Adherence: a review of education, research, practice, and policy in the United States

Non-adherence to medication and associated factors among type 2 diabetes patients at Clinique Medicale Fraternite, Rwanda: a cross-sectional study

BACKGROUND

Type 2 Diabetes Miletus (T2DM) is a public health burdens that alarmingly increases and leads to morbidity and mortality over the last decades globally. Its management is multifaceted and adherence to diabetic medications plays great roles in life of T2DM patients. But epidemiology on adherence and its associated factors remain unknown in Rwanda. Therefore, this study determined the extent of non-adherence and its predictors among T2DM patients seeking healthcare services at the Clinique Medicale la Fraternite.

METHODS

A cross-sectional study among 200 adults' patients with T2DM receiving care in the Medicale la Fraternite clinic was investigated. Bivariate and multivariate logistic regression models were performed based on odds ratio employed to examine associated predictors of non-adherence. The cut-off value for all statistical significances tests were considered at p < 0.05 with 95% for the confidence intervals.

RESULTS

Overall, more than a half of T2DM patients (53.5%) had poor medication adherence. Being females [OR = 2.1, 95%CI(1.13-3.71), p = 0.002], consuming anti-diabetic drugs for 4-10 years [OR = 2.18, 95%CI(1.09-4.34), p = 0.027], experiencing poor communication with healthcare providers [OR = 2.4; 95%CI (1.36-4.25), p = 0.003] and being perceived as burden of the family [OR = 5.8; 95%CI(1.3-25.7), p < 0.021] had higher odds of non-adherence to anti-diabetic medications. Those with poor HbA1C [OR = 4.26; 95%CI(1.7-10.67), p = 0.002] had 4.26 times higher odds to be non-adherent compared to those with good HbA1C. Respondents with primary [OR = 3.56; 95%CI (1.12-11.28), p = 0.031] and secondary education [OR = 2.96; 95%CI (1.11-7.87), p = 0.03] were more likely to be non-adherent than those with informal education respectively. Those with normal BMI [OR = 5.17; 95%CI(1.63-16.37), p = 0.005] and those with overweight or obese [OR = 3.6; 95%CI (1.04-9.1), p < 0.02] had higher odds of being non-adherent than those with underweight.

CONCLUSION

Sex, glycaemia, communication with healthcare providers, education and gycosylated hemoglobin were the major predictors of non-adherence. Interventions for tackling this problem through bringing together efforts to stem this epidemic and controlling predictors of non-adherence are urgently recommended.

Do We Need a Specific Guideline for Assessment and Improvement of Acromegaly Patients Adherence?

Background: Adherence to therapy is one of the most important elements during the therapeutic process ensuring the predefined therapeutic outcomes. The aim is to analyze the need and importance of treatment adherence guideline for acromegaly patients and the possibilities for its development and implementation in Bulgaria. Methods: A set of methods was applied: (1) a literature review in the electronic database for identification of articles and guidelines related to adherence and acromegaly; (2) analysis of Bulgarian legislative documents; (3) a pilot study for assessment of the level of treatment adherence among hospitalized Bulgarian acromegaly patients in 2018; (4) a plan for development and implementation of specific guideline was created entitled BULMEDACRO - BULgarian guideline for MEdication aDherence assessment and improvement in ACROmegaly. Results: No specific guidelines for evaluation, monitoring, reporting and/or improving adherence in acromegaly patients has been found in the literature. Requirements for regular assessment of the level of adherence, application of appropriate methods for improvement and monitoring are not sufficiently formulated and mandatory. The pilot study confirmed that therapy adherence among Bulgarian patients with acromegaly is relatively high as almost 90% of patients report that they strictly comply with their prescribed treatment regimen. It is necessary, however, a specific guideline focused on the methods for assessment and improvement of adherence, in order to ensure monitoring and follow-up of acromegaly patients. Conclusions: Patients with acromegaly should be the focus of specially designed national programs, initiatives and/or guidelines for regular evaluation and improvement of the adherence level. Despite the difficulties and the lack of an adequate legal basis, successive steps initiated by different stakeholder are needed.

Knowledge and comfort change with an active learning activity on medication adherence calculations

BACKGROUND AND PURPOSE

Medication adherence is perhaps the most prominent quality measure applied to pharmacies. Teaching students about nonadherence usually takes the form of lectures and simulated pill taking exercises. While these approaches have value, activities are needed in other aspects of medication adherence.

EDUCATIONAL ACTIVITY AND SETTING

This activity was used within a didactic course on endocrine therapeutics for second-year student pharmacists at a public pharmacy college. A 50-min didactic session was followed by an active learning session on medication adherence metrics, focused on the community pharmacy setting. The active learning session had students manually calculate the proportion of days covered and medication possession ratios for two refill histories and examine the output of one simulated adherence dashboard. Students completed an online survey via the course management website before and after the activity that assessed student knowledge of concepts that comprise the proportion of days covered (PDC) metric and three items on self-reported knowledge, comfort, and confidence. The pre and post survey were compared using chi-square and paired t-tests.

FINDINGS

A total of 90 pre-surveys and 77 post-surveys were completed, with 70 having both pre- and post- data for comparison of the scaled responses. There was a statistically significant improvement in student knowledge, comfort, and confidence scores as assessed by the surveys.

DISCUSSION

A hands-on approach using a calendar and a custom database workbook appeared to help most students improve their understanding of applied medication adherence calculations.

SUMMARY

A 50-min didactic background session on medication adherence metrics followed by a 50-min adherence metric calculation activity was effective in increasing student knowledge and confidence related to calculating adherence metrics.

A new health care professional-based model for medication adherence

This paper presents a practice-based conceptual (theoretical) model to address medication adherence. The study reviews literature for different rationales of medication adherence and its associated factors. It also reviews the interventions involved in improving medication adherence and its effect. It is known that many interventions applied have not received great success owing to the fact that they have not been employed in regular clinical practice. Furthermore, models or theories utilized for different interventions were based on patient perspective only. The model presented in the paper is based on health care professionals' perspective, with an aim to be employed in clinical practice. The model framework is based on five premises on the basis of which the two dynamics, patient and health care professional, work. The model is presented with a graphical representation and exemplary procedural framework. It is also compared to other related procedural models. It is suggested that using such a model will allow medication adherence as an integral part of health care outcomes.

A Narrative Review of Medication Adherence Educational Interventions for Health Professions Students

Objective. To review published educational interventions focusing on medication non-adherence. Methods. A literature search was performed of educational articles on the topic of medication adherence. Data on interventions and learning assessments were abstracted for relevant studies meeting search criteria. Results. Twenty studies met inclusion criteria. Sixteen included pill-taking experiences with regimens of candies or placebos and varied in their inclusion of novel elements to highlight issues such as stigma, regimen complexity, and adherence measurement. Three studies involved interacting with the public. Qualitative and quantitative methods were used to assess a variety of learning outcomes. Conclusion. Pill-taking experiences can help future providers appreciate the complex logistics of medication-taking, but are less capable of addressing the psychosocial aspects of adherence. A promising area for learning is to interact with actual medication users to understand their experiences and perspectives.

Adherence to antiretroviral therapy and its determinants among persons living with HIV/AIDS in Bayelsa state, Nigeria

Background:

A high level of adherence is required to achieve the desired outcomes of antiretroviral therapy. There is paucity of information about adherence to combined antiretroviral therapy in Bayelsa State of southern Nigeria.

Objectives:

The objectives of the study were to determine the level of adherence to combined antiretroviral therapy among the patients, evaluate the improvement in their immune status and identify reasons for sub-optimal adherence to therapy.

Methods:

The cross-sectional study involved administration of an adapted and pretested questionnaire to 601 consented patients attending the two tertiary health institutions in Bayesla State,

Nigeria:

The Federal Medical Centre, Yenagoa and the Niger-Delta University Teaching Hospital Okolobiri. The tool was divided into various sections such as socio-demographic data, HIV knowledge and adherence to combined antiretroviral therapy. Information on the patient’s CD4+ T cells count was retrieved from their medical records. Adherence was assessed by asking patients to recall their intake of prescribed doses in the last fourteen days and subjects who had 95-100% of the prescribed antiretroviral drugs were considered adherent.

Results:

Three hundred and forty eight (57.9%) of the subjects were females and 253 (42.1%) were males. The majority of them, 557 (92.7%) have good knowledge of HIV and combined anti-retroviral therapy with a score of 70.0% and above. A larger proportion of the respondents, 441 (73.4%), had ≥95% adherence. Some of the most important reasons giving for missing doses include, “simply forgot” 147 (24.5%), and “wanted to avoid the side-effects of drugs” 33(5.5%). There were remarkable improvements in the immune status of the subjects with an increment in the proportion of the subjects with CD4+ T cells count of greater than 350 cells/mm3 from 33 (5.5%) at therapy initiation to 338 (56.3%) at study period (p<0.0001).

Conclusion:

The adherence level of 73.4% was low which calls for intervention and improvement. The combined antiretroviral therapy has significantly improved the immune status of the majority of patients which must be sustained. “Simply forgot” was the most important reason for missing doses.

Are community-based pharmacists underused in the care of persons living with HIV? A need for structural and policy changes

OBJECTIVE

To describe community pharmacists' perceptions on their current role in direct patient care services, an expanded role for pharmacists in providing patient care services, and changes needed to optimally use pharmacists' expertise to provide high-quality direct patient care services to people living with human immunodeficiency virus (HIV) infections.

DESIGN

Cross-sectional study.

SETTING

Four Midwestern cities in the United States in August through October 2009.

PARTICIPANTS

28 community-based pharmacists practicing in 17 pharmacies.

INTERVENTIONS

Interviews.

MAIN OUTCOME MEASURES

Opinions of participants about roles of specialty and nonspecialty pharmacists in caring for patients living with HIV infections.

RESULTS

Pharmacists noted that although challenges in our health care system characterized by inaccessible health professionals presented opportunities for a greater pharmacist role, there were missed opportunities for greater level of patient care services in many community-based nonspecialty settings. Many pharmacists in semispecialty and nonspecialty pharmacies expressed a desire for an expanded role in patient care congruent with their pharmacy education and training.

CONCLUSION

Structural-level policy changes needed to transform community-based pharmacy settings to patient-centered medical homes include recognizing pharmacists as important players in the multidisciplinary health care team, extending the health information exchange highway to include pharmacist-generated electronic therapeutic records, and realigning financial incentives. Comprehensive policy initiatives are needed to optimize the use of highly trained pharmacists in enhancing the quality of health care to an ever-growing number of Americans with chronic conditions who access care in community-based pharmacy settings.

Assessing the adherence to and the therapeutic effectiveness of hypolipidemic agents in a population of patients in Brazil: a retrospective cohort study

Objective

to evaluate the relation between patient adherence and therapeutic effectiveness of hypolipidemic agents in clinical practice.

Methods

A retrospective cohort study of 417 patients using hypolipidemic drugs (simvastatin, atorvastatin) between 2003 and 2010 was performed. The population studied consists of patients assisted by the Public Health Service in the far-west region of the State of Santa Catarina, Brazil. The Medication Possession Ratio obtained from pharmacy refill data was used to measure patient adherence. Therapeutic effectiveness was evaluated based on the difference obtained in the serum levels of total cholesterol, LDL-cholesterol, HDL-cholesterol and triglycerides, before and after taking the drug, in an average time of 8.3 months.

Results

Following the treatment with hypolipidemic agents, it has been observed a reduction of 14.3% for total cholesterol, 19.6% for LDL-cholesterol, and 14.4% for triglycerides. HDL-cholesterol increased by an 8.0% average. The major changes in lipid profile were promoted by atorvastatin 20 mg daily. The medication adherence rate decreased over the monitoring period. Adherence rates below 60% were associated with therapeutic failure, while rates equal to 80% or higher were associated with the best response to the lipid-lowering drugs.

Conclusion

Adherence to hypolipidemic agents is higher at the beginning of the treatment, but it decreases over time, affecting the achievement of therapeutic goals.

Community-Based Pharmacists’ Needs for HIV-Related Training and Experience

Objective:

To examine pharmacists’ self-reported competence in providing care to persons living with HIV (PLWH) and their HIV-related training and experience needs.

Methods:

We interviewed 28 community-based pharmacists providing care to PLWH in 4 Midwestern cities. Results: Less than half (46%) of the pharmacists considered themselves competent to provide PLWH care, and less than a third (29%) worked with PLWH during their pharmacy residency. Specialty pharmacists need training on opportunistic infections and HIV-related comorbidities, nonspecialty pharmacists need general training in HIV treatment and patient communications skills, and all pharmacists require a mechanism to keep updated in the latest HIV treatment recommendations.

Conclusion:

In the current era of patient-centered care, a pharmacist that is well rounded—not just in dispensing antiretroviral medications but highly knowledgeable in different aspects of ART and HIV-specific patient care—can make a valuable contribution to the health care team. Pharmacy school curricula and continuing professional education need to be aligned to meet the knowledge and competency needs of community pharmacists who are strategically positioned to provide care to PLWH.

Women and men report different behaviours in, and reasons for medication non-adherence: a nationwide Swedish survey

Objective

The aim of the present study was to analyse gender differences in self-reported non-adherence (NA) to prescribed medication in the Swedish general population. We aimed to study unintentional and intentional NA as well as the reasons given for NA.

Methods

A questionnaire was mailed to a cross-sectional, random, national sample of people aged 18-84 years in Sweden (n=7985). The response rate was 61.1% (n=4875). The questionnaire covered use of prescription drugs, NA behaviour and reasons for NA.

Results

Use of prescription drugs was reported by 59.5% (n=2802) of the participants, and 66.4% (n=1860) of these participants did not adhere to the prescribed regimen. No overall gender differences in reporting NA were found. However, when analysing the various types of NA behaviour and the reasons for NA, different gender patterns emerged. Men were more likely to report forgetting [OR=0.77 (95%CI 0.65:0.92)], changing the dosage [OR=0.64 (95%CI 0.52:0.79)] and that they had recovered [14.3%, (OR=0.71 (95%CI 0.56:0.90)] as a reason. In contrast, more women than men reported filling the prescription but not taking the drug [OR=1.25 (95%CI 1.02:1.54)] and reported the development of adverse drug reactions (ADRs) [OR=1.89 (95%CI 1.37:2.59)] as a reason more commonly. The gender differences remained, in most cases, after controlling for confounders such as age, socioeconomic factors, medical problems and attitudes toward drugs.

Conclusions

Women and men have different patterns of NA behaviour and different reasons for NA. Therefore, if adherence is to be improved, a wide knowledge of all the reasons for NA is required, along with an understanding of the impact of gender on the outcomes.

Measuring the rate of therapeutic adherence among outpatients with T2DM in Egypt

BACKGROUND AND OBJECTIVE

The promotion of therapeutic adherence is considered as an integral component of pharmaceutical care practice and patient healthcare. It has been shown that despite effective methods of treatment, 50% of diabetic patients fail to achieve satisfactory glycemic control, which leads to accelerated development of complications and increased mortality. Clinical experience indicates that no improvement of metabolic control is possible without patients' adherence to medications. This study sought to examine the rate of medication adherence and different factors affecting it among Type 2 diabetic patients in Egypt.

METHODS

A total of 226 Type 2 diabetic patients who fulfilled the inclusion criteria were recruited in the current study. Adherence to the treatment was evaluated during patients' hospitalization in the Outpatient Clinics of Internal Medicine Department at University of Mansoura, Egypt. The medication adherence has been assessed during a personal interview with each patient using a multiple-choice graded questionnaire.

RESULTS

In the study population, the adherence rates to medication, dietary/exercise and appointment were observed to be suboptimal. The most important social factors that were significantly affecting adherence rate to the prescribed oral hypoglycemic agent(s) included marital status (P < 0.01), family support (P < 0.01), and socio-economical level (P < 0.01). Other patient factors that were significantly affecting therapeutic adherence were patient knowledge about the disease (P < 0.01), patients' beliefs and motivation about prescribed drugs (P < 0.01), and regularity of patients' self monitoring of blood glucose level (P < 0.01). Among drug factors which found to affect significantly the rate of medication adherence are the number of drugs taken (P < 0.05), complexity of drug regimen (P < 0.01), and the presence of drug side effects (P < 0.01). Economical factor played an equally important role. Direct and indirect care costs in relation to patients' income were significantly affecting the rate of adherence to medication (P < 0.01).

CONCLUSIONS

An improvement with the adherence to oral hypoglycemic agent(s) may be achieved through continuing patient education about diabetes, improvement of patients' economical levels as well as a reduction in the cost of medication. Pharmaceutical companies have to be involved and pharmacists have to be payed for helping chronically ill patients to take their medicines correctly for improving clinical outcomes.

Medication adherence: a review of pharmacy education, research, practice and policy in Finland

AIMS

To describe pharmacy education, research, practice and policy related to medication adherence in Finland since the year 2000.

METHODS

The three universities that provide pharmacy education (Åbo Akademi, University of Eastern Finland, and University of Helsinki) completed a structured pro-forma questionnaire regarding education related to medication adherence. A MEDLINE and EMBASE literature search was performed to identify English language peer-reviewed research that reported medication compliance, adherence or persistence. The Ministry of Social Affairs and Health was invited to nominate policies and documents related to medication adherence. A narrative review of medication counselling practices and professional service delivery through Finnish community pharmacies was undertaken.

RESULTS

Medication adherence was a theme integrated into obligatory and elective courses for bachelors and masters degree students. The literature search identified 33 English language peer-reviewed research articles reporting medication compliance, adherence or persistence published since the year 2000. Policy documents of the Ministry of Social Affairs and Health recognise that poor medication adherence may lead to suboptimal treatment outcomes, and encourage patient participation in treatment decision making. Adherence practice in Finnish pharmacies has been strongly linked to the development of medication counselling services.

CONCLUSIONS

Adherence research and education has focused on understanding and addressing the contextual factors that contribute to medication nonadherence. Adherence practice in community pharmacies has tended to focus on medication counselling and programs specific to particular disease states. Medication adherence is a topic that is integrated into courses for bachelor's and master's level pharmacy students in Finland.

Adherence policy, education and practice - an international perspective

Nonadherence to chronic therapy has become a large burden on the healthcare system of many countries. Community pharmacists are well positioned to address nonadherence as part of their overall patient care activities, and contribute to patients’ quality use of medicines. Between 2008 and 2010, a series of narrative, peer-reviewed articles were published in Pharmacy Practice which focused on community pharmacists’ activities in medication adherence, specifically in the areas of the education they receive, their practice, the research conducted and national or local policies. This editorial aims to summarise the key findings presented in the series, and highlight the pertinent issues and gaps in the literature. There is a need to implement global and long-term objectives focussing on enhancing the quality of education and competencies of community pharmacists and the research conducted in medication adherence, to develop guidelines for pharmacists and enhance the uptake of adherence promoting services in routine care.