barcelona, Barcelona, Spain.
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