Reprint of: Psychosocial factors associated with pharmacists' antidepressant drug treatment monitoring

OBJECTIVE

Patients undergoing antidepressant drug treatment (ADT) may face challenges regarding its adverse effects, adherence, and efficacy. Community pharmacists are well positioned to manage ADT-related problems. Little is known about the factors influencing pharmacists' ADT monitoring. This study aimed to identify the psychosocial factors associated with pharmacists' intention to perform systematic ADT monitoring and report on this monitoring.

DESIGN

Cross-sectional study based on the Theory of Planned Behavior (TPB).

SETTING AND PARTICIPANTS

Community pharmacists in the province of Quebec, Canada.

OUTCOME MEASURES

Pharmacists completed a questionnaire on their performance of ADT monitoring, TPB constructs (intention; attitude; subjective norm; perceived behavioral control; and attitudinal, normative, and control beliefs), and professional identity. Systematic ADT monitoring was defined as pharmacists' reporting 4 or more consultations with each patient during the first year of ADT to address adverse effects, adherence, and efficacy. Hierarchical linear regression models were used to identify the factors associated with the intention and reporting of systematic ADT monitoring and Poisson working models to identify the beliefs associated with intention.

RESULTS

A total of 1609 pharmacists completed the questionnaire (participation = 29.6%). Systematic ADT monitoring was not widely reported (mean score = 2.0 out of 5.0), and intention was moderate (mean = 3.2). Pharmacists' intention was the sole psychosocial factor associated with reporting systematic ADT monitoring (P < 0.0001; R² = 0.370). All TPB constructs and professional identity were associated with intention (P < 0.0001; R² = 0.611). Perceived behavioral control had the strongest association.

CONCLUSION

Interventions to promote systematic ADT monitoring should focus on developing a strong intention among pharmacists, which could, in turn, influence their practice. To influence intention, priority should be given to ensuring that pharmacists feel capable of performing this monitoring. The main barriers to overcome were the presence of only 1 pharmacist at work and limited time. Other factors identified offer complementary intervention targets.

Psychosocial factors associated with pharmacists' antidepressant drug treatment monitoring

OBJECTIVE

Patients undergoing antidepressant drug treatment (ADT) may face challenges regarding its adverse effects, adherence, and efficacy. Community pharmacists are well positioned to manage ADT-related problems. Little is known about the factors influencing pharmacists' ADT monitoring. This study aimed to identify the psychosocial factors associated with pharmacists' intention to perform systematic ADT monitoring and report on this monitoring.

DESIGN

Cross-sectional study based on the Theory of Planned Behavior (TPB).

SETTING AND PARTICIPANTS

Community pharmacists in the province of Quebec, Canada.

OUTCOME MEASURES

Pharmacists completed a questionnaire on their performance of ADT monitoring, TPB constructs (intention; attitude; subjective norm; perceived behavioral control; and attitudinal, normative, and control beliefs), and professional identity. Systematic ADT monitoring was defined as pharmacists' reporting 4 or more consultations with each patient during the first year of ADT to address adverse effects, adherence, and efficacy. Hierarchical linear regression models were used to identify the factors associated with the intention and reporting of systematic ADT monitoring and Poisson working models to identify the beliefs associated with intention.

RESULTS

A total of 1609 pharmacists completed the questionnaire (participation = 29.6%). Systematic ADT monitoring was not widely reported (mean score = 2.0 out of 5.0), and intention was moderate (mean = 3.2). Pharmacists' intention was the sole psychosocial factor associated with reporting systematic ADT monitoring (P < 0.0001; R² = 0.370). All TPB constructs and professional identity were associated with intention (P < 0.0001; R² = 0.611). Perceived behavioral control had the strongest association.

CONCLUSION

Interventions to promote systematic ADT monitoring should focus on developing a strong intention among pharmacists, which could, in turn, influence their practice. To influence intention, priority should be given to ensuring that pharmacists feel capable of performing this monitoring. The main barriers to overcome were the presence of only 1 pharmacist at work and limited time. Other factors identified offer complementary intervention targets.

TREATMENT COMPLETION AND IMPLEMENTATION BY PATIENTS INITIATING TICAGRELOR

BACKGROUND

In secondary prevention of adverse events and death following acute coronary syndrome, patients may benefit from adhering to a ticagrelor treatment.

OBJECTIVES

The authors assessed the proportion of new ticagrelor users who completed 12 months of treatment, explored the factors associated with treatment completion and, among the completers, evaluated the 12-month treatment implementation.

METHODS

A retrospective administrative health database inception cohort study was conducted in a population that included Quebec residents ≥18 years of age who initiated ticagrelor between January 1, 2012 and March 31, 2014. A patient still on ticagrelor at the end of the 12-month period after treatment initiation was considered to have completed the treatment. Factors associated with treatment completion were identified using log-binomial regression. Implementation was assessed using the proportion of days covered (PDC).

RESULTS

Of the 3,600 patients, 2,235 (62.1%) completed 12 months of treatment. The patients who were more likely to complete their treatment included those who had visited a general practitioner, had a percutaneous coronary intervention, used a statin or fibrate, and those who used an antihypertensive drug during the year preceding the ticagrelor treatment initiation. Older patients, those with atrial fibrillation, those who had ≥ 6 physician visits and those who used an anticoagulant were less likely to complete the 12-month treatment. The median PDC was 96.2%.

CONCLUSION

Treatment completion might be improved. Among patients who completed the treatment, implementation was high. The factors associated with completion could help to identify patients who might benefit from interventions that aim to optimize treatment completion.

Risk of pulmonary toxicity of bleomycin and filgrastim

OBJECTIVES

To estimate the relative risk of pulmonary toxicity in patients exposed to a bleomycin-based chemotherapy including filgrastim compared to a similar chemotherapy without filgrastim.

METHODS

We conducted a nested case-control study of patients treated with BEP (bleomycin, etoposide and cisplatin) for germ cell cancer or with ABVD (doxorubicin, bleomycin, vinblastine and dacarbazine) for Hodgkin's lymphoma at the Hôtel-Dieu de Lévis Hospital between 31 October 2000 and 30 June 2016. The relative risk was estimated by an adjusted odds ratio (aOR) using a propensity score-adjusted regression analysis.

RESULTS

Thirteen cases of pulmonary toxicity, representing 14.7% of the 88 patients included in the study, were matched with 65 controls. A higher proportion of women (31.8%) than men (11.3%) developed pulmonary toxicity although the difference was not statistically significant (P = 0.08). Within the cohort, two deaths related to lung toxicity were observed among cases where no filgrastim was used. The risk of pulmonary toxicity associated with the addition of filgrastim was not statistically significant (aOR = 2.48 95% CI = 0.50 to 12.19).

CONCLUSION

The results add further evidence that the concomitant use of filgrastim might not increase the risk of pulmonary toxicity of bleomycin. It also suggests that female patients might be more likely to develop this adverse effect. A clinical trial would be needed to confirm this result.

Neighbourhood Material and Social Deprivation and Exposure to Antidepressant Drug Treatment: A Cohort Study Using Administrative Data

OBJECTIVE

To assess whether neighbourhood deprivation is associated with exposure to an antidepressant drug treatment (ADT) and its quality among individuals diagnosed with unipolar depression and insured by the Quebec public drug plan.

METHOD

We conducted an administrative database cohort study of adults covered by the Quebec public drug plan who were diagnosed with a new episode of unipolar depression. We assessed material and social deprivation using an area-based index. We considered exposure to an ADT as having ≥1 claim for an ADT within the 365 days following depression diagnosis. Among those exposed to ADT, ADT quality was assessed with 3 indicators: first-line recommended ADT, persistence with the ADT, and compliance with the ADT. Generalized linear models were used to estimate adjusted prevalence ratios (aPR) and 95% confidence intervals (95% CI).

RESULTS

Of 100,432 individuals with unipolar depression, 65,436 (65%) were exposed to an ADT in the year following the diagnosis. Individuals living in the most materially deprived areas were slightly more likely to be exposed to an ADT than those living in the least deprived areas (aPR, 1.04; 95% CI, 1.03 to 1.06). The likelihoods of being exposed to a first-line ADT, persisting for the minimum recommended duration and complying with the ADT were independent of the deprivation levels.

CONCLUSIONS

Neighbourhood deprivation was not associated with ADT quality among individuals insured by the Quebec public drug plan. It might be partly attributable to the public drug plan whose goal is to provide equitable access to prescription drugs regardless of income.

Measuring adherence to oral antidiabetic multi-drug treatment: Comparative validity of prescription claims-based adherence measures against hospitalization

BACKGROUND

The use of prescription claims data to measure adherence to diabetes treatment is very common in research. However, there is no clear evidence regarding the accuracy of the methods used to assess adherence to multi-drug treatments for the many patients using multiple antidiabetic drugs.

PURPOSE

To assess the validity of prescription claims-based adherence measures in the context of multiple oral antidiabetic drug treatment.

METHODS

A cohort of patients who began their antidiabetic drug treatment with at least two oral antidiabetic drugs (new users) was created using Quebec medico-administrative data. Four different prescription claims-based adherence measures were assessed: proportion of days covered (PDC) by at least one class of drugs, mean PDC, PDC by all classes and daily polypharmacy possession ratio (DPPR). All-cause and diabetes-related hospitalizations were the validation criteria. To assess the validity of the measures, receiver operating characteristic (ROC) curves were plotted for each measure and each criterion.

RESULTS

A total of 5982 individuals were included. The areas under the ROC curves for the PDC by at least one class of drugs, the mean PDC, the PDC by all classes of drugs and the DPPR were respectively 0.54 (95% CI: 0.52-0.56), 0.51 (0.49-0.53), 0.50 (0.48-0.52) and 0.51 (0.49-0.53) with all-cause hospitalization as criterion and 0.55 (0.53-0.57), 0.53 (0.51-0.55), 0.51 (0.49-0.53) and 0.53 (0.51-0.55) using diabetes-related hospitalization as criterion.

CONCLUSIONS

The results suggest that all measures have poor validity in predicting hospitalizations thus raising concerns about their utility in the assessment of adherence to multi-drug treatment. Future research should assess the capacity of these measures to predict other outcomes more closely related to medication adherence.

Avoidable workload of care for patients living with HIV infection in Abidjan, Côte d'Ivoire: A cross-sectional study

OBJECTIVE

People living with HIV infection (PLWHIV) in Sub-Saharan Africa cope with an increasing workload of care (doctor visits, lab tests, medication management, refills, etc.) in a context of poor health service organization. We aimed to describe the workload of care for PLWHIV in Sub-Saharan Africa and assess to what extent simple adjustments in care organization could reduce this workload of care.

METHODS

Adult PLWHIV under antiretroviral treatment for at least 1 year were recruited in three centers (two public, one private) in Abidjan, Côte d'Ivoire. Using methods inspired from sociology, we precisely described all health-related activities (HRAs) performed by patients, in 1 month, in terms of time, money and opportunity costs. Then, we assessed the theoretical avoidable workload of care if patients' visits and tests had been grouped on the same days.

RESULTS

We enrolled 476 PLWHIV in the study. Patients devoted 6.7 hours (SD = 6.3), on average, in HRAs per month and spent 5% (SD = 11) of their monthly revenue, on average, on health activities. However, we found great inter-patient heterogeneity in the mixture of activities performed (managing medications; dietary recommendations; visits, tests, support groups; administrative tasks; etc.) and their time allocation, temporal dispersion and opportunity costs (personal, familial, social or professional costs). For 22% of patients, grouping activities on the same days could reduce both time and cost requirements by 20%.

CONCLUSION

PLWHIV in Côte d'Ivoire have a heavy workload of care. Grouping visits and tests on the same days may be a simple and feasible way to reduce patients' investment of time and money in their care.

The Development of a Community Pharmacy-Based Intervention to Optimize Patients' Use of and Experience with Antidepressants: A Step-by-Step Demonstration of the Intervention Mapping Process

Objective: To describe the development of a community pharmacy-based intervention aimed at optimizing experience and use of antidepressants (ADs) for patients with mood and anxiety disorders. Methods: Intervention Mapping (IM) was used for conducting needs assessment, formulating intervention objectives, selecting change methods and practical applications, designing the intervention, and planning intervention implementation. IM is based on a qualitative participatory approach and each step of the intervention development process was conducted through consultations with a pharmacists' committee. Results: A needs assessment was informed by qualitative and quantitative studies conducted with leaders, pharmacists, and patients. Intervention objectives and change methods were selected to target factors influencing patients' experience with and use of ADs. The intervention includes four brief consultations between the pharmacist and the patient: (1) provision of information (first AD claim); (2) management of side effects (15 days after first claim); (3) monitoring treatment efficacy (30-day renewal); (4) assessment of treatment persistence (2-month renewal, repeated every 6 months). A detailed implementation plan was also developed. Conclusion: IM provided a systematic and rigorous approach to the development of an intervention directly tied to empirical data on patients' and pharmacists' experiences and recommendations. The thorough description of this intervention may facilitate the development of new pharmacy-based interventions or the adaptation of this intervention to other illnesses and settings.

Effectiveness of motivational interviewing interventions on medication adherence in adults with chronic diseases: a systematic review and meta-analysis

Background

Medication adherence is frequently suboptimal in adults with chronic diseases, resulting in negative consequences. Motivational interviewing (MI) is a collaborative conversational style for strengthening a person's motivation and commitment to change. We aimed to assess whether MI interventions are effective to enhance medication adherence in adults with chronic diseases and to explore the effect of individual MI intervention characteristics.

Methods

We searched electronic databases and reference lists of relevant articles to find randomized controlled trials (RCTs) that assessed MI intervention effectiveness on medication adherence in adults with chronic diseases. A random-effects model was used to estimate a pooled MI intervention effect size and its heterogeneity (I 2 ). We also explored the effects of individual MI characteristics on MI intervention effect size using a meta-regression with linear mixed model.

Results

: Nineteen RCTs were identified, and 16 were included in the meta-analysis. The pooled MI intervention effect size was 0.12 [95% confidence interval (CI) = (0.05, 0.20), I 2 = 1%]. Interventions that were based on MI only [β = 0.183, 95% CI = (0.004, 0.362)] or those in which interventionists were coached during intervention implementation [β = 0.465, 95% CI = (0.028, 0.902)] were the most effective. MI interventions that were delivered solely face to face were more effective than those that were delivered solely by phone [β = 0.270, 95% CI = (0.041, 0.498)].

Conclusions

This synthesis of RCTs suggests that MI interventions might be effective at enhancing of medication adherence in adults treated for chronic diseases. Further research is however warranted, as the observed intervention effect size was small.

Patient perspectives on the role of community pharmacists for antidepressant treatment: A qualitative study

Objectives

Patients prescribed antidepressant drug treatment (ADT) for major depression report several needs in relation to their treatment, and a large proportion of these patients will end ADT prematurely. Community pharmacists may play an important role in monitoring ADT and supporting these patients. However, little is known about patient experiences of the services provided in community pharmacies. The objectives of this study were to 1) explore patients' experiences with the services community pharmacists provide for ADT and 2) identify potential avenues for improvement of pharmacists' services within the context of ADT.

Methods

A qualitative descriptive exploratory study was conducted among individuals diagnosed with major depression who had initiated ADT at some point in the 12 months prior to their participation in the study. A total of 14 persons recruited in a local health centre and a community-based organization participated in individual interviews. A thematic analysis of the interview transcripts was conducted.

Results

Pharmacists tend to concentrate their involvement in treatment at initiation and at the first refill when questions, uncertainties and side effects are major issues. Patients felt that the pharmacists' contributions consisted of providing information and reassurance; in these respects, their needs were met. Participants had few ideas as to what additional services pharmacists could implement to improve patients' experience with ADT. Patients' sole expectations were that pharmacists extend this information role to the whole length of the treatment and enhance the confidentiality of discussions in pharmacy.

Conclusion

Pharmacists should provide counselling throughout the entire treatment rather than passively waiting for patients to ask their questions. However, facilitation of open discussions may not be achieved unless confidentiality at pharmacies is secured.

Factors associated with antidiabetic medication non-adherence in patients with incident comorbid depression

AIM

To identify factors associated with antidiabetic drug (AD) non-adherence among patients with type 2 diabetes and depression.

STUDY DESIGN AND SETTINGS

We conducted a population-based retrospective cohort study among new AD users with a diagnosis of depression following AD initiation. We used public health insurance data from Quebec. The dependent variable was non-adherence (i.e., <90% of days covered by ≥1AD) in the year after a depression diagnosis. Different sociodemographic, clinical and medication-related variables were assessed as potential factors of non-adherence to AD treatment. We performed univariate and multivariate logistic regressions.

RESULTS

We identified 3106 new users of ADs with a diagnosis of depression between 2000 and 2006. Of these individuals, 52% were considered non-adherent to their ADs. Baseline non-adherence, younger age, the addition of another AD to the initial treatment, <4 drug claims, visits with several different physicians, high socioeconomic status, and a small number of diabetes complications were associated with AD non-adherence.

CONCLUSIONS

The factors identified in the present study may help clinicians recognize patients with type 2 diabetes and incident depression at increased risk for non-adherence. In these patients, close follow-up and targeted interventions could help improve adherence to AD treatment, improve glycemic control and reduce complications.

The Association between Depression and Medication Nonpersistence in New Users of Antidiabetic Drugs

OBJECTIVES

To measure the association between depression and nonpersistence with antidiabetic drugs (ADs) among new users of oral ADs and to estimate factors associated with nonpersistence among these new users with depression.

METHODS

We used administrative claims data to identify an adult cohort (≥18 years) of new oral AD users who were free of depression. We followed the patients from AD initiation until either discontinuation, ineligibility for the public drug plan, death, or the end of the study. A proportional hazard Cox regression model with depression as a time-dependent variable was used to compute the adjusted hazard ratio of nonpersistence. A proportional hazard Cox regression model was also used to identify factors associated with nonpersistence in the subcohort of patients with depression.

RESULTS

We identified 114,366 new oral AD users, of whom 4,808 were diagnosed with depression during the follow-up. A greater proportion (55.4%) of patients with depression (vs. 42.5% without depression) discontinued their treatment during the follow-up. The adjusted hazard ratio of nonpersistence with ADs was 1.52 (95% confidence interval 1.41-1.63). Among patients with depression, independent factors associated with nonpersistence included younger age at oral AD initiation (<45 years) and starting treatment with drugs other than metformin (especially polytherapy with insulin).

CONCLUSIONS

Patients with depression are more likely to discontinue their treatment. Health care professionals should pay attention to patients on AD therapy who also suffer from depression, especially if the patients are young or are using insulin because these patients are at an increased risk of nonpersistence.

Improving medication adherence among community-dwelling seniors with cognitive impairment: a systematic review of interventions

Background Medication non-adherence may lead to poor therapeutic outcomes. Cognitive functions deteriorate with age, contributing to decreased adherence. Interventions have been tested to improve adherence in seniors with cognitive impairment or Alzheimer disease (AD), but high-quality systematic reviews are lacking. It remains unclear which interventions are promising. Objectives We conducted a systematic review to identify, describe, and evaluate interventions aimed at improving medication adherence among seniors with any type of cognitive impairment. Methods Following NICE guidance, databases and websites were searched using combinations of controlled and free vocabulary. All adherence-enhancing interventions and study designs were considered. Studies had to include community dwelling seniors, aged 65 years or older, with cognitive impairment, receiving at least one medication for a chronic condition, and an adherence measure. Study characteristics and methodological quality were assessed. Results We identified 13 interventions, including six RCTs. Two studies were of poor, nine of low/medium and two of high quality. Seven studies had sample sizes below 50 and six interventions focused on adherence to AD medication. Six interventions tested a behavioral, four a medication oriented, two an educational and one a multi-faceted approach. Studies rarely assessed therapeutic outcomes. All but one intervention showed improved adherence. Conclusion Three medium quality studies showed better adherence with patches than with pills for AD treatment. Promising interventions used educational or reminding strategies, including one high quality RCT. Nine studies were of low/moderate quality. High quality RCTs using a theoretical framework for intervention selection are needed to identify strategies for improved adherence in these seniors.

Factors associated with adherence to asthma treatment with inhaled corticosteroids: A cross-sectional exploratory study

BACKGROUND

Understanding factors at the patient, provider or organizational level associated with inhaled corticosteroids (ICSs) adherence is important when planning adherence-enhancing interventions.

OBJECTIVE

To explore factors associated with adherence to ICS among patients with asthma aged 12-45 years.

METHODS

A cross-sectional study was conducted among patients with asthma reporting ICS prescription during the baseline interview of an intervention study. Three methods were used to measure ICS adherence: a 4-item self-report questionnaire, a single question (SQ) measuring past 7-day exposure to ICS and a medication possession ratio (MPR, i.e., the sum of ICS days of supply/365). We assessed 46 potential factors of ICS adherence derived from the Predisposing, Reinforcing and Enabling Constructs in Educational Diagnosis and Evaluation (PRECEDE) model. Their association with ICS adherence was measured using multivariate logistic regressions.

RESULTS

Among the 319 participants included, 16.0% were deemed adherent according to the 4-item questionnaire. This proportion was 43.0% and 9.1% for the SQ and the MPR method, respectively. Ten factors were associated with good ICS adherence. Among these factors, four were associated with adherence through one of the measuring methods: a low family income level, a high number of asthma drugs used, a good knowledge of asthma pathophysiology and the perception that following the ICS prescription was easy. Two factors emerged through more than one measure: perceiving asthma severity as moderate to very severe and perceiving a high risk of death if ICSs are not taken as prescribed.

CONCLUSION

ICS adherence was poor in those individuals with asthma. Future adherence-enhancing interventions could target the identified modifiable risk factors.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT02093013.

Association between interpersonal continuity of care and medication adherence in type 2 diabetes: an observational cohort study

BACKGROUND

Prior studies have shown that, compared to patients with a low level of interpersonal continuity of care, patients with a high level of continuity of care have a lower likelihood of hospital admission and emergency department visits, and a higher likelihood of patient satisfaction. We sought to determine whether higher levels of continuity of care are associated with medication persistence and compliance among new users of oral antidiabetic treatment.

METHODS

We conducted a medicoadministrative cohort study of new users of oral antidiabetics aged 18 years or more among people covered by the Quebec public drug plan. We excluded people with fewer than 730 days of treatment and those who had been in hospital for 275 days or more in the first or second year after initiation of antidiabetic treatment. We categorized continuity of care observed in the first year after treatment initiation as low, intermediate or high. The association between continuity of care and medication persistence and compliance was assessed using generalized linear models.

RESULTS

In this cohort of 60 924 new users of oral antidiabetic treatment, compared to patients with a high level of continuity of care, those with an intermediate and a low level of continuity of care were less likely to be persistent (adjusted prevalence ratio 0.97 [95% confidence interval (CI) 0.96-0.98] and 0.96 [95% CI 0.95-0.97], respectively) and compliant (adjusted prevalence ratio 0.98 [95% CI 0.97-0.99] and 0.95 [0.94-0.97], respectively) with their antidiabetic treatment.

INTERPRETATION

A higher level of interpersonal continuity of care was associated with a higher likelihood of drug persistence and compliance. Since the strength of this association was weak, further research is required to determine whether continuity of care plays a role in medication adherence.

Effect of contraindicated drugs for heart failure on hospitalization among seniors with heart failure: A nested case-control study

Little is known about the effect of nonsteroidal anti-inflammatory drugs (NSAIDs), thiazolidinediones (TZDs), nifedipine and nondihydropyridine calcium channel blockers (CCBs) usage on the risk of all-cause hospitalization among seniors with heart failure (HF). We assessed the risk of all-cause hospitalization associated with exposure to each of these drug classes, in a population of seniors with HF.Using the Quebec provincial databases, we conducted a nested case-control study in a population of individuals aged ≥65 with a first HF diagnosis between 2000 and 2009. Patients were considered users of a potentially inappropriate drug class if their date of hospital admission occurred in the interval between the date of the last drug claim and the end date of its days' supply. The risks of hospitalization were estimated using multivariate conditional logistic regression.Of the 128,853 individuals included in the study population, 101,273 (78.6%) were hospitalized. When compared to nonusers, users of NSAIDs (adjusted odds ratio: 1.16; 95% confidence interval: 1.13-1.20), TZD (1.09; 1.04-1.14), and CCBs (1.03; 1.01-1.05) had an increased risk of all-cause hospitalization, but not the users of nifedipine (1.00; 0.97-1.03).Seniors with HF exposed to a potentially inappropriate drug class are at increased risk of worse health outcomes. Treatment alternatives should be considered, as they are available.

Association between community pharmacy loyalty and persistence and implementation of antipsychotic treatment among individuals with schizophrenia

BACKGROUND

Non-adherence is a major obstacle to optimal treatment of schizophrenia. Community pharmacists are in a key position to detect non-adherence and put in place interventions. Their role is likely to be more efficient when individuals are loyal to a single pharmacy.

OBJECTIVE

To assess the association between the level of community pharmacy loyalty and persistence with and implementation of antipsychotic drug treatment among individuals with schizophrenia.

METHODS

A cohort study using databases from the Quebec health insurance board (Canada) was conducted among new antipsychotic users insured by Quebec's public drug plan. Level of community pharmacy loyalty was assessed as the number of pharmacies visited in the year after antipsychotics initiation. Persistence was defined as having an antipsychotic supply in the user's possession on the 730^th day after its initiation and implementation as having antipsychotics in the user's possession for ≥80% of the days in the second year after antipsychotics initiation (among persistent only). Generalized linear models were used to estimate adjusted prevalence ratios (aPR) and 95% confidence intervals (95%CI).

RESULTS

6,251 individuals were included in the cohort and 54.1% had their drug prescriptions filled in >1 pharmacy. When compared to those who had their prescriptions filled in a single pharmacy, those who had their prescriptions filled in ≥4 different pharmacies were 22% more likely to be non-persistent (aPR = 1.22; 95%CI = 1.10-1.37) and 49% more likely to have an antipsychotic for <80% of the days (aPR = 1.49; 95%IC = 1.28-1.74).

CONCLUSION

This first exploration of community pharmacy loyalty in the context of severe mental illness indicates that this healthcare organisation factor might be associated with antipsychotics persistence and implementation. Identification of individuals with low community pharmacy loyalty and initiatives to optimize community pharmacy loyalty could contribute to enhanced persistence and implementation.

Revisiting the internal consistency and factorial validity of the 8-item Morisky Medication Adherence Scale

Objective:

To assess the internal consistency and factorial validity of the adapted French 8-item Morisky Medication Adherence Scale in assessing adherence to noninsulin antidiabetic drug treatment.

Study Design and Setting:

In a cross-sectional web survey of individuals with type 2 diabetes of the Canadian province of Quebec, self-reported adherence to the antidiabetes drug treatment was measured using the Morisky Medication Adherence Scale-8. We assessed the internal consistency of the Morisky Medication Adherence Scale-8 with Cronbach’s alpha, and factorial validity was assessed by identifying the underlying factors using exploratory factor analyses.

Results:

A total of 901 individuals completed the survey. Cronbach’s alpha was 0.60. Two factors were identified. One factor comprised five items: stopping medication when diabetes is under control, stopping when feeling worse, feeling hassled about sticking to the prescription, reasons other than forgetting and a cross-loading item (i.e. taking drugs the day before). The second factor comprised three other items that were all related to forgetfulness in addition to the cross-loading item.

Conclusion:

Cronbach’s alpha of the adapted French Morisky Medication Adherence Scale-8 was below the acceptable value of 0.70. This observed low internal consistency of the scale is probably related to the causal nature of the items of the scale but not necessarily a lack of reliability. The results suggest that the adapted French Morisky Medication Adherence Scale-8 is a two-factor scale assessing intentional (first factor) and unintentional (second factor) non-adherence to the noninsulin antidiabetes drug treatment. The scale could be used to separately identify these outcomes using scores obtained on each of the sub-scales.

Factors associated with β-blocker initiation and discontinuation in a population-based cohort of seniors newly diagnosed with heart failure

PURPOSE

β-Blockers (bisoprolol, carvedilol, and metoprolol) are the cornerstone of heart failure (HF) management. The incidence rate of β-blocker initiation and discontinuation and their associated factors among seniors with a first HF diagnosis were assessed.

METHODS

A population-based inception cohort study that included all individuals aged ≥65 years with a first HF diagnosis in Quebec was conducted. β-Blockers initiation among 91,131 patients who were not using β-blockers at the time of HF diagnosis and discontinuation among those who initiated a β-blocker after HF diagnosis were assessed. Stepwise Cox regression analyses were used to calculate hazard ratios (HR) and to identify factors associated with β-blocker initiation and discontinuation.

RESULTS

After HF diagnosis, 32,989 (36.2%) individuals initiated a β-blocker. Of these, 15,408 (46.7%) discontinued their β-blocker during the follow-up. Individuals more likely to initiate a β-blocker were those diagnosed in a recent calendar year (2009: HR, 2.11; 95% confidence interval [CI], 2.00-2.23) and diagnosed by a cardiologist (HR, 1.38; 95% CI, 1.34-1.42). Individuals less likely to initiate were those aged ≥90 years (HR, 0.65; 95% CI, 0.61-0.68) and those with chronic obstructive pulmonary disease (HR, 0.66; 95% CI, 0.64-0.68). Individuals more likely to discontinue were those with more than nine medical consultations (HR, 1.14; 95% CI, 1.10-1.18) and those with dementia (HR, 1.13; 95% CI, 1.01-1.27). Individuals less likely to discontinue were those diagnosed in a recent calendar year (2009: HR 0.74; 95% CI, 0.65-0.82) and those exposed to another β-blocker before HF diagnosis (HR, 0.88; 95% CI, 0.85-0.91).

CONCLUSION

Quebec seniors seem to be underexposed to β-blocker following HF diagnosis. Among those who initiate β-blocker use, discontinuation is high. Better understanding of the underlying causes is needed to help target interventions to improve the management of HF.

Incidence of Depression and Associated Factors in Patients With Type 2 Diabetes in Quebec, Canada: A Population-Based Cohort Study

It has been reported that the risk of depression is higher among people with type 2 diabetes compared with a nondiabetic population. Among diabetic patients, depression has been associated with worse self-care behaviors, poor glycemic control, and an increased risk of diabetes complications. Identifying factors associated with the occurrence of depression may help physicians identify earlier diabetic patients at a high risk of developing depression, improve prevention, and accelerate proper treatment. To our knowledge, very few population-based studies have reported on the incidence of clinically diagnosed depression as a consequence of type 2 diabetes over a long follow-up period. The objective of this study was to estimate the incidence of clinically diagnosed depression among type 2 diabetic patients newly treated with oral antidiabetic drugs (ADs) and to identify factors associated with the occurrence of depression.Administrative claims data from the public health insurance plan were used to identify a cohort of new oral AD users aged ≥18 years between 2000 and 2006. Patients were followed from oral AD treatment initiation until the diagnosis of depression, ineligibility for the public drug plan, death, or the end of the study, whichever came first. Incidence rates were determined using person-time analysis. Factors associated with depression were identified using multivariable Cox regression analysis.We identified 114,366 new oral AD users, of which 4808 had a diagnosis of depression. The overall incidence rate of depression was 9.47/1000 person-years (PYs) (10.72/1000 PYs for women and 8.27/1000 PYs for men). The incidence of depression was higher during the year after oral AD treatment initiation. Independent factors associated with depression included having had mental disorders other than depression, hospitalization, a higher number of different drugs taken and of physicians visited during the year before oral AD initiation. Moreover, we observed a statistically significant age-by-socioeconomic status interaction.The incidence of diagnosed depression is higher during the first year after oral AD treatment initiation. Clinicians could pay particular attention to women, patients starting an AD at a young age, those with a low socioeconomic status, and especially those with a history of anxiety or dementia.

Predicting Noninsulin Antidiabetic Drug Adherence Using a Theoretical Framework Based on the Theory of Planned Behavior in Adults With Type 2 Diabetes: A Prospective Study

Understanding the process behind noninsulin antidiabetic drug (NIAD) nonadherence is necessary for designing effective interventions to resolve this problem. This study aimed to explore the ability of the theory of planned behavior (TPB), which is known as a good predictor of behaviors, to predict the future NIAD adherence in adults with type 2 diabetes. We conducted a prospective study of adults with type 2 diabetes. They completed a questionnaire on TPB variables and external variables. Linear regression was used to explore the TPB's ability to predict future NIAD adherence, which was prospectively measured as the proportion of days covered by at least 1 NIAD using pharmacy claims data. The interaction between past NIAD adherence and intention was tested. The sample included 340 people. There was an interaction between past NIAD adherence and intention to adhere to the NIAD (P = 0.032). Intention did not predict future NIAD adherence in the past adherers and nonadherers groups, but its association measure was high among past nonadherers (β = 5.686, 95% confidence interval [CI] -10.174, 21.546). In contrast, intention was mainly predicted by perceived behavioral control both in the past adherers (β = 0.900, 95% CI 0.796, 1.004) and nonadherers groups (β = 0.760, 95% CI 0.555, 0.966). The present study suggests that TPB is a good tool to predict intention to adhere and future NIAD adherence. However, there was a gap between intention to adhere and actual adherence to the NIAD, which is partly explained by the past adherence level in adults with type 2 diabetes.

Psychosocial factors associated with adherence to non-insulin antidiabetes treatments

AIMS

To discern psychosocial factors of non-insulin antidiabetes drug (NIAD) adherence.

METHODS

A cross-sectional study based on the theory of planned behavior (TPB). Adults with type 2 diabetes (T2D) who were members of Diabète Québec, a provincial association of persons with diabetes, and were prescribed at least one NIAD were invited to complete a web-based questionnaire. We measured variables ascertaining TPB constructs and other factors potentially associated with NIAD adherence (e.g., habit, social support, and mental health). NIAD adherence was assessed using the 8-item Morisky Medication Adherence Scale. Factors were identified using a multivariate logistic regression model.

RESULTS

In our study, 901 participants (373 women; 515 retired; mean age: 62.7 years) with T2D for a mean of 10 years, completed the questionnaire. Participants exhibited a high intention to adhere to their NIAD treatment (mean score=5.8/6), positive attitudes toward adherence (mean score=5.5/6), and elevated perceived behavioral control in taking their medication (mean score=5.7/6). Only 405 (45%) participants reported high adherence (score=8/8). Perceived behavioral control, habit, older age, no perceived side effects, a longer period since T2D diagnosis and a lower number of NIAD daily doses were significantly associated with adherence (p<0.05).

CONCLUSION

We identified several factors that may be modified for NIAD adherence and thereby provided insight into future adherence-enhancing intervention targets.

Persistence and compliance with newly initiated antihypertensive drug treatment in patients with chronic kidney disease

BACKGROUND

Patients with chronic kidney disease initiating an antihypertensive drug (AH) treatment must persist and comply with it to slow disease progression and benefit from the reduction of cardiovascular morbidity and mortality.

OBJECTIVES

This study evaluates the persistence and compliance with AH treatment and identifies the associated factors among chronic kidney disease patients who initiated AH treatment.

METHODS

A population-based cohort study using Quebec administrative data was conducted. Patients who still take any AH 1 year after initiation were considered persistent. Of these patients, those who had ≥80% of days covered with an AH in the year after initiation were considered compliant. Factors associated with persistence and compliance were identified using a modified Poisson regression.

RESULTS

Of the 7,119 eligible patients, 78.8% were persistent, 87.7% of whom were compliant with their AH treatment. Compared with patients on diuretic monotherapy, those who initially used angiotensin-converting enzyme inhibitor monotherapy, angiotensin II receptor blocker monotherapy, calcium channel blocker monotherapy, β-blocker monotherapy, or multidrug therapy were more likely to be persistent. In contrast, individuals who visited their physicians ≥17 times were less likely to be persistent than those who visited between 0 and 8 times. The patients who were more likely to be compliant had initially used an angiotensin-converting enzyme inhibitor, β-blocker, calcium channel blocker, or multitherapy as opposed to a diuretic.

CONCLUSION

A year after initiating AH treatment, nearly a third of chronic kidney disease patients were either not taking an AH or had not been compliant. Factors associated with persistence and compliance could help identify patients who need help in managing their AH treatment.

Effectiveness of an asthma integrated care program on asthma control and adherence to inhaled corticosteroids

OBJECTIVE

To measure the effectiveness of an integrated care program for individuals with asthma aged 12-45 years, on asthma control and adherence to inhaled corticosteroids (ICS).

METHODS

Researchers used a theoretical model to develop the program and assessed effectiveness at 12 months, using a pragmatic controlled clinical trial design. Forty-two community pharmacists in Quebec, Canada recruited participants with either uncontrolled or mild-to-severe asthma. One group was exposed to the program; another received usual care. Asthma control was measured with the Asthma Control Questionnaire; ICS adherence was assessed with the Morisky medication adherence scale and the medication possession ratio. Program effectiveness was assessed with an intention-to-treat approach using multivariate generalized estimating equation models.

RESULTS

Among 108 exposed and 241 non-exposed, 52.2% had controlled asthma at baseline. At 12-months, asthma control had improved in both groups but the interaction between study groups and time was not significant (p = 0.09). The proportion of participants with good ICS adherence was low at baseline. Exposed participants showed improvement in adherence and the interaction between study groups and time was significant (p = 0.02).

CONCLUSION

An integrated intervention, with healthcare professionals collaborating to optimize asthma control, can improve ICS adherence.

Association Between Loyalty to Community Pharmacy and Medication Persistence and Compliance, and the Use of Guidelines-Recommended Drugs in Type 2 Diabetes: A Cohort Study

Pharmacists record data on all drugs claimed and may build a personal relationship with their clients. We hypothesized that loyalty to a single pharmacy could be associated with a better quality of drug use.To assess the association between pharmacy loyalty and quality of drug use among individuals treated with oral antidiabetes drugs (OADs).This is a cohort study using Quebec Health Insurance Board data. Associations were assessed using multivariable logistic regression.New OAD users, aged ≥18 years.Individuals who filled all their prescription drugs in the same pharmacy during the first year of treatment were considered loyal. During year 2 of treatment we assessed 4 quality indicators of drug use: persistence with antidiabetes treatment, compliance with antidiabetes treatment among those considered persistent, use of an angiotensin-converting enzyme inhibitor or of an angiotensin II receptor blocker (ACEi/ARB), and use of a lipid-lowering drug.Of 124,009 individuals, 59.75% were identified as loyal. Nonloyal individuals were less likely to persist with their antidiabetes treatment (adjusted odds ratio = 0.89; 95% CI: 0.86-0.91), to comply with their antidiabetes treatment (0.82; 0.79-0.84), to use an ACEi/ARB (0.85; 0.83-0.88) and to use a lipid-lowering drug (0.83; 0.80-0.85). Quality of drug use decreased as the number of different pharmacies increased (linear contrast tests <0.001).Results underscore the important role pharmacists could play in helping their clients with chronic diseases to better manage their drug treatments. Further research is needed to determine to what extent the positive effects associated with pharmacy loyalty are specifically due to pharmacists.

Effectiveness and Content Analysis of Interventions to Enhance Oral Antidiabetic Drug Adherence in Adults with Type 2 Diabetes: Systematic Review and Meta-Analysis

OBJECTIVES

To estimate the pooled effect size of oral antidiabetic drug (OAD) adherence-enhancing interventions and to explore which of the behavior change techniques (BCTs) applied in the intervention groups modified this pooled intervention effect size.

METHODS

We searched relevant studies published until September 3, 2013, on MEDLINE, Embase, PsycInfo, the Cochrane Library, CINAHL, Current Contents Connect, and Web of Science. Selected studies were qualitatively synthesized, and those of at least medium quality were included in the meta-analysis. A random-effects model was used to pool effectiveness (Hedges's g) and to examine heterogeneity (Higgins I(2)). We also explored the influence on the pooled effectiveness of unique intervention BCTs (those delivered to the intervention groups but not control groups in a trial) by estimating their modifying effects.

RESULTS

Fourteen studies were selected for the qualitative synthesis and 10 were included in the meta-analysis. The pooled effectiveness of the interventions was 0.21 (95% confidence interval -0.05 to 0.47; I(2) = 82%). Eight unique BCTs were analyzed. "Cope with side effects" (P = 0.003) and "general intention formation" (P = 0.006) had a modifying effect on the pooled effectiveness. The pooled effectiveness of the interventions in which "cope with side effects" was applied was moderate (0.64; 95% confidence interval 0.31-0.96; I(2) = 56%).

CONCLUSIONS

The overall effectiveness of OAD adherence-enhancing interventions that have been tested is small. Helping patients cope with side effects or formulate desired treatment outcomes could have an impact on the effectiveness of OAD adherence-enhancing interventions. Only those interventions that include helping patients to cope with side effects appear to be particularly effective in improving OAD adherence.

Patients' beliefs about adherence to oral antidiabetic treatment: a qualitative study

PURPOSE

The purpose of this study was to elicit patients' beliefs about taking their oral antidiabetic drugs (OADs) as prescribed to inform the development of sound adherence-enhancing interventions.

METHODS

A qualitative study was performed. Adults with type 2 diabetes who had been taking an OAD for >3 months were solicited to participate in one of six focus groups. Discussions were facilitated using a structured guide designed to gather beliefs related to important constructs of the theory of planned behavior. Four coders using this theory as the theoretical framework analyzed the videotaped discussions.

RESULTS

Forty-five adults participated. The most frequently mentioned advantages for OAD-taking as prescribed were to avoid long-term complications and to control glycemia. Family members were perceived as positively influential. Carrying the OAD at all times, having the OAD in sight, and having a routine were important facilitating factors. Being away from home, not accepting the disease, and not having confidence in the physician's prescription were major barriers to OAD-taking.

CONCLUSION

This study elicited several beliefs regarding OAD-taking behavior. Awareness of these beliefs may help clinicians adjust their interventions in view of their patients' beliefs. Moreover, this knowledge is crucial to the planning, development, and evaluation of interventions that aim to improve medication adherence.

High users of emergency departments in Quebec among patients with both schizophrenia and a substance use disorder

OBJECTIVE

The study assessed factors associated over time with high use of emergency departments by patients in Quebec who had schizophrenia and a co-occurring substance use disorder.

METHODS

The cohort study included 2,921 patients who received a diagnosis of schizophrenia in 2006 and had at least one emergency department visit during fiscal year 2006-2007. Generalized estimating equations were used to estimate predictors of high use of emergency departments over time.

RESULTS

After adjustment for all covariates, predictors of high use over time were as follows: living in either a university medical region (OR=2.10) or a peripheral medical region (OR=2.10), frequent hospitalization (OR=1.16), and greater number of psychiatric (OR=1.64) or physical comorbidities (OR=1.23).

CONCLUSIONS

Because high use of emergency departments is a strong indicator of poor care continuity, identified associated factors could help develop and offer new programs to be deployed in the community to better support these patients with greater needs.

Disentangling the influence of neighborhood and individual characteristics on early residential mobility among newly diagnosed patients with schizophrenia: a multilevel analysis

PURPOSE

Early residential mobility of schizophrenic patients may relate to discontinuity of treatment and adverse outcome. However, factors influencing early residential mobility of these patients are still poorly examined. The aim of this study was to disentangle the influence of individual and neighborhood characteristics on early residential mobility of schizophrenic patients.

METHODS

The study used administrative data of 13, 400 individuals newly diagnosed with schizophrenia in Quebec between 2001 and 2002. These individuals were nested in 163 different health territories. Multilevel analyses were used to assess the contribution of individual and neighborhood characteristics on early residential mobility.

RESULTS

The final model indicates that at the individual level, being men, wonder patients and physical comorbidity increased the likelihood of early residential mobility whereas older patients were less likely to migrate earlier. The health territory level explains about 7 % of the variation of early residential mobility and variables influencing residential mobility at this level are the fourth and the third quartiles of the population density.

CONCLUSIONS

Factors influencing early residential mobility of schizophrenic patients are located at both individual and neighborhood levels. This suggests that policies targeting only one-level factors are unlikely to significantly delays early residential mobility.

Myocardial infarction and gastro-intestinal bleeding risks associated with aspirin use among elderly individuals with type 2 diabetes

INTRODUCTION

The benefit of aspirin in primary prevention of myocardial infarction and the associated gastro-intestinal bleeding risks have not been well established in the elderly population with diabetes.

METHODS

Using Quebec administrative databases, we conducted two nested case-control analyses within a cohort of individuals aged ≥ 66 years newly treated with an oral antidiabetes drug between 1998 and 2003. The 28,067 individuals had no cardiovascular disease recorded in the database in the year prior cohort entry. They had not used prescribed aspirin, antiplatelet, or anticoagulant drugs, and were not hospitalized for gastro-intestinal bleeding in the year prior cohort entry. The odds of myocardial infarction and gastro-intestinal bleedings were compared between individuals who were current, past, or non-users of aspirin.

RESULTS

There were 1101 (3.9%) cases of myocardial infarction. Compared to non-users, neither aspirin users (OR 0.89; 95% CI 0.71-1.13) nor aspirin past users (0.81; 0.62-1.06) showed a statistically significant lower risk of myocardial infarction. There were 373 (1.3%) cases of gastro-intestinal bleeding. Current users of aspirin had about a 2-fold greater risk of gastro-intestinal bleeding compared to non-users (2.19; 1.53-3.13).

CONCLUSIONS

Our results suggest that individual assessment of bleeding risk and cardiovascular risk is mandatory among elderly people with diabetes before introducing aspirin therapy.

Important treatment gaps in vascular protection for the elderly after type 2 diabetes therapy initiation

BACKGROUND

Canadian practice guidelines recommend the use of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) for vascular protection in individuals with diabetes who are at high risk of cardiovascular events, including those ≥ 65 years. We estimated the proportion of elderly persons who initiated an ACEI or an ARB in the year after beginning oral antidiabetes (OAD) treatment, and we identified factors associated with this initiation.

METHODS

Using the Quebec Health Insurance Board (RAMQ) databases, we conducted a population-based cohort study of individuals ≥ 65 years recently prescribed an OAD. We excluded those who were already taking an ACEI or ARB. Factors associated with ACEI or ARB initiation were identified using multivariate logistic regression.

RESULTS

Among 43,700 individuals, 13,621 (31.2%) initiated an ACEI or ARB in the year after beginning OAD. Individuals were more likely to begin an ACEI or an ARB if they initially received both metformin and a sulfonylurea, lived in a rural region, began OAD treatment between 2001 and 2006, were hospitalized, or had ≥ 22 medical visits in the year before OAD initiation. Individuals ≥ 75 years, those who were prescribed an OAD by a general practitioner, initially received a sulfonylurea, or received ≥ 4 different medications in the year before OAD initiation were less likely to begin an ACEI or ARB.

CONCLUSIONS

In the elderly not already taking ACEIs or ARBs, a low proportion of those undertaking OAD treatment are prescribed the recommended cardioprotection of an ACEI or ARB in the following year. Interventions are needed to close this treatment gap.

The adequacy of pharmaceutical treatment of schizophrenia in Quebec varies with age, but is not influenced by sex or neighbourhood deprivation

OBJECTIVE

Though high discontinuation rates for antipsychotics (APs) by patients with schizophrenia are frequently reported, the percentage of patients receiving pharmaceutical treatment for schizophrenia in routine practice in accordance with international clinical guidelines is unknown. Further, it is unknown if these rates are influenced by levels of neighbourhood deprivation or by a patient's age or sex. Our study aims to investigate if inequalities in AP treatment could be observed between patients living in neighbourhoods with the highest levels of material and social deprivation and those with the lowest deprivation levels, between patients from different age groups, or between men and women.

METHODS

We conducted a secondary analysis of medical-administrative data of a cohort of adult patients in the province of Quebec with a medical contact for schizophrenia in a 2-year period (2004-2005). We assessed the proportion of patients that filled at least 1 prescription for an AP and received adequate pharmaceutical treatment, defined as being in possession of APs at least 80% of the time as outpatients during a 2-year follow-up period.

RESULTS

Among the 30 544 study patients, 88.5% filled at least 1 prescription for an AP, and 67.5% of the treated patients received adequate treatment. Though no clinically significant differences were observed by deprivation or sex, younger age was associated with lower proportions of patients receiving adequate treatment (46% of treated patients aged between 18 and 29 years, compared with 72% aged between 30 and 64 years, and 77% aged 65 years and over).

CONCLUSIONS

In Quebec's routine practice, over 70% of treated patients aged 30 and over received adequate pharmacological treatment, regardless of sex or neighbourhood socioeconomic status. In contrast, in patients aged between 18 and 29 years this percentage was 47%. This is a discouraging finding, especially because optimal treatment in the early phase of disease is reported to result in the best long-term outcomes.

Spatio-temporal clustering of the incidence of schizophrenia in Quebec, Canada from 2004 to 2007

Exploring spatio-temporal patterns of disease incidence can help to identify areas of significantly elevated or decreased risk, providing potential etiologic clues. In this study, we present a spatio-temporal analysis of the incidence of schizophrenia in Quebec from 2004 to 2007 using administrative databases from the Régie de l'Assurance Maladie du Quebec and the hospital discharge database. We conducted purely spatial analyses for each age group adjusted by sex for the whole period using SatScan (version 9.1.1). Findings from the study indicated variations in the spatial clustering of schizophrenia according to sex and age. In term of incidence rate, there are high differences between urban and rural-remote areas, as well as between the two main metropolitan areas of the province of Quebec (Island of Montreal and Quebec-City).

Hypoglycemia-related emergency department visits and hypoglycemia-related hospitalizations among new users of antidiabetes treatments

OBJECTIVE

To describe the burden of severe hypoglycemia among new users of insulin and oral antidiabetes drugs (OAD) in terms of 2 hypoglycemia-related outcomes: emergency department (ED) visit and hospitalization.

METHODS

We conducted an inception cohort study using the databases of the Quebec health insurance board and the Quebec registry of hospitalizations. The source population was made of individuals 18 years of age or older who were newly dispensed an antidiabetes treatment made of either insulin or OAD between January 1, 2000 and December 31, 2008. Individuals were followed from initiation of antidiabetes treatment to December 31, 2008, occurrence of hypoglycemia-related outcome, loss of eligibility to the drug plan or death, whichever came first. Individuals' characteristics at antidiabetes treatment initiation were described using frequency distributions. The incidence rate for the occurrence of hypoglycemia-related ED visit and hypoglycemia-related hospitalization were calculated using the Kaplan-Meier method.

RESULTS

A total of 188 659 new users of antidiabetes treatment were included in the cohort. A total of 3575 (1.9%) individuals had at least 1 hypoglycemia-related ED visit whereas 194 (0.1%) had at least 1 hypoglycemia-related hospitalization. Incidence rates for the occurrence of hypoglycemia-related ED visits and hypoglycemia-related hospitalizations were 5.2 and 0.3 cases per 1000 patient years, respectively.

CONCLUSION

Although the incidence of ED visit or hospitalization due to hypoglycemia seems low, severe hypoglycemia episodes could be associated with a high economic burden.

Comparative safety of antipsychotics: another look at the risk of diabetes

OBJECTIVE

The association between the use of antipsychotics and diabetes mellitus (DM) is still unclear, as depicted by several conflicting reports. Our study aims to assess the risk of DM in new users of antipsychotics.

METHODS

Our nested case-control study used the Quebec Health Insurance Board databases. People in the source cohort were DM-free and had initiated an antipsychotic treatment. Subjects were cohort members who initiated an antidiabetic or had a diagnosis of DM during their follow-up period. Three variables were used to assess antipsychotic exposure: the antipsychotic used (any typical, clozapine, olanzapine, quetiapine, risperidone, or more than 1 drug); the number of 30-day periods of use; and antipsychotic use at index date (current or past). A paired multivariate logistic regression model was used to calculate adjusted odds ratios.

RESULTS

Among the 88 467 people included in the cohort, 6109 subjects with DM were identified and were matched to 61 090 control subjects. New users of quetiapine were less likely to develop DM than new users of typical antipsychotics (OR, 0.89; 95% CI 0.81 to 0.99). The risk of DM was not statistically different across the atypical antipsychotics. A longer exposure to any antipsychotic (for each 30-day period, OR 1.009; 95% CI 1.006 to 1.011) and current use of antipsychotics (OR 1.26; 95% CI 1.17 to 1.36) were associated with DM.

CONCLUSION

These results suggest that metabolic parameters of people exposed to antipsychotics should be monitored, irrespective of the drug taken, among the drugs available at the time of analysis.

[Health inequities in mood disorders based on material and social deprivation in dwelling sectors ]

OBJECTIVE

To compare mood disorder (MD) prevalence in Quebec in 2006, and compare health services and medication use, mortality and morbidity in patients with MD based on sex and the dwelling sector level of material and social deprivation. The objective was also to identify subgroups of individuals using health services in a larger proportion and having a higher risk of morbidity and mortality.

METHOD

We conducted a secondary analysis of the Régie de l’assurance maladie du Québec medico-administrative data. The cohort is composed of adults diagnosed with MD and living in Quebec in 2006. Variables include: physician consultation, medication demand, consultation for substance or alcohol abuse, emergency visit, hospitalization for a mental disorder, and death. Dwelling sector types are defined by crossing Pampalon material and social deprivation quintiles.

RESULTS

MD prevalence in 2006 was 3.06% (177 850 patients), with prevalence in women 1.7-fold with respect to men. Findings show a higher MD prevalence as well as a higher mortality and morbidity rate in materially and socially deprived dwelling sectors. Young men also represent a specifically vulnerable subgroup for many study variables.

CONCLUSION

Public policies aimed at improving material conditions (income, education, employment) and breaking out social isolation would have an important impact on the population mental health. Public health program development should pay close attention to young men population.

Acetylsalicylic acid for primary prevention of cardiovascular diseases in older patients with diabetes: do the benefits overcome the risks?

Cardiovascular diseases (CVDs) represent a huge health burden for older patients with diabetes. Acetylsalicylic acid (ASA) has long been used as a cardioprotective agent in primary and secondary prevention of CVD. However, there are important issues regarding the benefits and risks of ASA therapy in primary prevention of CVDs, for the older group in general and for individuals of all ages with diabetes. In this review, we summarize the benefits and risks related to ASA therapy by outlining the evidence for older patients and for patients with diabetes. There appear to be significant gaps in knowledge. The balance of benefits and risks is not well defined but ASA treatment seems to be unfavorable in many older patients.

Treatment prevalence and incidence of schizophrenia in Quebec using a population health services perspective: different algorithms, different estimates

PURPOSE

Using a population health services perspective, this article defines and assesses an efficient criteria-based algorithm to identify treatment prevalent and incident cases of schizophrenia. We refer here "treatment" prevalence and incidence since its evaluation depends on a patient receiving a health care service with a diagnosis of schizophrenia.

METHODS

A population-based cohort study was conducted among all adults having a hospital discharge or a physician claim for schizophrenia in the public health plan databases between January 1996 and December 2006. Four algorithms to characterize patients with schizophrenia were defined. To identify treatment incident cases in 2006, we removed from the treatment prevalent pool patients with a previous record of schizophrenia between 1996 and 2006 (10-year clearance period). Using this 10-year period as reference, Kappa coefficients (KC) and positive predictive values (PPV) were calculated to determine the "optimal" length of clearance period to identify incident cases.

RESULTS

The lifetime treatment prevalence and incidence of schizophrenia varied from 0.59 to 1.46% and from 42 to 94 per 100,000, respectively. When compared to the 10-year clearance period, the KC is excellent in a clearance period of 6-7 years. To achieve a PPV of 90%, a clearance period of 7-8 years would be necessary.

CONCLUSIONS

With an appropriate algorithm, treatment prevalence and incidence of schizophrenia can be conveniently estimated using administrative data. These estimates are a vital step toward appropriate planning of services for schizophrenia.

Persistence patterns with oral antidiabetes drug treatment in newly treated patients--a population-based study

OBJECTIVE

We assessed persistence patterns with oral antidiabetes drug (OAD) in patients newly dispensed with different OAD classes.

METHODS

We conducted a population-based cohort study using Quebec Health Insurance Board data. Patients aged 18 years or more newly dispensed an OAD between January 1, 1998 and December 31, 2003 were included in the study (n=98,940). Persistence was defined as consistently refilling a prescription for the initial OAD within three times the days' supply of the preceding claim. For nonpersistent patients, a second course of therapy was defined as treatment initiation with any OAD after a first discontinuation. Patients were followed from treatment initiation up to December 31, 2004, ineligibility for the drug plan or death, whichever came first, and treatment discontinuation or second course of treatment. Cox regression models were used to compute adjusted hazards ratios (AHR) of persistence and initiation of second courses of therapy.

RESULTS

The probability of persisting with the initial OAD over a 12-month period was 65% and 56% for patients initiated on metformin and sylfonylurea, respectively. Compared to metformin, the likelihood of discontinuing the initial OAD over the study period was significantly higher for patients on sulphonylureas (AHR: 1.32; 95% CI 1.29-1.34). Patients started on sulphonylureas were also less likely to start a second course of therapy after a first treatment discontinuation (AHR: 0.91; 95% CI 0.89-0.93).

CONCLUSIONS

Compared to diabetic patients initiated on metformin, those initiated on sulphonylureas displayed poorer persistence patterns.

Combining multicriteria decision analysis, ethics and health technology assessment: applying the EVIDEM decision-making framework to growth hormone for Turner syndrome patients

OBJECTIVES

To test and further develop a healthcare policy and clinical decision support framework using growth hormone (GH) for Turner syndrome (TS) as a complex case study.

METHODS

The EVIDEM framework was further developed to complement the multicriteria decision analysis (MCDA) Value Matrix, that includes 15 quantifiable components of decision clustered in four domains (quality of evidence, disease, intervention and economics), with a qualitative tool including six ethical and health system-related components of decision. An extensive review of the literature was performed to develop a health technology assessment report (HTA) tailored to each component of decision, and content was validated by experts. A panel of representative stakeholders then estimated the MCDA value of GH for TS in Canada by assigning weights and scores to each MCDA component of decision and then considered the impact of non-quantifiable components of decision.

RESULTS

Applying the framework revealed significant data gaps and the importance of aligning research questions with data needs to truly inform decision. Panelists estimated the value of GH for TS at 41% of maximum value on the MCDA scale, with good agreement at the individual level (retest value 40%; ICC: 0.687) and large variation across panelists. Main contributors to this panel specific value were "Improvement of efficacy", "Disease severity" and "Quality of evidence". Ethical considerations on utility, efficiency and fairness as well as potential misuse of GH had mixed effects on the perceived value of the treatment.

CONCLUSIONS

This framework is proposed as a pragmatic step beyond the current cost-effectiveness model, combining HTA, MCDA, values and ethics. It supports systematic consideration of all components of decision and available evidence for greater transparency. Further testing and validation is needed to build up MCDA approaches combined with pragmatic HTA in healthcare decision-making.