Medication Adherence In Chronic Disease Research Articles

Role of pharmacists in the application of the transtheoretical model approach to enhance medication adherence in chronic diseases

AbstractAdherence to prescribed medications is one of the most important aspects contributing to successful treatment. Medication adherence through self‐management of chronic diseases is thought to be necessary to achieve improvements in quality of life for patients. Many models and interventions have been tested to enhance self‐management, but to date none have been convincingly successful. The challenges inherent to disease self‐management are fundamentally socio‐behavioural issues, and the use of a model such as the transtheoretical model (TTM) has potential to be of assistance. Described here is a brief summary of a systematic review that was conducted to assess the potential for the use of the TTM in improving disease self‐management activities for patients with chronic diseases, particularly type 2 diabetic patients. Seven studies describing the effect of the TTM on different aspects of medication adherence were reviewed. All the studies reviewed suggest that a TTM approach can help patients with chronic diseases change their behaviour to incorporate more desirable characteristics that will help them manage chronic conditions. However, at present there are still not enough studies to definitively determine whether pharmacists could practically use the TTM to enhance medication adherence.

Mobile Text Messaging and Adherence of Patients to Medication Prescriptions: A txt a dA keeps da doctR awA?

Low patientmedication adherence is one of the 2 largest unsolved gaps in health care, with the other being suboptimal therapyprescription. For example, oral anticoagulation (OAC) is firmlyrecommended inpatientswithatrial fibrillationathigh risk for stroke, but typically about half of the eligible patients donot receiveOAC.1Of those patients who receive OAC, approximately half will not begin therapy or will stop therapy within a year,2 and of those patients persisting with an OAC regimen, only half take their pills consistently as prescribed.3As a consequence,most patientswill not reap the full health benefits fromproven therapies such asOAC. There is rising interest inmedication adherence research,4 but these well-meaning efforts have not yet led to substantial and reliable adherence improvements when looking at the entire adherence research field. Are we perhaps missing the signal of specific interventions? In this issueof JAMAInternalMedicine, Thakkar et al5 provideafocusedandthoroughmeta-analysisof randomizedclinical trials that aimed to improve medication adherence in patients with chronic disease by the specific means of mobile telephone textmessaging (TM), amongwhom they observed adoubling of the relative odds of improving adherence. Technology-mediated interventions are logical candidates for innovations inadherenceresearch,especially if theyareaswidely used as mobile telephones. Research testing new technologies naturally lags behind the introduction and uptake of the technology,6 which is why most of the included randomized clinical trialswerepublished in thepast 5years, renderingmobile telephone TM the “new kid on the block.” The kid has shown potential, but—as Thakkar et al5 indicate—caution is warrantedwhen interpreting the results.Most studieshad fundamental methodological weaknesses that are common in medication adherence research to date,7 and several of these shortcomings are lethal to the case of whether TM interventions areworth the effort and resources required to create and conduct them. First, did the pooled studies truly show an improvement in adherence for chronic disease? Most studies used selfreport to measure adherence, but self-report typically overestimatesadherence,especially inunmaskedtrialsas theserandomized clinical trialswere.Unobtrusivemeasurements such as pharmacy claims data would be more objective and accurate. Furthermore, lasting effects are crucial for chronic disease, but these studies had amedian interventionduration of only 12 weeks, and no study reported on adherence beyond the active intervention period. Second, and even more important, measuring a clinical outcome could assess whether the adherence improvement translated into benefits important to the patient, but the randomized clinical trials in the meta-analysis by Thakkar et al5 did not measure such outcomes, nor would it have been feasible to do so in these small and short-term studies. Therefore, TM has not been subjected to the acid test of whether it makes a clinically useful difference. Third, because the meta-analysis focused on one type of intervention, the authors chose to conveniently pool the results using standardized effect sizes, but it is hard to ignore the many differences among the studies. The substantial statistical heterogeneity (I2 = 62%) across the included clinical trials reflects obvious differences in the following characteristics: (1) The clinical conditions varied, with some patients requiring chronic daily lifelong treatment (eg, for human immunodeficiency virus) vs intermittent or seasonal treatment (eg, for allergic rhinitis) vs treatments that are typically required in the long term but may be discontinued after clinical remission (eg, in the case of epilepsy). (2) The medication regimens used differed, including the timing and frequency of intake, absence of noticeable benefits (eg, blood pressure lowering), severity of adverse effects, and route of administration. (3) Different adherence outcomes were used, including self-report, pill count, medication event monitoring systems, and pharmacy dispensing data, reported as continuous measures or dichotomous measures, with cutoffs for good adherence ranging from 80% to 95%. Adding to the adherence outcome heterogeneity is the large variation in follow-up time, and the absence of (or ambiguity about using) intent-to-treat analyses in half of the studies. (4) There was variation in baseline adherence, with only 2 studies using low baseline adherence as an eligibility criterion. Failure to focus on those patients who can benefit from interventions minimizes the effect sizes that can be observed, limits the power of studies to detect differences, and wastes resources. (5) The study settings differed, with a wide variety represented—from hospitals in Africa (9 of the studies were set in developing countries) to the general population in Denmark—indicating substantive differences in cultures, languages, resources, health services, priorities, and personal finances. (6) The intervention design varied, such that different TM approaches were used, with various message frequencies, timing, content, framing, degree of personalization, ability for patients to respond, and degree of automation. These issues of heterogeneity might be mitigated by distinguishing studies based on methodological rigor and relRelated article page 340 Research Original Investigation Text Messaging for Medication Adherence in Chronic Disease

Effects of breast cancer on chronic disease medication adherence among older women.

The purpose of this study was to determine the effects of breast cancer on chronic disease medication adherence among older women. The Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked data and a 5% random sample of Medicare enrollees were used. Stage I-III breast cancer patients diagnosed in 2008 and women without cancer were eligible. Three cohorts of medication users 66+ years were identified using diagnosis codes and prescription fill records: diabetes, hypertension, and lipid disorders. For each cohort, breast cancer patients were frequency matched to comparison women by age and geographic area. Medication adherence was measured by the proportion of days covered and medication persistence. During the post-baseline period, the percentage of breast cancer patients who were non-adherent was 26.2% for diabetes medication, 28.9% for lipid-lowering medication, and 14.2% for hypertension medication. Breast cancer patients experienced an increased odds of diabetes medication non-adherence [odds ratio (OR) = 1.44; 95% confidence interval (CI) = 1.07 to 1.95] and were more likely to be non-persistent with diabetes medication (hazard ratio = 1.31; 95%CI: 1.04 to 1.66) relative to women without cancer. The study failed to show a difference between breast cancer and comparison women in the odds of non-adherence to hypertensive (OR = 0.87; 95%CI: 0.71 to 1.05) or lipid-lowering medication (OR = 0. 91; 95%CI: 0.73 to 1.13) with a proportion of days covered threshold of 80%. Special attention should be given to the coordination of primary care for older breast cancer patients with diabetes. Copyright © 2016 John Wiley & Sons, Ltd.

Patient considerations in the treatment of COPD: focus on the new combination inhaler umeclidinium/vilanterol

Medication adherence among patients with chronic diseases, such as COPD, may be suboptimal, and many factors contribute to this poor adherence. One major factor is the frequency of medication dosing. Once-daily dosing has been shown to be an important variable in medication adherence in chronic diseases, such as COPD. New inhalers that only require once-daily dosing are becoming more widely available. Combination once-daily inhalers that combine any two of the following three agents are now available: 1) a long-acting muscarinic antagonist; 2) a long acting beta2 agonist; and 3) an inhaled corticosteroid. A new once-daily inhaler with both a long-acting muscarinic antagonist, umeclidinium bromide, and a long acting beta2 agonist, vilanterol trifenatate, is now available worldwide for COPD treatment. It provides COPD patients convenience, efficacy, and a very favorable adverse-effects profile. Additional once-daily combination inhalers are available or will soon be available for COPD patients worldwide. The use of once-daily combination inhalers will likely become the standard maintenance management approach in the treatment of COPD because they improve medication adherence.

Understanding if, how and why non-adherent decisions are made in an Australian community sample: a key to sustaining medication adherence in chronic disease?

Adherence to medications for chronic disease is sub-optimal. Current adherence-enhancing strategies do not seem to adequately address the fundamental need to sustain adherence or prevent non-adherence. Intentional non-adherence, involving active medication-taking decisions, is not well described within the Australian community setting. Understanding if, how and why non-adherent decisions are made may help develop strategies to sustain adherence in chronic disease. This study aimed to describe intentional non-adherent behavior in chronic disease within the Australian community setting and identify the factors that promote and prevent non-adherent decisions. In-depth, semi-structured interviews were conducted with 21 patients (12 rural, 9 metropolitan; New South Wales) prescribed medications for a diverse range of chronic conditions. Using the Theory of Planned Behavior as the theoretical framework, an iterative thematic framework analysis method was used to characterize the intentions and the decisions underlying non-adherent behavior. Data were indexed and charted within the thematic framework using Excel, and linked themes were combined, and associations and explanations drawn. Although there was a strong intent to follow prescribers' recommendations, most patients described instances of intentionally non-adherent behavior. Trading between perceived treatment inefficacy, unfavorable side effects and unaffordable medication costs promoted non-adherent decisions; trusting prescriber-patient relationships, positive family values and lack of perceived control over treatment choice maintained adherent intentions. Intentional non-adherence was mostly temporary. Intentional medication non-adherence in chronic disease appears reversible and amenable to interventions that address treatment-related barriers such as medication affordability. Strategies that strengthen patient-prescriber relationships and empower patients as informed decision-makers may help maintain adherence intentions. Crucially, regular and sustained interventions that are refreshed to meet the changing needs of patients are needed to curb the temporal decline in adherence to chronic disease medications.

Genome-wide association study of medication adherence in chronic diseases in the korean population.

Medication adherence is generally defined as the extent of voluntary cooperation of a patient in taking medicine as prescribed. Adherence to long-term treatment with chronic disease is essential for reducing disease comorbidity and mortality. However, medication non-adherence in chronic disease averages 50%. This study was conducted a genome-wide association study to identify the genetic basis of medication adherence. A total of 235 medication non-adherents and 1,067 medication adherents with hypertension or diabetes were used from the Korean Association Resource project data according to the self-reported treatment status of each chronic disease, respectively. We identified four single nucleotide polymorphisms with suggestive genome-wide association. The most significant single nucleotide polymorphism was rs6978712 (chromosome 7, p = 4.87 × 10-7), which is located proximal to the GCC1 gene, which was previously implicated in decision-making capability in drug abusers. Two suggestive single nucleotide polymorphisms were in strong linkage disequilibrium (r2 > 0.8) with rs6978712. Thus, in the aspect of decision-making in adherence behavior, the association between medication adherence and three loci proximal to the GCC1 gene seems worthy of further research. However, to overcome a few limitations in this study, defining the standardized phenotype criteria for self-reported adherence should be performed before replicating association studies.

Targeted Cancer Therapy: From Bench to Bedside to Patient

Targeted Cancer Therapy: From Bench to Bedside to Patient

Dosing frequency and medication adherence in chronic disease.

Prior research has shown a decrease in medication adherence as dosing frequency increases; however, meta-analyses have not been able to demonstrate a significant inverse relationship between dosing frequency and adherence when comparing twice-daily versus once-daily dosing. To determine the effect of scheduled dosing frequency on medication adherence in patients with chronic diseases. A systematic literature search of Medline and Embase from January 1986 to December 2011 and a hand search of references were performed to identify eligible studies. Randomized and observational studies were included if they utilized a prospective design, assessed adult patients with chronic diseases, evaluated scheduled oral medications taken 1 to 4 times daily, and measured medication adherence for at least 1 month using an electronic monitoring device. Manual searches of reference sections of identified studies and systematic reviews were also performed to find other potentially relevant articles. Standard definitions for medication taking, regimen, and timing adherence were used and evaluated. Studies were pooled using a multivariate linear mixed-model method to conduct meta-regression accounting for both random and fixed effects, weighted by the inverse of the variance of medication adherence. Fifty-one studies, comprising 65, 76, and 47 dosing frequency arms for the taking, regimen, and timing adherence endpoints were included. Unadjusted adherence estimates were highest when the least stringent definition, taking adherence, was used (range for dosing frequencies: 80.1%-93.0%) and lowest when the most stringent definition, timing adherence, was used (range for dosing frequencies: 18.8%-76.9%). In multivariate meta-regression analyses, the adjusted weighted mean percentage adherence rates for all regimens dosed more frequently than once per day were significantly lower compared with once-daily regimens (for 2-times, 3-times, and 4-times daily regimens, respectively: differences for taking adherence: -6.7%, -13.5%, and -19.2%; regimen adherence: -13.1%, -24.9%, and -23.1%; and timing adherence: -26.7%, -39.0%, and -54.2%). Patients with chronic diseases appear to be more adherent with once-daily compared with more frequently scheduled medication regimens. The use of more stringent definitions of adherence magnified these findings.

Medication adherence with disease modifying treatments for multiple sclerosis among US employees

Objective:Medication adherence in chronic diseases like multiple sclerosis (MS) plays an important role in predicting long-term outcomes, yet existing data on adherence in employee populations are not found. The objective of this study is to compare adherence among employees treated with disease modifying treatments (DMTs) for MS in the year following treatment initiation.Methods:A healthcare claims database of US employees from 2001 to 2008 was used to identify patients with MS based on two or more DMT prescriptions or one DMT prescription with an MS diagnosis (ICD-9 340.xx). Employees continuously employed and with health plan coverage for 1 year following DMT initiation were eligible. Two measures were used in estimating adherence after DMT initiation: (1) persistence (the number of days from DMT initiation to the first 30-day gap in supply) and, (2) annual compliance, assessed by the medication possession ratio (MPR = number of days with a medication supply in the year divided by 365 days). Wilcoxon tests on time-to-event data and t-tests were used to compare persistence and MPR, respectively, between DMT groups. Other measures of resource utilization were also compared.Results:Overall, 358 employees [179 interferon [IFN]-β1a-IM (Avonex = ‘A’); 63 IFN-β1b (Betaseron = ‘B’); 20 IFN-β1a-SC (Rebif = ‘R’); 96 glatiramer acetate (Copaxone = ‘C’)] were eligible for analysis. No significant differences in age, gender, and certain job-related variables existed between cohorts. Persistence was better for ‘A’ than ‘B’ (p = 0.039), ‘C’ (p = 0.0007), and ‘R’ (p = 0.130). At 1 year, a greater proportion of ‘A’ employees were persistent (60.34%) than ‘B’ (42.86%, p = 0.016), ‘C’ (42.71%, p = 0.0052), and ‘R’ (45.00%, p = 0.190). ‘A’ also had the highest MPR (0.782) which was significantly higher than ‘C’ (MPR = 0.698, p = 0.0160) and statistically equivalent to ‘B’ (MPR = 0.705, p = 0.0576) and ‘R’ (MPR = 0.761, p = 0.7347).* Avonex is a registered trade name of Biogen Idec Pharmaceuticals, Cambridge, MA, USA.† Betaseron is a registered trademark of Bayer HealthCare Pharmaceuticals Inc., West Haven, CT, USA.‡ Rebif is a registered trademark of EMD Serono, Inc. Rockland, MA, USA and its affiliates.§ Copaxone is a registered trademark of Teva Pharmaceutical Industries Ltd., Petach Tikva, Israel.Limitations:The study has limitations characteristic of administrative claims database studies and small sample sizes. The population may not be representative of undiagnosed/untreated MS patients, those not able to maintain employment, and those not using the initial therapy.Conclusions/relevance:Among employees treated with ‘A’, ‘B’, ‘C’, and ‘R’ for MS, ‘A’ patients had significantly greater medication adherence.

Depression is an important contributor to low medication adherence in hemodialyzed patients and transplant recipients

End-stage renal disease (ESRD) is a growing public health concern and non-adherence to treatment has been associated with poorer health outcomes in this population. Depression, likely to be the most common psychopathology in such patients, is associated with increased morbidity and mortality. We compared psychological measures and self-reported medication adherence of 94 kidney transplant recipients to those of 65 patients receiving hemodialysis in a major medical center in Brooklyn, New York. Compared to the transplant group, the hemodialysis cohort was significantly more depressed as determined by the Beck Depression Inventory score. They also had a significantly lower adherence to medication as reported on the Medication Therapy Adherence Scale. Using hierarchical multiple regression analysis, the variance in depression was the only statistically significant predictor of medication adherence beyond gender and mode of treatment, accounting for an additional 12% of the variance. Our study strongly suggests that a depressive affect is an important contributor to low medication adherence in patients with ESRD on hemodialysis or kidney transplant recipients.

Medication Adherence in Chronic Disease: Issues in Posttransplant Immunosuppression

Poor medication adherence is a widespread problem that undermines the potential benefits of medical treatment. Typical adherence rates among chronic disease patients are approximately 50%, and these low adherence rates have a substantial economic impact, estimated at $100 to $300 billion annually. Nonadherence to immunosuppressants among transplant recipients is surprisingly frequent, and the consequences are serious. Among adult renal transplant patients, the median rate of nonadherence is approximately 22% and is associated with acute rejection episodes and approximately 36% of all graft losses. In the United States, nonadherence results in an estimated 903 episodes of acute rejection and 1319 renal transplants failures annually, costing approximately $15 million and $100 million, respectively. Drug regimen complexity is known to impact adherence. Research demonstrates an inverse relationship between dosing frequency and medication adherence in various chronic diseases, with once-daily dosing resulting in the highest adherence rates. Reducing the dosing frequency may positively impact both clinical and patient-reported outcomes, as well as health care costs. However, the increased costs of less frequently administered drugs must be outweighed by the net savings achieved through improved adherence rates and better health outcomes. If trends among patients with chronic diseases apply, once-daily dosing regimens may improve adherence rates by approximately 6% to 14% among renal transplant patients and could substantially reduce the number of acute rejection episodes and graft failures, although the exact economic impact is difficult to estimate. Further research into adherence issues in transplant patients and the potential clinical and economic benefits of once-daily dosing of immunosuppressants is warranted.

The Importance of Medication Adherence in Improving Chronic-Disease Related Outcomes

in chronic conditions is a recognized public health problem. Rates of nonadherence with any medication treatment may vary from 15% to 93%, with an average estimated rate of 50%. 3 The association among increased medication adherence, improved health outcomes, and lower healthcare costs is well known. 4 Many factors may influence patients’ adherence to the medication intervention: patients’ demographics, cost of medications, number of medications taken by the patient, nature of the medical intervention, and nature of the medical condition. 5,6 Healthcare costs have shown to vastly differ among patients with high and low adherence, with a clear relationship seen between increased medication adherence and lower healthcare costs. 7 Patients’ failure to adhere to the medication regimen may cost as much as $300 billion to the healthcare systems in the United States. 8 In this issue of Medical Care, Sokol and colleagues present the findings of a retrospective cohort study of 137,277 patients enrolled in medical and prescription benefit plans, in which they examine the relationship between medication adherence and healthcare utilization and costs for 4 chronic conditions: diabetes, hypertension, hypercholesterolemia, and congestive heart failure. This research represents an important milestone in our understanding of the role of medication adherence in chronic diseases. 9 Not only does this research show that higher medication adherence is associated with lower avoidable healthcare utilization and morbidity across many chronic conditions, it establishes the role of increased medication utilization and adherence in the effective management of the chronic disease condition. Medication nonadherence with medication regimens is a well-recognized, but understudied, public health problem. 1– 8 This effort by Sokol and colleagues represents one of the first times the ramifications of medication nonadherence in affecting patient morbidity are studied and compared across 4 prevalent chronic medical conditions using large patient samples. The next steps after establishing the clear associative relationship between medication nonadherence and poor patient outcomes should be: 1) to confirm these strong associative relationships as being causal by using

Treatment adherence in chronic disease

Research has addressed the problem of poor adherence for the past 4 decades. Much of the research has focused on the prevalence and predictors of adherence, research methodologies, and the development of measures of adherence. To a much lesser extent, attention has been given to intervention studies designed to evaluate strategies to improve adherence to treatment regimens. This article provides an up-to-date review of the literature on medication adherence in chronic disease.