Potential Nonadherence Research Articles

Demonstrating a Technology-Mediated Intervention to Support Medication Adherence in Community-Dwelling Older Adults in Primary Care: A Feasibility Study

Background: Medication non-adherence can lead to significant morbidity and mortality. This 4-week feasibility study aims to demonstrate that the eDosette intervention can be implemented with older adults in primary care. Method: Fifty-six older adults from four primary care sites in Southwestern Ontario, Canada participated. The intervention involved generating, for pharmacist review, weekly medication administration records based on transmitted data captured by the eDosette. The primary outcome is implementation feasibility defined by recruitment, adherence rates, frequency of captured missed and late doses, descriptions of clinical work resulting from the intervention, and participant feedback. Results: The recruitment rate was 24% (57/240); one withdrew due to personal reasons. The mean observed adherence rate was 82% (range 49%-100%). Overall, participants missed 505 and took 2,105 doses late; 118 clinical decisions occurred with 72 unique medication changes in 31 participants. Participants found the eDosette easy to use and did not feel that they were viewed negatively because of their potential non-adherence. Conclusion: The eDosette intervention could be feasibly implemented in primary care with older adults. Providing information about when an older adult takes their medications could play a role in medication adherence by prompting more informed discussions between the older adult and primary care clinicians.

Monitoring self-reported adherence to antiretroviral therapy in public HIV care facilities in Brazil: A national cross-sectional study.

Introduction:Patient adherence to antiretroviral therapy (ART) is critical for HIV treatment success. Monitoring rates of adherence in public HIV outpatient care facilities can improve outcomes in Brazil where ART is universally available.Methods:We conducted a national cross-sectional survey of ART adherence in 2010. Participants were selected using a multistage probability sample. First, HIV outpatient care facilities were stratified according to 7 Organizational Quality Classification (OQC) groups and regions. Second, 1 or 2 facilities were selected per region for each OQC group. Finally, patients were randomly selected at each facility. In a first component, patients were invited to answer to a web-based questionnaire (WebAd-Q), a validated self-reported tool that includes 3 questions on adherence to ART in the past 7 days (time scheduling—timing, drug regimen—medication, and pill counts—dose), herein named indicators of potential nonadherence (IPN). In addition, a subsample of participants were interviewed in order to obtain further data on sociodemographic and clinical characteristics (second component). The proportion of each IPN was estimated using weighted data to account for the sampling design with 95% confidence interval (CI) and descriptive analysis was carried out.Results:Fifty-five facilities were chosen and 2424 patients completed the WebAd-Q in the first component of the study, while 598 patients were interviewed for the second component. The weighted proportions of the IPN were 50.9%, 31.8%, and 19.5%, for timing, medication, and dose, respectively, while11.7% had all 3 indicators, varying from 5.9% in the Southeast and 21.9% in the Northeast regions. Overall, 61.1% of the patients had at least 1 IPN (95% CI: 58.5–63.7%). Patients reporting depression symptoms, illicit drug use and those who missed medical appointments had worse nonadherence outcomes.Conclusions:Overall, there was a high proportion of all indicators IPN and timing was the main component associated with low adherence. Although these indicators may not necessarily indicate individual nonadherence, they represent a worrisome scenario in the public Brazilian HIV care facilities. On a routine basis, these facilities can identify gaps in providing counseling and ART orientation to their clientele and develop innovative strategies to prevent nonadherence.

Journal Digest

Journal Digest

Adherence to Follow-Up Recommendations by Triathlon Competitors Receiving Event Medical Care.

Introduction. We sought to investigate triathlete adherence to recommendations for follow-up for participants who received event medical care. Methods. Participants of the 2011 Ironman Syracuse 70.3 (Syracuse, NY) who sought evaluation and care at the designated finish line medical tent were contacted by telephone approximately 3 months after the initial encounter to measure adherence with the recommendation to seek follow-up care after event. Results. Out of 750 race participants, 35 (4.6%) athletes received event medical care. Of these 35, twenty-eight (28/35; 80%) consented to participate in the study and 17 (61%) were available on telephone follow-up. Of these 17 athletes, 11 (11/17; 65%) of participants reported that they had not followed up with a medical professional since the race. Only 5 (5/17; 29%) confirmed that they had seen a medical provider in some fashion since the race; of these, only 2 (2/17; 12%) sought formal medical follow-up resulting from the recommendation whereas the remaining athletes merely saw their medical providers coincidentally or as part of routine care. Conclusion. Only 2 (2/17; 12%) of athletes who received event medical care obtained postrace follow-up within a one-month time period following the race. Event medical care providers must be aware of potential nonadherence to follow-up recommendations.

Medication Adherence in Kidney Transplant Recipients in an Urban Indian Setting.

Medication nonadherence is a known problem after renal transplantation and can vary from one setting to another. Since it can lead to negative outcomes, it is important to develop intervention strategies to enhance adherence in a given setting using determinants identified through exploratory studies. We explored nonadherence in renal transplant recipients. A longitudinal survey was done with adult renal transplant recipients at a tertiary care public and two private hospitals of Kolkata. Subjects were followed-up for 1 year. After screening for medication adherence status by the four-item Morisky Medication Adherence Scale, those admitting to potential nonadherence were probed further. A patient was deemed to be nonadherent if failing to take medicines on appointed time (doses missed or delayed by more than 2 h) more than three times in any month during the observation period. A pretested questionnaire was used to explore potential determinants of nonadherence. Data of 153 patients recruited over a 2-year were analyzed. The extent of nonadherence with immunosuppressant regimens was about 31% overall; 44% in the public sector and 19% in the private sector (P < 0.001). Nonadherence with other medication was around 19% in both the sectors. Several potential demographic, socioeconomic and psychosocial determinants of nonadherence were identified on univariate analysis. However, logistic regression analysis singled out only the economic status. This study had updated the issue of nonadherence in renal transplant recipients in the Indian setting. Strategies to improve medication adherence can be planned by relevant stakeholders on the basis of these findings.

6.51 MEDICATION ADHERENCE AND USE OF ILLICIT SUBSTANCES IN PEDIATRIC AND YOUNG ADULT PATIENTS PRESCRIBED STIMULANT MEDICATIONS INDICATED FOR ATTENTION-DEFICIT/HYPERACTIVITY DISORDER

This study aimed to identify potential nonadherence among pediatric, adolescent, and young adult patients prescribed attention-deficit/hyperactivity disorder (ADHD) stimulant medications and assess the differences in illicit substance and/or nonprescribed medication use in patients testing positive versus negative for the ADHD medication.

(207) Predictors of medication adherence assessed by urine drug monitoring in patients prescribed opioid medications: relationship with opioid dose

Medication monitoring is recommended for patients prescribed an opioid for an extended period. This study evaluated the relationship between the prescribed dose of hydrocodone and the likelihood of finding hydrocodone or its metabolites with urine testing. Urine samples submitted to the laboratory between January 2013 and June 2015 from patients documented on the laboratory requisition to have been prescribed hydrocodone as their sole opiate medication were analyzed. The first sample obtained from each patient was tested for the presence of hydrocodone and its metabolites using liquid chromatography/tandem mass spectrometry. Samples were classified as positive for hydrocodone if parent drug and/or metabolite(s) were confirmed and negative if neither were detected. Adjusted odds ratio (aOR) and 95% confidence interval (CI) were calculated using multiple logistic regression analysis with the following independent variables: sex, age decade, primary payor, geographic region, year tested, and dose category. Of 178,582 unique samples analyzed, 28.4% were classified as negative for hydrocodone. Demographic factors most strongly associated with potential nonadherence were age (highest rate for age 20-29 years [37.6%] and lowest rate for age ≥60 years [23.2%]) and payor type (highest rate for Medicaid [36.2%] and lowest rates for workers’ compensation [25.0%] and commercial insurance [25.4%]). The rate of potential nonadherence decreased as prescribed hydrocodone dose increased, from 37.1% for patients prescribed 5 to 20 mg/day to 17.5% for those prescribed 60 to 120 mg/day (aOR, 0.35; 95% CI, 0.34-0.37). Among patients prescribed hydrocodone, potential nonadherence was common and varied with both patient characteristics and with prescribed dose. Understanding factors associated with potential nonadherence may inform strategies to use urine drug monitoring to better manage patients and improve treatment outcomes. Support: Ameritox Ltd.

Specific adverse effects of antiepileptic drugs--A true-to-life monotherapy study.

In patients taking antiepileptic drugs (AEDs) for epilepsy, adverse effects (AEs) often lead to unfavorable quality of life, impaired adherence, and, eventually, discontinuation of pharmacological treatment. In a true-to-life sample of subjects from our academic epilepsy outpatient clinic, we aimed to identify predictors for overall high AE burden and for specific AEs focusing on patients on monotherapy. All patients ≥16years of age with epilepsy for ≥12months were routinely asked to complete the Liverpool Adverse Event Profile (LAEP) just before their appointment. Demographic, epilepsy, and treatment variables were derived from our comprehensive outpatient database. Out of 841 patients, 438 (61% female, mean age: 44.7±17.1years) on monotherapy were included in this study. Levetiracetam (n=151), lamotrigine (n=167), valproic acid (n=73), or controlled-release carbamazepine (n=47) were the most commonly used antiepileptic drugs (AEDs). Independent predictors for general high AE burden (LAEP score≥45) were duration of epilepsy, lack of 12-month seizure freedom, and partial epilepsy, but none of the four individual AEDs. The most frequent LAEP-defined specific AEs were sleepiness, difficulty concentrating, tiredness, and memory problems. The three most frequent independent predictors for each of the 19 AEs were lack of 12-month seizure freedom (13/19 AEs), individual AED (7/19 AEs), and partial epilepsy (6/19 AEs). Levetiracetam was independently associated with anger/aggression, nervousness/agitation, upset stomach, depression, and sleep disturbance; lamotrigine with nervousness/agitation, upset stomach, and difficulty concentrating; and valproic acid with upset stomach and shaky hands. Individual AEDs independently predicted some specific AEs, but not overall high AE burden. Our findings may help to characterize patients with epilepsy who are at high risk for specific AEs. Dose reduction or change to another AED may reduce LAEP score and potential nonadherence.

Model-Based Approach for Optimization of Atazanavir Dose Recommendations for HIV-Infected Pediatric Patients

Atazanavir (Reyataz; ATV) is a well-tolerated protease inhibitor (PI) that is indicated as a once-daily treatment for HIV infections. These features of ATV, combined with its virologic potency, make it particularly desirable for the treatment of HIV-infected pediatric patients. The objective of this study was to use a model-based approach to recommend body weight-based ATV capsule doses for pediatric patients. ATV concentration-time data from three adult studies and one pediatric study were described by a C(0)-delinked one-compartment model to guard against introducing bias in pharmacokinetic (PK) parameter estimates due to the potential nonadherence in outpatient studies. The apparent clearance (CL/F) and apparent volume of distribution (V/F) were determined to increase with body weight, and CL/F was 40.9% lower in patients receiving ATV comedication with ritonavir (RTV). The relative bioavailability (F(rel)) of ATV was 132% higher with RTV comedication and was 35.5% lower for the ATV powder formulation than the capsule formulation. Model-based simulations were used to recommend weight-based ATV capsule doses of 150 to 300 mg boosted with 100 mg RTV for pediatric patients weighing ≥15 kg, such that the exposures in these patients are similar to those obtained in HIV-infected adults treated with the recommended ATV/RTV dose of 300/100 mg.

Descriptive analysis of mail interventions with physicians and patients to improve adherence with antihypertensive and antidiabetic medications in a mixed-model managed care organization of commercial and Medicare members.

Medication nonadherence is a major concern for many health care stakeholders. Improving medication adherence in health plan members who have both hypertension and diabetes is essential for the successful management of these chronic diseases, with anticipated outcomes in decreased health care utilization, all-cause mortality and cost. To (a) identify patients who are potentially nonadherent to antidiabetic or antihypertensive agents within 1 managed care organization and (b) determine the relationship of rates of medication nonadherence with 2 mail intervention programs that involved quarterly medication-specific profiles of patients with potential nonadherence sent to primary care physicians (PCPs) and general medication adherence letters sent to patients with potential nonadherence. The study sample consisted of commercial members, Medicare Advantage-Prescription Drug Plan (MA-PD) members and Medicare Prescription Drug Plan (PDP) members who filled prescriptions for antihypertensive and antidiabetic medications and utilized their managed care pharmacy benefit during each measurement quarter (3 months) in the 2-year study period. Nonadherence was defined as a medication possession ratio (MPR) less than 77.0% for 1 or more antihypertensives and/or antidiabetic medications for each standalone calendar quarter. The first intervention, letters to PCPs with patient-specific medication profiles for 2008 Q2, began 6-8 weeks after 2008 Q2 and continued for each standalone calendar quarter through the end of the study period in 2010 Q1 (January 1, 2010, through March 31, 2010). We assumed that patient care was managed by PCPs for hypertension and diabetes treatment. The medication profile also included antihyperlipidemic medication claims information, but there was no adherence analysis performed for antihyperlipidemic medications. The second intervention, letters sent to potentially nonadherent patients, began 6-8 weeks after 2009 Q1 for patients with MPR less than 77% for 1 or more antidiabetic or antihypertensive medications in 2009 Q1 and continued for each standalone calendar quarter through the end of the study period in 2010 Q1. Because there were 2 different interventions, 2 baseline adherence rates were calculated, for 2008 Q2 for the PCP mailing and for 2009 Q1 for the patient mailing. Compared with the baseline nonadherence rate in 2008 Q2 (35.6%), a small increase in nonadherence was observed in 2008 Q3 (36.4%), following by 6 calendar quarters of lower rates of nonadherence with a 27.7% nonadherence rate in the last measurement period in 2010 Q1. Compared with the nonadherence rate of 30.8% in baseline 2 (2009 Q1), the patient mailings were associated with small increases in nonadherence to 31.4% in 2009 Q2 and 31.1% in 2009 Q3, respectively, followed by lower nonadherence rates in 2009 Q4 (29.2%) and 2010 Q1 (27.7%). A 2-part intervention that involved mailings to PCPs for patients with both diabetic and antihypertensive medications who were potentially nonadherent to at least 1 medication, followed 9 months later by a general mailing sent to these potentially nonadherent patients regarding medication adherence, was associated with apparent improvement. However, the effect of the 2-part intervention on medication nonadherence could not be isolated because of coincident disease management interventions in diabetes and hypertension during the 2-year study period.

Clinical Practice Guidelines and Diagnostic Uncertainty in the Management of Early Rheumatoid Arthritis

Clinical practice guidelines (CPG) are “systematically developed statements to assist practitioner and patient decisions about healthcare for specific clinical circumstances,” and are intended to improve the quality of care for individuals with a specific diagnosis by encouraging physicians to adopt more evidence-based practice1. Over the past decade, several sets of CPG for the management of rheumatoid arthritis (RA) have been developed and disseminated2–4. Many studies have demonstrated substantial gaps between disseminated CPG and clinical practice, including some in RA5,6. However, requisite to drawing meaningful conclusions about physician adherence to CPG is a more detailed understanding of the circumstances leading to perceived suboptimal healthcare practices. In an effort to explore reasons for potential nonadherence to CPG in RA, in this issue of The Journal , Benhamou and colleagues examined physician prescribing patterns for early RA7 prior to publication of 2 sets of CPG addressing prescription of first-line disease-modifying antirheumatic drugs (DMARD)2,3. Utilizing ESPOIR (French acronym for “Study and Followup of Undifferentiated Early Arthritis”), a French multicenter observational cohort study that included 813 patients with early RA between 2002 and 2005, the authors found a 58% physician adherence rate with the French Society of Rheumatologists’ STPR (French acronym for “Therapeutic strategies in RA”) working group guidelines, and a 54% adherence with … Address reprint requests to Dr. Hersh. E-mail: hersha{at}peds.ucsf.edu

Development and validation of the Beliefs and Behaviour Questionnaire (BBQ)

Objective To develop and validate a questionnaire to screen for potential nonadherence in patients with chronic ailments. Methods Themes from qualitative interviews with chronic obstructive pulmonary disease patients were used in developing content of the questionnaire. The questionnaire was distributed to 525 ambulatory patients with chronic lung diseases. Principal components analysis was performed to identify the subscales in the questionnaire. Internal consistency, validity and stability of the subscales were also evaluated. Results The 30-item Beliefs and Behaviour Questionnaire (BBQ) measures beliefs, experiences and adherent behaviour on five-point Likert-type scales. Two hundred and eighty patients (53.3%) with a mean age of 71.1 years responded to the questionnaire. The ‘beliefs’ section had a two-factor solution—‘confidence’ and ‘concerns’ with internal consistencies of 0.82 and 0.45, respectively. The two domains identified from the section ‘experiences’—satisfaction’ and ‘disappointment’ had internal consistencies of 0.85 and 0.52, respectively. The ‘behaviour’ section, separately entitled the Tool for Adherence Behaviour Screening (TABS), had a two-factor solution—‘adherence’ and ‘nonadherence’, with internal consistencies of 0.80 and 0.59, respectively. All the domains demonstrated comparable reliabilities across two different patient populations. Their temporal stabilities ranged between 0.62 and 0.94. Conclusion The validity, reliability and utility of the BBQ and the TABS, a sub-scale of the BBQ that screens both intentional and unintentional nonadherence to pharmacological and non-pharmacological disease management, have been established. Practice implications The BBQ and the TABS have potential applications in screening adherence beliefs, experiences and behaviour in both clinical practice and research.

Barriers to Anti-inflammatory Medication Use in Childhood Asthma

To identify parental barriers to anti-inflammatory medication use and to develop an instrument for use in research and health care settings to identify at-risk populations. Instrument development consisted of 4 phases: 1) gaining the professional perspective (N = 8 experts in asthma management), 2) gaining the perspective of parents of children with asthma (qualitative interviews with 21 parents), 3) instrument pretesting and refinement (N = 133 parents), and 4) determining the instrument's psychometric properties. Study participants were diverse in race, socioeconomic status, and the child's illness severity. The final instrument consisted of 51 questions in 5 domains (nature of disease, cause, ideas about medications, treatment expectations, and health care provider relationship). The final instrument exhibited strong reliability (Cronbach alpha =.87) and validity. Significant barriers to appropriate anti-inflammatory medication use were parents' diminished treatment expectations and fears about anti-inflammatory medications. Minority families were more likely than white families to view asthma as unpredictable and uncontrollable (P =.01) and to have negative attitudes toward anti-inflammatory medications (P =.004). Eight questions were significantly correlated with a suboptimal medication regimen and may serve as a "quick screen" for potential nonadherence in clinical settings. Diminished treatment expectations and negative attitudes toward anti-inflammatories may be powerful predictors of nonadherence to medications.