Frequency of missed doses and its effects on the regulation of glucose levels in patients with type 2 diabetes: A retrospective analysis

This study aimed to investigate the association between medication adherence to oral hypoglycemic agents (OHAs) and HbA1c levels in patients with type 2 diabetes mellitus (T2DM) for more than 48 weeks, as well as the factors affecting long-term adherence to OHAs. This retrospective study included 83 patients who had been receiving OHAs for T2DM for ≥48 weeks. Medication adherence values (MAVs) were calculated using the following formula: (total prescription days - prescription days of OHAs brought at admission)/(days from the initiation of OHAs to hospitalization). We assessed the association between HbA1c and MAVs using the Jonckheere-Terpstra test. Furthermore, we examined the association between patient- and medication-related factors and MAVs affecting HbA1c levels. Based on the results, MAVs were categorized as MAV ≤0.86 and MAV >0.86, and factors affecting MAVs were analyzed. Logistic regression analysis revealed that the total number of medications, the number of nonhypoglycemic agents, and a family history of diabetes were independent determinants of MAV ≤0.86 (P < .05). Multiple regression analyses indicated that the number of dosages per day and the timing of OHA administration at lunch were independent determinants of lower MAVs (P < .05). Our findings suggest that poor medication adherence is associated with elevated HbA1c levels in T2DM patients. Independent factors contributing to poor adherence include a lower number of prescribed medications, fewer nonhypoglycemic agents, no family history, a higher daily dosage frequency, and the administration of OHAs at lunch.

Patient Pill Organization Strategies and Adherence Measured in a Cross-Sectional Study of Hypertension

BACKGROUND

The strategies patients use to organize medications (eg, pill dispenser) may be reflected in adherence measured at follow-up. We studied whether medication organization strategies patients use at home are associated with adherence measured using pharmacy-fills, self-report, and pill counts.

DESIGN

Secondary analysis of data from a prospective randomized clinical trial.

SETTING

Eleven US safety-net and community primary care clinics.

PATIENTS

Of the 960 enrolled self-identified non-Hispanic Black and White patients prescribed antihypertensive medications, 731 patients reported pill organization strategies and were included.

VARIABLE

Patients were asked if they use any of the following medication organization strategies: finish previous refills first; use a pill dispenser; combine same prescriptions; or combine dissimilar prescriptions.

OUTCOMES

Adherence to antihypertensive medications using pill counts (range, 0.0-1.0% of the days covered), pharmacy-fill (proportion of days covered >90%), and self-report (adherent/non-adherent).

RESULTS

Of the 731 participants, 38.3% were men, 51.7% were age ≥65, 52.9% self-identified as Black or African American. Of the strategies studied, 51.7% finished previous refills first, 46.5% used a pill dispenser, 38.2% combined same prescriptions and 6.0% combined dissimilar prescriptions. Median (IQR) pill count adherence was 0.65 (0.40-0.87), pharmacy-fill adherence was 75.7%, and self-reported adherence was 63.2%. Those who combined same prescriptions had significantly lower measured pill count adherence than those who did not (0.56 (0.26-0.82) vs 0.70 (0.46-0.90), p<0.01) with no significant difference in pharmacy-fill (78.1% vs 74%, p=0.22) or self-reported adherence (63.0% vs 63.3%, p=0.93).

CONCLUSION

Self-reported medication organization strategies were common. Combining same prescriptions was associated with lower adherence as measured using pill counts but not pharmacy-fills or self-report. Clinicians and researchers should identify the pill organization strategies used by their patients to understand how these strategies may influence measures of patient adherence.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03028597; https://clinicaltrials.gov/ct2/show/NCT03028597 (Archived by WebCite at http://www.webcitation.org/72vcZMzAB).

Validation of an Announced Telephone Pill Count Compared to a Home-Visit Pill Count in People With Type 2 Diabetes or Cardiovascular Disease

We aimed to assess the validity of an announced telephone pill count in people with type 2 diabetes or cardiovascular disease by comparing this method to a home-visit pill count. We also assessed whether a second telephone pill count improved accuracy. People aged ≥35 years using oral type 2 diabetes or cardiovascular disease medication were included. Thirty-four participants completed a telephone pill count followed by a home-visit pill count, and a subsample of this population (n = 11) completed a second telephone pill count. Scatterplots were used for a visual representation of the number of pills counted with both methods, intraclass correlation coefficients for agreement, and Bland-Altman plots for absolute differences and outliers. A total of 203 pill counts were conducted. The study population consisted of 53% men, with a mean age of 69.6 (±9.2) years and an average of 6.1 (±2.8) medication prescriptions per participant. Scatterplots showed that pills counted with both methods were mostly scattered around the y = x equation. Agreement between the first telephone pill count and home-visit pill count was high, with intraclass correlation coefficients of 0.96 (medication count level) and 0.98 (individual level). No learning effects were observed in the subsample (n = 11), the intraclass correlation coefficient for the first telephone pill count was 0.88 versus 0.89 for the second telephone pill count. Bland-Altman plots indicated high agreement between the two methods. An announced telephone pill count is considered a valid alternative for a home-visit pill count in people with type 2 diabetes or cardiovascular disease. A single pill count appears sufficient.

Medication adherence in older people with rheumatoid arthritis is lower according to electronic monitoring than according to pill count

Objectives

Suboptimal medication adherence is a serious problem in the treatment of chronic inflammatory diseases. To measure medication adherence, electronic monitoring is regarded as superior to pill count. GLORIA is an ongoing two-year trial on the addition of low-dose (5 mg/d) prednisolone or placebo to standard care in older people (65+ years) with RA. During the entire trial, adherence is measured with electronic caps, and with pill counts. The objective is to describe medication adherence patterns, and to compare the adherence results of the two methods.

Methods

The recorded adherence patterns of patients (blinded for treatment group) were classified according to descriptive categories. The cutoff for good adherence was set at 80% of prescribed pills taken.

Results

Trial inclusion closed in 2018 at 451 patients, but trial follow-up is ongoing; the current dataset contains adherence data of 371 patients. Mean number of recorded 90-day periods per patient was 4 (range 1–8). Based on pill count over all periods, 90% of the patients had good adherence; based on cap data, only 20%. Cap data classified 30% of patients as non-user (<20% of days an opening) and 40% as irregular user (different adherence patterns, in or between periods).

Conclusion

In our trial of older people with RA, the majority appeared to be adherent to medication according to pill count. Results from caps conflicted with those of pill counts, with patterns suggesting patients did not use the bottle for daily dispensing, despite specific advice to do so.

Trial registration

NCT02585258. ClinicalTrials.gov (https://www.clinicaltrials.gov/)

Comparison of Different Adherence Measures in Adolescent Outpatients with Depressive Disorder

PURPOSE

Adolescent depression can have a chronic course; hence, the importance of adherence to antidepressant medication for successful treatment outcomes is emphasized. This study aimed to examine different adherence measures and identify clinical factors that influence adherence in adolescent depression.

PATIENTS AND METHODS

A prospective study was conducted for patients diagnosed with depressive disorder according to the Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition from outpatient psychiatric settings at Korea University Medical Center, Guro Hospital. Patient demographics were obtained from a questionnaire, interview, and review of chart records. Adherence was assessed by four methods (Medication Event Monitoring System [MEMS], pill count, clinical rating scale, and patient's self-report). The Toronto Side Effect Scale was used to evaluate side effects, and specific depressive symptoms were assessed using the Hamilton Rating Scale for Depression and Childhood Depression Inventory-Korean version. The Multidimensional Scale of Perceived Social Support was administered to analyze social support, and the Parenting Stress Index-Short Form was used to evaluate parental stress levels. We used concordance correlation analysis to evaluate the relationship among the four adherence measures and the relationship between adherence level and clinical factors.

RESULTS

Overall, the study enrolled 48 outpatients (mean age 16.33±1.93 years). The mean duration of illness was 1.27±2.17 years. Adherence rates for MEMS, clinician rating scale, pill count, and self-report after conversion to dichotomous measures were 67.5%, 48.9%, 60.0%, and 56.3%, respectively. Only the duration of illness remained significantly correlated with MEMS (r = 0.510, p =0.001).

CONCLUSION

Pill count exhibited a higher degree of agreement with MEMS adherence than the other two adherence measures, possibly indicating that pill count may be a considerably reliable measure of adherence. Furthermore, MEMS adherence was positively correlated with disease duration, suggesting that the longer the duration of illness, the higher the adherence.

Impact of Pharmacist-directed Counseling and Message Reminder Services on Medication Adherence and Clinical Outcomes in Type 2 Diabetes Mellitus

Introduction:

Medication nonadherence is the most common issue observed in the management of diabetes because of complex and lifelong therapy. The study aimed to assess the effect of pharmacist-directed counseling and daily text message reminder on medication adherence and clinical profile of patients with type II diabetes.

Materials and Methods:

This prospective, open-labeled, randomized control trial was carried out in outpatient medical department of a secondary care referral hospital. A total of 330 patients who met study criteria were enrolled and randomized into an intervention group (n = 165), received counseling and daily messages about medication intake and control group (n = 165), and usual care by physician. Medication adherence and clinical outcomes such as glycosylated hemoglobin (HbA1C), systolic blood pressure (SBP), low-density lipoprotein (LDL) cholesterol, triglyceride (TG) levels, and body mass index (BMI) were recorded at baseline and follow-up visits. Two-sample Wilcoxon rank sum test was used to compare the mean difference of medication adherence and paired t-test was used to compare clinical outcomes.

Results and Discussion:

The mean age of intervention and control groups were 57.1 ± 8.55 and 58.5 ± 8.53 years, respectively. The mean difference of medication adherence from baseline to second follow-up visit was significantly more in intervention group (12.2 ± 7.1%) compared to that in control group (0.75 ± 10.2 %) with a P < 0.001. From baseline to second follow-up visit, HbA1C (7.79 ± 0.67 to 6.91 ± 0.83 %), SBP (136.75 ± 20.09 to 126.23 ± 18.22 mm Hg), and LDL cholesterol (104.14 ± 26.23 to 98.29 ± 20.87 mg/dL) levels were significantly reduced in intervention group compared to that in control group with a P < 0.01. No significant improvement was observed in TG (169± 33.71 to 168 65 ± 33.90 mg/dL) and BMI (27.9 ± 4.21 to 27.1 ± 3.12 Kg/m²) levels from baseline to second follow-up visit.

Conclusion:

Pharmacist-directed patient counseling combined with message reminder showed a greater effect on the improvement of medication adherence and control of glycemia, blood pressure, and lipid profile in diabetes.

Universal test and treat is not associated with sub-optimal antiretroviral therapy adherence in rural South Africa: the ANRS 12249 TasP trial

INTRODUCTION

HIV treatment guidelines now recommend antiretroviral therapy (ART) initiation regardless of CD4 count to maximize benefit both for the individual and society. It is unknown whether the initiation of ART at higher CD4 counts would affect adherence levels. We investigated whether initiating ART at higher CD4 counts was associated with sub-optimal adherence (<95%) during the first 12 months of ART.

METHODS

A prospective cohort study nested within a two-arm cluster-randomized trial of universal test and treat was implemented from March 2012 to June 2016 to measure the impact of ART on HIV incidence in rural KwaZulu-Natal. ART was initiated regardless of CD4 count in the intervention arm and according to national guidelines in the control arm. ART adherence was measured monthly using a visual analogue scale (VAS) and pill counts (PC). HIV viral load was measured at ART initiation, three and six months, and six-monthly thereafter. We pooled data from participants in both arms and used random-effects logistic regression models to examine the association between CD4 count at ART initiation and sub-optimal adherence, and assessed if adherence levels were associated with virological suppression.

RESULTS

Among 900 individuals who initiated ART ≥12 months before study end, median (IQR) CD4 at ART initiation was 350 cells/mm3 (234, 503); median age was 34.6 years (IQR 27.4 to 46.4) and 71.7% were female. Adherence was sub-optimal in 14.7% of visits as measured by VAS and 20.7% by PC. In both the crude analyses and after adjusting for potential confounders, adherence was not significantly associated with CD4 count at ART initiation (adjusted OR for linear trend in sub-optimal adherence with every 100 cells/mm3 increase in CD4 count: 1.00, 95% CI 0.95 to 1.05, for VAS, and 1.03, 95% CI 0.99 to 1.07, for PC). Virological suppression at 12 months was 97%. Optimal adherence by both measures was significantly associated with virological suppression (p < 0.001 for VAS; p = 0.006 for PC).

CONCLUSIONS

We found no evidence that higher CD4 counts at ART initiation were associated with sub-optimal ART adherence in the first 12 months. Our findings should alleviate concerns about adherence in individuals initiating ART at higher CD4 counts, however long-term outcomes are needed. ClinicalTrials.gov NCT01509508.

A scoping review of studies comparing the medication event monitoring system (MEMS) with alternative methods for measuring medication adherence

Different methods are available for measuring medication adherence. In this paper, we conducted a scoping review to identify and summarize evidence of all studies comparing the Medication Event Monitoring System (MEMS) with alternative methods for measuring medication adherence. A literature search was performed using the open database www.iAdherence.org that includes all original studies reporting findings from the MEMS. Papers comparing methods for measuring adherence to solid oral formulations were included. Data was extracted using a standardized extraction table. A total of 117 articles fulfilled the inclusion criteria, including 251 comparisons. Most frequent comparisons were against self-report (n = 119) and pill count (n = 59). Similar outcome measures were used in 210 comparisons (84%), among which 78 used dichotomous variables (adherent or not) and 132 used continuous measures (adherence expressed as percentage). Furthermore, 32% of all comparisons did not estimate adherence over the same coverage period and 44% of all comparisons did not use a statistical method or used a suboptimal one. Only eighty-seven (35%) comparisons had similar coverage periods, similar outcome measures and optimal statistical methods. Compared to MEMS, median adherence was grossly overestimated by 17% using self-report, by 8% using pill count and by 6% using rating. In conclusion, among all comparisons of MEMS versus alternative methods for measuring adherence, only a few used adequate comparisons in terms of outcome measures, coverage periods and statistical method. Researchers should therefore use stronger methodological frameworks when comparing measurement methods and be aware that non-electronic measures could lead to overestimation of medication adherence.

Nonadherence to Antiretroviral Therapy Among People Living with HIV/AIDS Attending Two Tertiary Care Hospitals in District of Northern India

Introduction:

Adherence to antiretroviral therapy is a principal predictor for the success of human immunodeficiency virus (HIV) treatment. It remains as a challenge to acquired immunodeficiency syndrome (AIDS) treatment and care with the widespread of the associated risks. Therefore, study aims to assess nonadherence level and factors associated with nonadherence to ART among people living with HIV/AIDS (PLHA).

Materials and Methods:

A hospital-based, cross-sectional study was conducted at two tertiary care hospital of Lucknow. A total of 322 adult HIV-positive patients registered in the ART center were included. Systematic random sampling was used to recruit patients. Nonadherence was assessed on the basis of pill count method.

Results:

A total of 10.9% of patients were found to be nonadherent to ART. Principal causes cited were being busy with other work (40.0%), felt sick or ill (28.5%), not having money (14.2%), and being away from home (11.4). Multivariate logistic regression analysis revealed that nonadherence was significantly associated with nonbeneficial perceptions towards ART (odds ratio (OR) 18.5; 95% confidence interval (CI) 3.2-106.6; P = 0.001), being counseled for adherence for more than 3 months (OR 13.9; 95% CI 1.6-118.9; P = 0.01), presence of depression (OR 2.6; 95% CI 1.0-6.7; P = 0.04), and those who were not satisfied with healthcare facilities (OR 5.63; 95% CI 1.88-16.84; P = 0.00).

Conclusion:

Although adherence to ART varies between individuals and over time, the factors that affect nonadherence can be addressed with proper periodic counseling and motivation of patients and their family members. Adherence to highly active antiretroviral therapy (HAART) could delay the progression of this lethal disease and minimize the risk of developing drug resistance.

Adherence of antidepressants during pregnancy: MEMS compared with three other methods

BACKGROUND

Data about adherence of antidepressants during pregnancy are lacking. However, it is important to gain insight into adherence in this population to reduce perinatal risks for relapse of depression.

OBJECTIVE

The objective of this study was to search for an inexpensive and easy method to implement daily for assessing medication adherence during pregnancy.

METHODS

An observational study was conducted to measure adherence by comparing pill count, Beliefs about Medicine questionnaire (BMQ) and blood level monitoring against the standard, the Medication Event Monitoring System (MEMS). We used a logistic regression model to determine potential predictors for poor adherence (age, marital class, highest level of education, monthly net income, employment, smoking, alcohol use and type of antidepressant).

RESULTS

From January 2010 until January 2012, 41 women were included within the first trimester of pregnancy; data could be evaluated in 29 women. Using MEMS, 86% of the women took in more than 80% of all prescribed doses on time and could be classified as adherent. Pill counts showed good agreement with MEMS. We did not find predictors for poor adherence in our study population.

CONCLUSION

Adherence of antidepressants during pregnancy using MEMS is 86%. There was a good agreement between MEMS and pill counts. This method may serve as a good alternative that can be easily implemented into daily practice.

How should we measure medication adherence in clinical trials and practice?

OBJECTIVE

To determine if simple adherence measures, such as twenty-four hour recall and refill history, are accurate for routine use, compared to more time-consuming measures such as pill counts.

DESIGN

Randomized, double-blind, placebo-controlled trial.

SETTING

Walter Reed Army Medical Center, a tertiary medical center in Washington.

PATIENTS

Men and women >30 years old with known coronary heart disease and taking a statin medication.

INTERVENTION

Clinical pharmacists met with patients for adherence assessments.

MAIN OUTCOME MEASURES

Adherence was measured by pill counts, twenty-four hour recall by patient, and refill history per computer record. Temporal changes in these adherence measures were assessed using general linear models for repeated measures.

RESULTS

Adherence was consistently greater for the experimental agent than for the statin therapy (n = 148). Mean pill count adherence for statin drug was 78.7 +/- 25.2% compared to 93.5 +/- 11.6% (P < 0.001) for the study agent. Refill history and twenty-four hour recall inaccurately measured adherence when compared to pill counts. Adherence, as determined by pill count, for both experimental (P = 0.029) and statin therapy (P = 0.015) showed significant variability across time in general linear models. Neither refill history nor twenty-four hour recall was sensitive to temporal changes.

CONCLUSIONS

Twenty-four hour recall and refill history inaccurately measure medication adherence for both clinical trial and clinical practice pharmacotherapies. Further, these measures are insensitive to changes in adherence. For a single or multiple assessments across time, pill count more accurately measures medication adherence. Pill count should be the standard for monitoring medication adherence for both clinical trials and clinical practice.