Multicultural medication adherence: a comparative study

Scope of Outcomes in Trials and Observational Studies of Interventions Targeting Medication Adherence in Rheumatic Conditions: A Systematic Review

OBJECTIVE

Nonadherence to medications is common in rheumatic conditions and associated with increased morbidity. Heterogeneous outcome reporting by researchers compromises the synthesis of evidence of interventions targeting adherence. We aimed to assess the scope of outcomes in interventional studies of medication adherence.

METHODS

We searched electronic databases to February 2019 for published randomized controlled trials and observational studies of interventions with the primary outcome of medication adherence including adults with any rheumatic condition, written in English. We extracted and analyzed all outcome domains and adherence measures with prespecified extraction and analysis protocols.

RESULTS

Overall, 53 studies reported 71 outcome domains classified into adherence (1 domain), health outcomes (38 domains), and adherence-related factors (e.g., medication knowledge; 32 domains). We subdivided adherence into 3 phases: initiation (n = 13 studies, 25%), implementation (n = 32, 60%), persistence (n = 27, 51%), and phase unclear (n = 20, 38%). Thirty-seven different instruments reported adherence in 115 unique ways (this includes different adherence definitions and calculations, metric, and method of aggregation). Forty-one studies (77%) reported health outcomes. The most frequently reported were medication adverse events (n = 24, 45%), disease activity (n = 11, 21%), bone turnover markers/physical function/quality of life (each n = 10, 19%). Thirty-three studies (62%) reported adherence-related factors. The most frequently reported were medication beliefs (n = 8, 15%), illness perception/medication satisfaction/satisfaction with medication information (each n = 5, 9%), condition knowledge/medication knowledge/trust in doctor (each n = 3, 6%).

CONCLUSION

The outcome domains and adherence measures in interventional studies targeting adherence are heterogeneous. Consensus on relevant outcomes will improve the comparison of different strategies to support medication adherence in rheumatology.

Clinical guidelines for the prevention and treatment of osteoporosis: summary statements and recommendations from the Italian Society for Orthopaedics and Traumatology

BACKGROUND

The Italian Society for Orthopaedics and Traumatology conceived this guidance-which is primarily addressed to Italian orthopedic surgeons, but should also prove useful to other bone specialists and to general practitioners-in order to improve the diagnosis, prevention, and treatment of osteoporosis and its consequences.

MATERIALS AND METHODS

Literature reviews by a multidisciplinary team.

RESULTS

The following topics are covered: the role of instrumental, metabolic, and genetic evaluations in the diagnosis of osteoporosis; appraisal of the risk of fracture and thresholds for intervention; general strategies for the prevention and treatment of osteoporosis (primary and secondary prevention); the pharmacologic treatment of osteoporosis; the setting and implementation of fracture liaison services for tertiary prevention. Grade A, B, and C recommendations are provided based on the main levels of evidence (1-3). Toolboxes for everyday clinical practice are provided.

CONCLUSIONS

The first up-to-date Italian guidelines for the primary, secondary, and tertiary prevention of osteoporosis and osteoporotic fractures are presented.

Culturally Responsive Interventions to Enhance Immunosuppressive Medication Adherence in Older African American Kidney Transplant Recipients

Context

Immunosuppressive medication nonadherence is variable among older kidney transplant recipients and is a problem in African American recipients despite the severe consequences of this behavior. Many factors place older African American recipients at risk for medication nonadherence.

Objective

To provide an overview of interventions to enhance immunosuppressive medication adherence in older African American kidney transplant recipients using a culturally responsive model. Culturally sensitive, innovative, and transformation interventions are discussed. Situations when each intervention would be most and least appropriate are described.

Conclusion

Moving culturally appropriate interventions forward into practice and testing their effectiveness in improving adherence outcomes in vulnerable, older African American kidney transplant recipients is a worthy practice and research goal for transplant nursing.

Packaging interventions to increase medication adherence: systematic review and meta-analysis

OBJECTIVE

Inadequate medication adherence is a widespread problem that contributes to increased chronic disease complications and health care expenditures. Packaging interventions using pill boxes and blister packs have been widely recommended to address the medication adherence issue. This meta-analysis review determined the overall effect of packaging interventions on medication adherence and health outcomes. In addition, we tested whether effects vary depending on intervention, sample, and design characteristics.

RESEARCH DESIGN AND METHODS

Extensive literature search strategies included examination of 13 computerized databases and 19 research registries, hand searches of 57 journals, and author and ancestry searches. Eligible studies included either pill boxes or blister packaging interventions to increase medication adherence. Primary study characteristics and outcomes were reliably coded. Random-effects analyses were used to calculate overall effect sizes and conduct moderator analyses.

RESULTS

Data were synthesized across 22,858 subjects from 52 reports. The overall mean weighted standardized difference effect size for two-group comparisons was 0.593 (favoring treatment over control), which is consistent with the mean of 71% adherence for treatment subjects compared to 63% among control subjects. We found using moderator analyses that interventions were most effective when they used blister packs and were delivered in pharmacies, while interventions were less effective when studies included older subjects and those with cognitive impairment. Methodological moderator analyses revealed significantly larger effect sizes in studies reporting continuous data outcomes instead of dichotomous results and in studies using pharmacy refill medication adherence measures compared with studies with self-report measures.

CONCLUSIONS

Overall, meta-analysis findings support the use of packaging interventions to effectively increase medication adherence. Limitations of the study include the exclusion of packaging interventions other than pill boxes and blister packs, evidence of publication bias, and primary study sparse reporting of health outcomes and potentially interesting moderating variables such as the number of prescribed medications.

Medication adherence Part three: Strategies for improving adherence

PURPOSE

This is the third of a three part series on Medication Adherence in which the authors describe the continuum of adherence to nonadherence of medication usage.

DATA SOURCES

Research articles through Medline and PubMed.

CONCLUSIONS

Understanding the magnitude and scope of the problem of medication nonadherence is the first step in reaching better adherence rates. The second step is to evaluate the risk factors for each patient for medication adherence/nonadherence. Steps are then taken to prevent nonadherence.

IMPLICATIONS FOR PRACTICE

The implications for nurse practitioners include using time with patients to assist them in adherence, building a trusting relationship with patients, and developing protocols for assessing and preventing nonadherence.

Interventions to improve osteoporosis medication adherence and persistence: a systematic review and literature appraisal by the ISPOR Medication Adherence & Persistence Special Interest Group

This study aims to systematically review, critically appraise and identify from the published literature, the most effective interventions to improve medication adherence in osteoporosis. A literature search using Medline, EMBASE, Cochrane library, and Cumulative Index to Nursing and Allied Health Literature was undertaken to identify prospective studies published between January 1, 1999 and June 30, 2012. We included studies on adult users of osteoporosis medications that tested a patient adherence intervention (e.g., patient education, intensified patient care, different dosing regimens) and reported quantitative results of adherence. The Delphi list was modified to assess the quality of studies. Of 113 articles identified, 20 studies fulfilled the inclusion criteria. The most frequent intervention was education (n = 11) followed by monitoring/supervision (n = 4), drug regimens (n = 2), drug regimens and patient support (n = 1), pharmacist intervention (n = 1), and electronic prescription (n = 1). Although patient education improved medication adherence in four studies, two large-scale randomized studies reported no benefits. Simplification of dosing regimens (with and without patient support program) was found to have a significant clinical impact on medication adherence and persistence. Monitoring/supervision showed no impact on medication persistence while electronic prescription and pharmacist intervention increased medication adherence or persistence. In conclusion, this review found that simplification of dosing regimens, decision aids, electronic prescription, or patient education may help to improve adherence or persistence to osteoporosis medications. We identified wide variation of quality of studies in the osteoporosis area. The efficacy of patient education was variable across studies, while monitoring/supervision does not seem an effective way to enhance medication adherence or persistence.

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

BACKGROUND

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

OBJECTIVES

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

DESIGN

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

SETTING

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

METHODS

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

RESULTS

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

DISCUSSION

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

Medication adherence in people of culturally and linguistically diverse backgrounds: a meta-analysis

BACKGROUND

Medication adherence is of particular importance for people of culturally and linguistically diverse (CALD) backgrounds due to language difficulties, lack of social and organizational supports, lack of access to healthcare resources, and disengagement with the health-care system.

OBJECTIVE

To evaluate the impact of interventions to improve medication adherence in people of CALD backgrounds through a systematic review and meta-analysis.

METHODS

A search was performed using the following databases: Cochrane Database of Systematic Reviews, Cumulative Index to Nursing & Allied Health Literature, EMBASE, Journals@Ovid, PsychInfo, PubMed, Science Direct, Scopus, and Web of Science. Databases were searched from January 1978 to October 2009.

RESULTS

Forty-six articles reviewed were assessed as being relevant, which included 36 randomized controlled trials, 2 observational cohort studies, and 8 quasi-experimental studies. The most common method for assessing medication adherence was self-reporting measures, such as the Morisky Scale and its modifications. Few studies used combinations of adherence measures, and adherence involving a medication event monitoring system (MEMS) was used in only 6 studies. Individuals of CALD backgrounds were recruited with people of non-CALD backgrounds and subsequent analyses tended to be undertaken of the whole sample. Twenty studies showed statistically significant improvements in medication adherence, 15 of which were randomized controlled trials. Six of the successful interventions involved delivery by a bilingual person or the use of translated materials and 4 involved the use of a conceptual model. Meta-analyses demonstrated modest improvements in medication adherence.

CONCLUSIONS

Relatively little high-quality work has been conducted on adherence-enhancing interventions for people of CALD backgrounds. Greater attention needs to be given to examining the needs of specific CALD population groups. Future researchers should consider rigorously testing interventions that take into account the enormous diversity and differences that exist within any particular CALD group.

The devil is in the detail - a multifactorial intervention to reduce blood pressure in co-existing diabetes and chronic kidney disease: a single blind, randomized controlled trial

Background

About 30-60% of individuals are non-adherent to their prescribed medications and this risk increases as the number of prescribed medications increases. This paper outlines the development of a consumer-centred Medicine Self-Management Intervention (MESMI), designed to improve blood pressure control and medication adherence in consumers with diabetes and chronic kidney disease recruited from specialist outpatients' clinics.

Methods

We developed a multifactorial intervention consisting of Self Blood Pressure Monitoring (SBPM), medication review, a twenty-minute interactive Digital Versatile Disc (DVD), and follow-up support telephone calls to help consumers improve their blood pressure control and take their medications as prescribed. The intervention is novel in that it has been developed from analysis of consumer and health professional views, and includes consumer video exemplars in the DVD. The primary outcome measure was a drop of 3-6 mmHg systolic blood pressure at three months after completion of the intervention. Secondary outcome measures included: assessment of medication adherence, medication self-efficacy and general wellbeing. Consumers' adherence to their prescribed medications was measured by manual pill count, self-report of medication adherence, and surrogate biochemical markers of disease control.

Discussion

The management of complex health problems is an increasing component of health care practice, and requires interventions that improve patient outcomes. We describe the preparatory work and baseline data of a single blind, randomized controlled trial involving consumers requiring cross-specialty care with a follow-up period extending to 12 months post-baseline.

Trial Registration

The trial was registered with the Australian and New Zealand Clinical Trials Register (ACTRN12607000044426).

Pharmacotherapeutics in older adults

The process of aging influences both pharmacodynamics and pharmacokinetics. In addition to this, the issue of the increased incidence of chronic diseases as the age of people and the effects of medications in older adults becomes very complex. This article will review the influence of the aging process on the absorption, distribution, metabolism, and excretion of drugs. Specific concerns of older adults, including drug groups and side effects of concern, drug-induced geriatric syndromes, and medication adherence, are also discussed.

Non-compliance: the Achilles' heel of anti-fracture efficacy

About 50% of patients fail to comply or persist with anti-osteoporosis treatment regimens within 1 year. Poor compliance is associated with higher fracture rates. Causes of poor compliance are unknown. As it is not possible to predict poor compliance, close monitoring of compliance is needed. Despite evidence supporting the anti-fracture efficacy of several pharmacological agents, approximately 50% of patients do not follow their prescribed treatment regimen and/or discontinue treatment within 1 year. Poor compliance is associated with higher fracture rates and increased morbidity, mortality and cost. However, as poor compliance, even to placebo, is associated with adverse outcomes, the higher morbidity appears to be only partly the result of lack of treatment: as yet, undefined characteristics place poor compliers at higher risk of morbidity and mortality. Only a small proportion (e.g., 6%) of the variability in compliance is explained by putative causal factors such as older age, co-morbidity or greater number of medications. Regimens with longer dosing intervals, such as weekly dosing, improve compliance, persistence and outcomes, but only modestly. As it is not possible to predict poor compliance, close monitoring of compliance should be an obligatory duty in clinical care. How this is best achieved has yet to be established, but poor persistence occurs as early as 3 months of starting treatment, indicating the need for early monitoring.

[Follow-up of osteoporosis treatment]

There is no linear relation between changes in bone mineral density (BMD) and reduction in fracture risk with antiresorptive agents. Interpretation of BMD changes at the individual level requires calculating the smallest significant change at each measurement center. BMD measurement is essential before administration of antiresorptive or anabolic agents for prevention or treatment of postmenopausal osteoporosis. Biochemical markers of bone turnover can be monitored after 6 months of treatment. Their interpretation requires careful assessment of their intraindividual variability.

Strategies and issues for managing menopause-related symptoms in diverse populations: ethnic and racial diversity

Menopause is a naturally occurring "equal opportunity" event that every woman who lives beyond the age of approximately 52 years will experience. During the next 20 years, approximately 3.5 million African American women, 2 million Latinas, and 1 million Asian American women will enter the menopause. How a woman approaches the menopausal transition depends on a number of factors, from educational level to socioeconomic status; health-related factors, including stress; and marital status. Increasingly, the roles of race and ethnicity, as they relate to menopausal symptoms, are being explored. Understanding similarities and differences among women of color in perceptions, attitudes, and expectations surrounding the menopause can help provide culturally appropriate care and promote lifestyles that may decrease symptoms and increase quality of life. For example, minority women are usually the gatekeepers for healthcare for themselves and their families and have a highly developed social support network, often including extended family, a church community, and involvement in sororal or social organizations. In the future, research on menopausal symptoms among women of different racial/ethnic groups should focus on exploring in greater detail the effect of dietary factors and body mass index, additional evaluation of pituitary sensitivity, and use of complementary and alternative medicines in symptom management, with a better understanding of the risks and benefits of such therapies.