Maintenance Medication Adherence Research Articles

Relationship between medication adherence and self-assessment responses in patients with asthma

Digital inhalers can help patients and healthcare professionals identify poor maintenance medication adherence in patients with asthma. Digihaler integrated inhalers transmit data wirelessly to a smart phone application (App), which allows for inhaler usage tracking. The App includes a voluntary, non-respiratory-specific, daily self-assessment (DSA). The CONNECT2 study (NCT04677959) compared the Digihaler Maintenance and Reliever Digital System (MRDS; fluticasone propionate/salmeterol and albuterol Digihalers) with standard of care (SoC) maintenance and reliever inhalers in participants with asthma.

CO52 Impact of Digital Interventions on Maintenance Treatment Adherence in Asthma: A Systematic Literature Review (SLR) and Meta-Analysis

Globally, 339 million people suffer from asthma which is one of the most common chronic diseases. The adherence to maintenance medication remains poor regardless of effective treatments such as inhaled corticosteroids (ICS). The SLR aimed to determine the influence of digital interventions to improve maintenance medication adherence in adolescent and adult patients with asthma.

Assessment of Real-World Escalation to Biologics in US Patients With Asthma

Previous studies indicate that suboptimal medication adherence may contribute to uncontrolled asthma. Global Initiative for Asthma (GINA) guidelines recommend treatment escalation to biologics for patients with uncontrolled asthma despite adherence to high-dose maintenance medication and who have eosinophilic/allergic biomarkers or require maintenance oral corticosteroids. This study aimed to describe the clinical status of patients with asthma escalated to biologic therapy. This retrospective claims database analysis enrolled US patients with asthma who were escalated to biologics between January 2016 and June 2020. Exacerbations, control status, GINA step, and maintenance medication adherence during the 12 months before biologic therapy initiation were analyzed. Asthma control was assessed using both the European Respiratory Society/American Thoracic Society (ERS/ATS) and Stempel criteria. Adherence was defined as the proportion of days covered (PDC) by maintenance medication claims. Of 1786 patients escalated to biologics, 506 were included for analysis. During the 12 months before escalation, 346 patients had confirmed exacerbations. Uncontrolled asthma status was estimated in 55% and 70% of patients (ERS/ATS and Stempel criteria, respectively). GINA step was inferred for 395 patients: 154 were at step 2, 11 at step 3, 104 at step 4, and 126 at step 5. Of 403 patients with maintenance medication claims, 63% had suboptimal maintenance medication adherence (PDC <80%). In this study, most patients initiating biologic therapy had mild-to-moderate asthma or suboptimal maintenance medication adherence, possibly indicating inappropriate escalation. Incorporating objective medication adherence monitoring into existing guidelines may reduce inappropriate escalation to biologics.

Prediction of treatment nonadherence among older adults with chronic obstructive pulmonary disease using Medicare real-world data.

BACKGROUND: Suboptimal maintenance medication (MM) adherence remains a clinical problem among Medicare beneficiaries with chronic obstructive pulmonary disease (COPD). OBJECTIVE: To inform risk-based personalized decision-making, this study sought to develop and validate prediction models of nonadherence to COPD MMs for Medicare beneficiaries. METHODS: This was a retrospective cohort study of beneficiaries aged 65 years and older with COPD and inhaled MMs. Nonadherence (proportion of days covered < 0.8) was measured in 12 months following the first MM fill after COPD diagnosis. Logistic and least absolute shrinkage selector operator regressions were implemented, and area under the receiver operating characteristic curve (AUROC) evaluated model accuracy, as well as positive predictive values and negative predictive values. Our models evaluated different sets of predictors for two cohorts: those with an MM prescription before COPD diagnosis (prevalent users) and those without (new users). RESULTS: Among 16,157 prevalent and 40,279 new users of MMs, 11,271 (69.8%) and 34,009 (84.4%), respectively, were nonadherent. The best-performing logistic models achieved AUROCs of 0.8714 and 0.881, positive predictive values of 0.881 and 0.881, and negative predictive values of 0.559 and 0.578, respectively, for prevalent and new users. The least absolute shrinkage selector operator models had similar accuracy. Models with baseline-only predictors had average performance (AUROC < 0.72). The most important predictors were initial MM adherence, short-acting bronchodilator use, and asthma. CONCLUSIONS: To our knowledge, this study is the first to develop predictive models of nonadherence to COPD MMs. Generated models achieved good discrimination and underlined the importance of early adherence. Well-performed models can be useful for care decision-making and interventions to improve COPD medication adherence after the first critical few months following a treatment episode. DISCLOSURES: All authors declared no conflicts of interest.

Higher short-acting beta-agonist use is associated with greater COPD burden.

The COPD Assessment Test (CAT) is a self-administered questionnaire that measures symptomatic burden. CAT is used as part of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines refined ABCD tool and is usually performed during office visit assessment. Electronic medication monitors (EMMs) capture utilization of short-acting beta-agonists (SABA) that may indicate disease worsening in real-time. The primary objective was to assess the relationship of CAT with SABA utilization. From 8/2017-1/2019, COPD patients ≥40 years of age were enrolled in a digital health platform consisting of EMMs and a mobile application to track time and date of SABA use. Patients with a completed CAT and ≥81 days of continuous EMM data were included in analyses. Using one-way ANOVA, SABA use and maintenance medication adherence were compared by CAT score categories: <10 (low burden), 10-20 (medium), 21-30 (high), and 31-40 (very high). Associations were additionally estimated in patients who used ≥1 puff/week of their rescue and maintenance medication. The population included 2196 COPD patients (mean age: 60 years). CAT scores from low to high burden were associated with greater SABA use, from 0.8 to 1.9 puffs/day (+1.1 [95% CI: 0.6, 1.6 puffs/day], P < 0.001), and lower adherence, from 69% to 59%, (-10% [95% CI: -1, -19%], P = 0.04). Sensitivity analyses yielded similar results. This study found a significant association between greater SABA use and lower adherence with higher burden CAT scores. This finding may suggest that passive collection of inhaled medications could serve as a surrogate for CAT.

PRS11 HEALTHCARE COSTS AMONG PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) AND CONCURRENT LONG-TERM USE OF PRESCRIPTION OPIOIDS

COPD contributes significant economic burden worldwide and is the third leading cause of mortality. The potential impact of concurrent prescription opioid use on healthcare costs among patients with COPD is not well understood. The study objective was to assess the impact of long-term prescription opioid use (≥90-day supply in a one-year period) compared to no opioid use on all-cause healthcare costs among patients with COPD. Patients with COPD diagnosis were identified using ICD9-CM diagnosis codes and COPD maintenance medication prescription claims from the Truven Health MarketScan® Commercial Claims and Encounters Database from July 1, 2008 to December 31, 2009. COPD patients with prescription opioid claims were matched 1:1 to non-users of opioids on age, sex, severe and moderate COPD exacerbations, oxygen therapy use, short-acting beta2-agonist use, maintenance medication adherence, and asthma. Generalized linear regression model with gamma distribution and log-link function was used to identify the adjusted impact of long-term prescription opioid use versus no opioid use on direct, all-cause healthcare costs (prescription medications and medical costs) in a one-year period among COPD patients. A total of 5,541 matched pairs of prescription opioid users versus non-users of opioids were identified. Long-term prescription opioid users (n=566) had significantly higher mean Deyo-Charlson comorbidity scores (2.4±1.8 vs 1.7±1.2, p<0.0001), presence of comorbid chronic conditions (86.6% vs 76.3%, p<0.0001) and comorbid pain conditions (93.5% vs 70.7%, p<0.0001) compared to non-users of opioids. After adjusting for confounders, long-term prescription opioid users had significantly higher healthcare costs ($23,996 ± 1,106 vs. $13,394 ± 513, p<0.0001) compared to non-users of opioids among COPD patients. Long-term use of prescription opioids among COPD patients is associated with significantly higher all-cause healthcare costs. Additional research is needed to improve the management of COPD patients using prescription opioids on a long-term basis to lower healthcare costs.

Adherence to Maintenance Medications among Older Adults with Chronic Obstructive Pulmonary Disease. The Role of Depression.

Among individuals with chronic obstructive pulmonary disease (COPD), depression is one of the most common yet underrecognized and undertreated comorbidities. Although depression has been associated with reduced adherence to maintenance medications used in other conditions, such as diabetes, little research has assessed the role of depression in COPD medication use and adherence. The objective of this study was to assess the impact of depression on COPD maintenance medication adherence among a nationally representative sample of Medicare beneficiaries newly diagnosed with COPD. We used a 5% random sample of Medicare administrative claims data to identify beneficiaries diagnosed with COPD between 2006 and 2010. We included beneficiaries with 2 years of continuous Medicare Parts A, B, and D coverage and at least two prescription fills for COPD maintenance medications after COPD diagnosis. We searched for prescription fills for inhaled corticosteroids, long-acting β-agonists, and long-acting anticholinergics and calculated adherence starting at the first fill. We modeled adherence to COPD maintenance medications as a function of new episodes of depression, using generalized estimated equations. Our primary outcome was adherence to COPD maintenance medications, measured as proportion of days covered. The exposure measure was depression. Both COPD and depression were assessed using diagnostic codes in Part A and B data. Covariates included sociodemographics, as well as clinical markers, including comorbidities, COPD severity, and depression severity. Of 31,033 beneficiaries meeting inclusion criteria, 6,227 (20%) were diagnosed with depression after COPD diagnosis. Average monthly adherence to COPD maintenance medications was low, peaking at 57% in the month after first fill and decreasing to 35% within 6 months. In our adjusted regression model, depression was associated with decreased adherence to COPD maintenance medications (odds ratio, 0.93; 95% confidence interval, 0.89-0.98). New episodes of depression decreased adherence to maintenance medications used to manage COPD among older adults. Clinicians who treat older adults with COPD should be aware of the development of depression, especially during the first 6 months after COPD diagnosis, and monitor patients' adherence to prescribed COPD medications to ensure best clinical outcomes.

Improving Maintenance Medication Adherence in Adult Inflammatory Bowel Disease Patients: A Pilot Study.

Medication nonadherence in inflammatory bowel disease (IBD) may lead to suboptimal control of the disease, decreased quality of life, and poor outcomes. This pilot study evaluated the feasibility, intervention mechanism, and potential effectiveness of a three-month continuous self-improvement (CSI) intervention to enhance medication adherence (MA) in adult nonadherent IBD patients. Adult IBD patients taking a daily or twice-daily dosed maintenance medication were screened electronically for two months to determine baseline MA levels. Nonadherent IBD participants were randomized to the CSI or the attention control (AC) intervention and monitored for three months. The CSI intervention consisted of a data evaluation and system refinement process in which system changes were identified and implemented. The AC group was given educational information regarding IBD disease process, extra-intestinal manifestations of IBD, and medical therapy. Demographic statistics, change scores for within and between-group differences, and effect size estimates were calculated. Nine nonadherent participants (medication adherence score <0.85) were eligible for randomization. The intervention was found feasible and acceptable. Although no statistically significant improvement in MA was found (P=0.14), adherence improved in 3 of 4 of the CSI group and 1 of 2 in the attention control group. The effect size calculation of 1.9 will determine the sample size for future study. The results of this pilot study showed the intervention was feasible and had a positive effect on MA change score and adherence levels. A larger fully powered study is needed to test of the effectiveness of this innovative intervention.

Association between depression and maintenance medication adherence among Medicare beneficiaries with chronic obstructive pulmonary disease

Depression is a significant comorbidity in patients with chronic obstructive pulmonary disease (COPD). Although comorbid depression is associated with low use and poor adherence to medications treating other chronic conditions, evidence of the relationship between depression and COPD management is limited. This study estimated the association between depression and COPD maintenance medication (MM) adherence among patients with COPD. This cross-sectional study used a 5% random sample of 2006-2007 Chronic Condition Warehouse data. Medicare beneficiaries enrolled in Parts A, B, and D plans with diagnosed COPD who survived through 2006 were included (n = 74,863). COPD MM adherence was measured as medication discontinuation and proportion of days covered (PDC). Depression was identified through the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Multivariable models with modified generalized estimating equations were used to estimate adjusted association between depression diagnosis and medication adherence, controlling for sociodemographics, comorbidities, and disease severity. Among the sample, about one third (33.6%) had diagnosed depression. More than half (61.8%) of beneficiaries with COPD filled at least one COPD MM prescription. Depressed beneficiaries had a higher likelihood of using COPD MM than non-depressed beneficiaries (adjusted prevalence ratios [PR] = 1.02; 95% confidence intervals [CI] = 1.01, 1.03). Among COPD MM users, depressed beneficiaries were more likely to discontinue medications (PR = 1.09; 95% CI = 1.04, 1.14) and less likely to exhibit PDC ≥ 0.80 (PR = 0.89; 95% CI = 0.86, 0.92) than non-depressed beneficiaries. Depression is prevalent in Medicare beneficiaries with COPD and independently associated with lower COPD MM adherence. Interventions to improve medication adherence for COPD patients may consider management of comorbidities such as depression.

A Pilot Study to Improve Maintenance Medication Adherence in Adult Inflammatory Bowel Disease Patients

A Pilot Study to Improve Maintenance Medication Adherence in Adult Inflammatory Bowel Disease Patients

Association of Chronic Obstructive Pulmonary Disease Maintenance Medication Adherence With All-Cause Hospitalization and Spending in a Medicare Population

BackgroundAlthough maintenance medications are a cornerstone of chronic obstructive pulmonary disease (COPD) management, adherence remains suboptimal. Poor medication adherence is implicated in poor outcomes with other chronic conditions; however, little is understood regarding links between adherence and outcomes in COPD patients. ObjectiveThis study investigates the association of COPD maintenance medication adherence with hospitalization and health care spending. MethodsUsing the 2006 to 2007 Chronic Condition Warehouse administrative data, this retrospective cross-sectional study included 33,816 Medicare beneficiaries diagnosed with COPD who received at least 2 prescriptions for ≥1 COPD maintenance medications. After a 6-month baseline period (January 1, 2006 to June 30, 2006), beneficiaries were followed through to December 31, 2007 or death. Two medication adherence measures were assessed: medication continuity and proportion of days covered (PDC). PDC values ranged from 0 to 1 and were calculated as the number of days with any COPD maintenance medication divided by duration of therapy with these agents. The association of adherence with all-cause hospital events and Medicare spending were estimated using negative binomial and γ generalized linear models, respectively, adjusting for sociodemographics, Social Security disability insurance status, low-income subsidy status, comorbidities, and proxy measures of disease severity. ResultsImproved adherence using both measures was significantly associated with reduced rate of all-cause hospitalization and lower Medicare spending. Patients who continued with their medications had lower hospitalization rates (relative rate [RR] = 0.88) and lower Medicare spending (–$3764), compared with patients who discontinued medications. Similarly, patients with PDC ≥0.80 exhibited lower hospitalization rates (RR = 0.90) and decreased spending (–$2185), compared with patients with PDC <0.80. ConclusionsCOPD patients with higher adherence to prescribed regimens experienced fewer hospitalizations and lower Medicare costs than those who exhibited lower adherence behaviors. Findings suggested the clinical and economic importance of medication adherence in the management of COPD patients in the Medicare population.

PILOT INTERVENTION TO IMPROVE MEDICATION ADHERENCE IN NONADHERENT INFLAMMATORY BOWEL DISEASE PATIENTS

The purpose of this study is to assess current medication adherence rates and evaluate the feasibility of a continuous self improvement (CSI) intervention in adult nonadherent inflammatory bowel disease (IBD) participants via electronic monitoring (EM) in a mid-western IBD clinic. In the United States, 1.4 million people have been diagnosed with IBD. The medication regimen for IBD is complex and lifelong, which has shown to increase medication nonadherence rates. IBD medication nonadherence ranges from 7-72%, with no demographic, treatment or clinical factors consistently predicting nonadherence. IBD medication nonadherence leads to suboptimal control of the disease, decreased quality of life, and increased healthcare utilization and costs. Five intervention studies attempting to enhance IBD medication adherence have resulted in virtually no improvement in adherence. CSI is an innovative personal system-based intervention. Through data evaluation and system refinement processes, personal system changes are identified and implemented. As adherent behavior becomes habitual, less energy, motivation, and intention are required to maintain adherence. Pilot randomized controlled trial. Nineteen adult IBD participants screened for medication nonadherence via electronic monitoring for 2-months. The medication adherence score captures the variability in medication dosing and timing. A window of time was used to determine medication adherence which then allowed calculation of a medication adherence score. The ‘on time’ window was calculated as +/- 25% of the prescribed medication dosing interval; ‘early’ or ‘late’ window was +/- 50%, and ‘missed’ window as calculated as a dose not taken within +/- 50% of the prescribed time. This calculation approach had been successfully used on once /twice daily dosed medications in previous studies. Feedback on the screening EM data was delivered by the primary investigator (PI), sharing how the current personal system creates the nonadherence. The PI guided the participant through the CSI process, identifying established routines/systems where medication taking could be enhanced for the next 3-months. Feasibility/acceptability of the intervention will be evaluated along with medication adherence change scores in the CSI group after the 3-month study. Of the 19 participants completing the screening period, nine participants were found to be nonadherent (47.4%) with medication adherence score less than 0.85; three nonadherent participants did not complete the study as one was taken off immunosuppressive medications, and two were lost to follow-up. Six participants were randomized, four participants to CSI and two participants to attention control. CSI feasibility and medication adherence scores are pending. CSI may be a feasible intervention to improve medication adherence in adult IBD patients. A fully powered study is needed to examine the effect of CSI on maintenance medication adherence in adult IBD patients.