Factors associated with medication refill adherence in cardiovascular-related diseases: a focus on health literacy

The association between health literacy and self-management abilities in adults aged 75 and older, and its moderators

PURPOSE

Low health literacy is an important predictor of poor health outcomes and well-being among older adults. A reason may be that low health literacy decreases older adults' self-management abilities. We therefore assessed the association between health literacy and self-management abilities among adults aged 75 and older, and the impact of demographic factors, socioeconomic factors, and health status on this association.

METHODS

We used data of 1052 older adults, gathered for a previously conducted randomized controlled trial on Embrace, an integrated elderly care model. These data pertained to health literacy, self-management abilities, demographic background, socioeconomic situation, and health status. Health literacy was measured by the validated three-item Brief Health Literacy Screening instrument. Self-management abilities were measured by the validated Self-Management Ability Scale (SMAS-30).

RESULTS

After adjustment for confounders, self-management abilities were poorer in older adults with low health literacy (β = .34, p < .001). This was more pronounced in medium- to high-educated older adults than in low-educated older adults. Sex, age, living situation, income, presence of chronic illness, and mental health status did not moderate the association between health literacy and self-management abilities.

CONCLUSIONS

Low health literacy is associated with poor self-management abilities in a wide range of older adults. Early recognition of low health literacy among adults of 75 years and older and interventions to improve health literacy might be very beneficial for older adults.

Health Literacy and Older Adults: A Systematic Review

Objective: The objective of this review was to assess published literature relating to health literacy and older adults. Method: The current review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses. Results: Eight articles met inclusion criteria. All studies were conducted in urban settings in the United States. Study sample size ranged from 33 to 3,000 participants. Two studies evaluated health-related outcomes and reported significant associations between low health literacy and poorer health outcomes. Two other studies investigated the impact of health literacy on medication management, reporting mixed findings. Discussion: The findings of this review highlight the importance of working to improve health care strategies for older adults with low health literacy and highlight the need for a standardized and validated clinical health literacy screening tool for older adults.

Medication Adherence Does Not Explain Black-White Differences in Cardiometabolic Risk Factor Control among Insured Patients with Diabetes

BACKGROUND

Among patients with diabetes, racial differences in cardiometabolic risk factor control are common. The extent to which differences in medication adherence contribute to such disparities is not known. We examined whether medication adherence, controlling for treatment intensification, could explain differences in risk factor control between black and white patients with diabetes.

METHODS

We identified three cohorts of black and white patients treated with oral medications and who had poor risk factor control at baseline (2009): those with glycated hemoglobin (HbA1c) >8 % (n = 37,873), low-density lipoprotein cholesterol (LDL-C) >100 mg/dl (n = 27,954), and systolic blood pressure (SBP) >130 mm Hg (n = 63,641). Subjects included insured adults with diabetes who were receiving care in one of nine U.S. integrated health systems comprising the SUrveillance, PREvention, and ManagEment of Diabetes Mellitus (SUPREME-DM) consortium. Baseline and follow-up risk factor control, sociodemographic, and clinical characteristics were obtained from electronic health records. Pharmacy-dispensing data were used to estimate medication adherence (i.e., medication refill adherence [MRA]) and treatment intensification (i.e., dose increase or addition of new medication class) between baseline and follow-up. County-level income and educational attainment were estimated via geocoding. Logistic regression models were used to test the association between race and follow-up risk factor control. Models were specified with and without medication adherence to evaluate its role as a mediator.

RESULTS

We observed poorer medication adherence among black patients than white patients (p < 0.01): 50.6 % of blacks versus 39.7 % of whites were not highly adherent (i.e., MRA <80 %) to HbA1c oral medication(s); 58.4 % of blacks and 46.7 % of whites were not highly adherent to lipid medication(s); and 33.4 % of blacks and 23.7 % of whites were not highly adherent to BP medication(s). Across all cardiometabolic risk factors, blacks were significantly less likely to achieve control (p < 0.01): 41.5 % of blacks and 45.8 % of whites achieved HbA1c <8 %; 52.6 % of blacks and 60.8 % of whites achieved LDL-C <100; and 45.7 % of blacks and 53.6 % of whites achieved SBP <130. Adjusting for medication adherence/treatment intensification did not alter these patterns or model fit statistics.

CONCLUSIONS

Medication adherence failed to explain observed racial differences in the achievement of HbA1c, LDL-C, and SBP control among insured patients with diabetes.

Associations and implications of low health literacy in Parkinson's Disease

BACKGROUND

Low health literacy (HL) indicates a limited ability to understand and use basic information to make appropriate healthcare decisions. While low HL is associated with higher morbidity, mortality, and healthcare costs in multiple chronic conditions, little is known about HL and its associations in Parkinson's disease (PD).

METHODS

Cross-sectional study of non-demented adults with PD participating in the National Parkinson Foundation Parkinson's Outcomes Project at the University of Pennsylvania. Subjects were administered two brief HL assessments-the Rapid Estimate of Adult Literacy in Medicine-Short Form (REALM-SF), a word-recognition test, and the Newest Vital Sign (NVS), a test of literacy, numeracy and understanding of health information-as well as demographic and clinical questionnaires. Adverse outcomes included falls in the 3 months preceding the study visit, and hospital admissions, emergency room visits, infections, or injuries in the preceding year. Caregiver burden was measured using the Multidimensional Caregiver Strain Index.

RESULTS

168 subjects completed both HL screens (mean 65.8 years, 65.5% male, 65.2% Hoehn & Yahr Stage 2). Using the REALM-SF, 97.6% of subjects had adequate HL. Using the NVS, however, 29.8% had low HL, which was associated with older age, lower education, male gender, greater disease severity, and poorer cognition. Low HL was associated with hospital admission and increased caregiver burden.

CONCLUSIONS

Low HL is common and associated with greater caregiver burden and a higher likelihood of hospitalization in patients with PD. Since HL is associated with both disease severity and adverse outcomes, it may be an important, modifiable contributor to morbidity.

The Effect of Health Literacy on Medication Knowledge and Medication Discrepancy in Chinese Americans

Background. Functional health literacy (FHL) is increasingly recognized as a useful predictor of health outcomes in different populations. However, the effect of FHL on medication knowledge and medication discrepancy in Chinese Americans is not well defined. Objectives. To examine the effects of FHL on medication knowledge and medication discrepancy in Chinese American patients. Methods. This was a cross-sectional study conducted at an academic internal medicine clinic. The Short Test of Functional Health Literacy in Adults was used to assess participants' FHL. Data for patients' demographic information, medication knowledge, and medication discrepancy (direction discrepancy and name discrepancy) were collected through patient interviews and chart reviews. The primary outcome was medication knowledge of purpose and the secondary outcomes included medication direction discrepancy and medication name discrepancy. Results. Of the 158 Chinese American patients who participated in the study, 54% had adequate FHL. More participants with adequate FHL had correct medication knowledge compared to participants with inadequate FHL (87% vs 56%, respectively, odds ratio = 3.4, 95% confidence interval = 1.2-9.7). Fewer participants with adequate FHL had medication direction discrepancy compared to those with inadequate FHL (42% vs 62%, odds ratio = 0.18, 95% confidence interval = 0.06-0.55). Both adequate and inadequate FHL groups had high prevalence of medication name discrepancy (77% vs 89%) even though the between-group difference was insignificant. Conclusions. Adequate FHL among Chinese American patients is significantly associated with increased medication knowledge of purpose and decreased medication direction discrepancy. Both adequate and inadequate FHL groups had high prevalence of medication name discrepancy.

The association between health beliefs and medication adherence among patients with type 2 diabetes

BACKGROUND

Type 2 diabetes is a major risk factor for cardiovascular disease and microvascular complications. Approximately 20.5% of adults between the ages of 20-79 are diagnosed with type 2 diabetes in Saudi Arabia. Nonadherence with type 2 diabetes medications is an established contributor to higher prevalence in other countries. No published studies have used a theoretical framework to explain or predict medication-taking behavior in Saudi Arabian type 2 diabetes (T2D) patients.

OBJECTIVE

The purpose of this study was to investigate type 2 diabetes medication adherence using a theoretical framework, the Health Belief Model (HBM). The specific objectives were to 1) assess self-report of medication-taking in a Saudi T2D convenience sample; 2) investigate self-reported HBM constructs for T2D, its complications, and medication-taking in this sample, and 3) test the ability for self-reported health beliefs to predict specific medication-taking behaviors among the sample.

METHODS

A cross-sectional study was conducted in a convenience sample at an outpatient pharmacy in Saudi Arabia. Adult type 2 diabetes patients on at least one prescribed diabetes medication, who were cognitively capable, and came themselves for prescription pickup, were eligible to participate. Patients completed a questionnaire or were interviewed. Data were collected for demographics, medical history, self-reported medication adherence, and type 2 diabetes medication-taking HBM items. Three measures collected self-report of medication adherence: new multi-dimensional adherence measure (MDAM), previously validated stage of change, and medication-taking recall- 7days (MTR-7). Descriptive statistics were generated and regression analyses were used to explain self-report of adherence.

RESULTS

Just over half (54%) of the 220 participants were male, mean age was 52 ± 11.2 years, and most (59%) had less than high school education. Approximately 58% were on oral medications only and the rest were on either insulin alone or a combination of oral and insulin; 16.7% reported knowing their hemoglobin A1C (A1C). For adherence, most reported taking the prescribed dose every time taken; however, 60% were not taking it the prescribed number of times per day and 50%, not the prescribed time of day (interval). Over 40% reported low adherence on stage of change and MTR-7. Perceived susceptibility, perceived medication benefits, and self-efficacy were significant HBM predictors for medication adherence (R² = 0.42).

CONCLUSIONS

The MDAM has research and practice potential because it evaluates sub-behaviors of medication-taking separately and as a score. Patient perceptions and beliefs should be assessed as part of a patient-centered medication adherence intervention.

Health literacy and medication administration performance by caregivers of adults with developmental disabilities

OBJECTIVES

To measure health literacy (HL) of caregivers of adults with intellectual/developmental disabilities (IDDs); to determine the association between HL and a medication administration task (MAT) assessment; and to identify caregiver characteristics associated with higher HL and MAT scores.

DESIGN

Cross-sectional study.

SETTING

Southeastern Michigan.

PARTICIPANTS

Caregivers, aged 18 years or older, who provided supportive care of adults with IDDs.

INTERVENTIONS

Survey and demonstration.

MAIN OUTCOME MEASURES

Short Test of Functional Health Literacy in Adults (STOFHLA); a MAT assessment consisting of interpretation of five sets of medication instructions followed by demonstration of understanding using a pill box; and a survey of caregivers' demographics, medication-related experiences, education, characteristics of persons for whom they provide care, and care-related activities performed.

RESULTS

A total of 47 caregivers provided data. Caregivers had a mean age of 45.7 ± 14.6 years; 41 (87.2%) were women and 38 (80.9%) had education beyond high school. Caregivers were involved in obtaining medication from pharmacies, reminded the person with IDD to take medications and/or administered them to the person, documented medication and health information, and accompanied persons with IDD to physician offices. Most did not conduct monitoring procedures. The STOFHLA mean score was 34.5 ± 2.5 (median, 35; range, 22-36), while the MAT mean score was 12.0 ± 2.2 (median, 12; range, 6-15). Compared with family caregivers, direct support staff more frequently had undergone some medication training and had other people with whom they could discuss medication questions, but they had worked with the person with IDD a significantly shorter amount of time. No significant differences in STOFHLA and MAT scores between the family caregivers and direct support staff were observed. Caregiver education was significantly correlated with the STOFHLA score. MAT scores were not significantly correlated with caregiver characteristics.

CONCLUSION

Caregivers are involved in the medication use process for people who have IDD. Ensuring caregiver understanding of medication regimens and/or improving medication-related HL may be an important step to ensure safe and effective use of medications by people with IDD.

Reprint of: Health literacy in Canada and the ophthalmology patient

Health literacy represents the cognitive and social skills that determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health.(1) According to the 2003 International Adult Literacy and Life Skills Survey (IALSS), over 12 million (60%) adult Canadians lack the capacity to obtain, understand, and act on health information and services, as well as make appropriate health decisions on their own.(2,3) Of these 12 million Canadians, the elderly are the most health illiterate age group in Canada. What this suggests for Canadian physicians is that to improve the CanMEDS roles of communicator and health advocate,(4) physicians need to recognize health literacy as a modifiable contributor of poor health outcomes and work to remove literacy-related barriers.(5) This is particularly important for ophthalmologists who manage chronic illnesses in elderly patients.(2,6,7) The objective of this review is 2-fold. The first objective is to describe health literacy in Canada and provide a summary on the current state of health literacy research, both generally in medicine and specifically to Ophthalmology. The second objective is to propose a 3-step approach of evidence based techniques for managing low health literate patients in clinic.

Pharmaceutical Cost-Saving Strategies and their Association with Medication Adherence in a Medicare Supplement Population

BACKGROUND

On average, Medicare Supplement insureds take about seven unique prescription medications each year, resulting in substantial out-of-pocket drug copayments, in addition to Medicare Supplement and Part D premiums. To help alleviate this financial burden, many individuals resort to cost-saving strategies that are not trackable by Part D insurance plans, likely resulting in an underestimation of medication adherence rates.

OBJECTIVE

We aimed to estimate utilization rates of cost-saving strategies, measure member characteristics associated with these strategies and estimate if these strategies are associated with medication adherence.

DESIGN

This was a cross-sectional analysis of a 2012-2013 survey of AARP® Medicare Supplement plan insureds with Part D pharmaceutical coverage.

PARTICIPANTS

The study included 5,784 community-dwelling survey respondents ≥ 65 years of age, living in ten states and with self-reported use of prescription medications.

MAIN MEASURES

Self-reported use of cost-saving strategies included: obtaining free samples from physicians, splitting pills so medications lasted longer, purchasing medications from other countries and/or over the internet, or purchasing medications through the Veterans Administration. Propensity weighted multivariate regressions were utilized to determine characteristics associated with the use of such strategies and the association with medication adherence as measured from Medicare Part D claims.

KEY RESULTS

Among those taking medications, 39.6% used cost-saving strategies. Those using these strategies were significantly (p < 0.05) more likely to be male, non-minority, have more comorbid conditions, have more disabilities and use more medications. Few variables were significantly related to pharmaceutical nonadherence, but those who were nonadherent were significantly more likely to use more medications, split pills, obtain free samples from their physicians and be male.

CONCLUSION

Cost-saving strategies are used extensively as a means to augment Medicare Part D coverage. These strategies are associated with measured medication nonadherence and likely result in underreporting of medication adherence rates. Pharmacy management programs should consider these additional medication sources in assisting plan members to problem solve cost-related medication management issues.

Decisional capacity and medication adherence among youth with HIV

This exploratory study examined the degree to which decisional capacity (DC) is associated with measures of self-reported medication adherence. We hypothesized that youth with higher levels of DC would report greater levels of antiretroviral medication adherence. Seventy-two (72) youth with HIV aged 13-24 participated in this study. Data collection included administration of the MacArthur Competence Tool for Treatment and measures of adherence (i.e., seven-day self-report interview, visual analog scale, and biological indicators). Data were analyzed using descriptive statistics, intercorrelations, and multiple and Poisson regression analyses. Youth with HIV who exhibited greater understanding of their disease were more likely to report fewer missed doses in the last seven days. Findings build upon literature in the areas of DC and health literacy and highlight the potential utility of enhancing HIV disease understanding among youth with HIV.

Low health literacy associated with higher medication costs in patients with type 2 diabetes mellitus: Evidence from matched survey and health insurance data

OBJECTIVE

Studies have shown that people with lower levels of health literacy create higher emergency, inpatient and total healthcare costs, yet little is known about how health literacy may affect medication costs. This cross-sectional study aims at investigating the relationship between health literacy and three years of medication costs (2009-2011) in a sample of patients with type 2 diabetes.

METHODS

391 patients from the German-speaking part of Switzerland who were insured with the same health insurer were interviewed. Health literacy was measured by a validated screening question and interview records were subsequently matched with data on medication costs. A bootstrap regression analysis was applied to investigate the relationship between health literacy and medication costs.

RESULTS

In 2010 and 2011 lower levels of health literacy were significantly associated with higher medication costs (p<.05).

CONCLUSION

The results suggest that diabetic patients with lower health literacy will create higher medication costs.

PRACTICE IMPLICATIONS

Besides being sensitive towards patients' health literacy levels, healthcare providers may have to take into account its potential impact on patients' medication regimen, misuse and healthcare costs.

Patient-reported medication adherence barriers among patients with cardiovascular risk factors

BACKGROUND

Many patients experience barriers that make it difficult to take cardiovascular disease (CVD)-related medications as prescribed. The Cardiovascular Intervention Improvement Telemedicine Study (CITIES) was a tailored behavioral pharmacist-administered and telephone-based intervention for reducing CVD risk.

OBJECTIVES

To (a) describe patient-reported barriers to taking their medication as prescribed and (b) evaluate patient-level characteristics associated with reporting medication barriers.

METHODS

We recruited patients receiving care at primary care clinics affiliated with Durham Veterans Affairs Medical Center. Eligible patients were diagnosed with hypertension and/or hyperlipidemia that were poorly controlled (blood pressure of > 150/100 mmHg and/or low-density lipoprotein value > 130 mg/dL). At the time of enrollment, patients completed an interview with 7 questions derived from a validated medication barriers measure. Patient characteristics and individual medication treatment barriers are described. Multivariable linear regression was used to examine the association between a medication barrier score and patient characteristics.

RESULTS

Most patients (n = 428) were married or living with their partners (57%) and were men (85%) who were diagnosed with hypertension and hyperlipidemia (64%). The most commonly reported barriers were having too much medication to take (31%) and forgetting whether medication was taken at a particular time (24%). In adjusted analysis, those who were not employed (1.32, 95% CI = 0.50-2.14) or did not have someone to help with tasks, if needed (1.66, 95% CI = 0.42-2.89), reported higher medication barrier scores. Compared with those diagnosed with hypertension and hyperlipidemia, those with only hypertension (0.91, 95% CI = 0.04-1.79) reported higher medication barrier scores.

CONCLUSIONS

Barriers to medication adherence are common. Evaluating and addressing barriers may increase medication adherence.

Quantifying the contribution of statins to the decline in population mean cholesterol by socioeconomic group in England 1991 - 2012: a modelling study

Background

Serum total cholesterol is one of the major targets for cardiovascular disease prevention. Statins are effective for cholesterol control in individual patients. At the population level, however, their contribution to total cholesterol decline remains unclear. The aim of this study was to quantify the contribution of statins to the observed fall in population mean cholesterol levels in England over the past two decades, and explore any differences between socioeconomic groups.

Methods and Findings

This is a modelling study based on data from the Health Survey for England. We analysed changes in observed mean total cholesterol levels in the adult England population between 1991-92 (baseline) and 2011-12. We then compared the observed changes with a counterfactual ‘no statins’ scenario, where the impact of statins on population total cholesterol was estimated and removed. We estimated uncertainty intervals (UI) using Monte Carlo simulation, where confidence intervals (CI) were impractical. In 2011-12, 13.2% (95% CI: 12.5-14.0%) of the English adult population used statins at least once per week, compared with 1991-92 when the proportion was just 0.5% (95% CI: 0.3-1.0%). Between 1991-92 and 2011-12, mean total cholesterol declined from 5.86 mmol/L (95% CI: 5.82-5.90) to 5.17 mmol/L (95% CI: 5.14-5.20). For 2011-12, mean total cholesterol was lower in more deprived groups. In our ‘no statins’ scenario we predicted a mean total cholesterol of 5.36 mmol/L (95% CI: 5.33-5.40) for 2011-12. Statins were responsible for approximately 33.7% (95% UI: 28.9-38.8%) of the total cholesterol reduction since 1991-92. The statin contribution to cholesterol reduction was greater among the more deprived groups of women, while showing little socio-economic gradient among men.

Conclusions

Our model suggests that statins explained around a third of the substantial falls in total cholesterol observed in England since 1991. Approximately two thirds of the cholesterol decrease can reasonably be attributed non-pharmacological determinants.

Health literacy in HIV treatment: accurate understanding of key biological treatment principles is not required for good ART adherence

Findings on the relationship between health literacy and outcomes in HIV have been inconsistent. Health literacy has previously been operationalized as general functional literacy, but has not included content knowledge about HIV disease and treatment. Semi-structured interviews with people living with HIV in 2 U.S. cities, including questions about the etiology, pathophysiology and treatment of HIV. We compared responses to biomedical conceptions. The 32 respondents were demographically diverse. Although most understood that HIV degrades the immune system, none could explain the nature of a virus, or the mechanism of antiretroviral (ARV) drug action. Fewer than half accurately reported that it is desirable to have a high CD4+ cell count and low viral load. A minority understood the concept of drug resistance. While most believed that strict adherence to ARV regimens was important to maintain health, three believed that periodic treatment interruption was beneficial, and three believed they should not take ARVs when they used alcohol or illicit drugs. Respondents generally had very limited, and often inaccurate biomedical understanding of HIV disease. Most reported good regimen adherence but did not have any mechanistic rationale for it. The failure to find a consistent relationship between health literacy and ARV adherence may be largely because most people simply follow their doctors' instructions, without the need for deep understanding.

Statins and Nonadherence

Statin nonadherence is a major challenge to optimal management. Patients nonadherent to statin therapy do not receive the expected benefit relative to the degree of low-density lipoprotein cholesterol (LDL-C) lowering obtained. This is important because new evidence guidelines recommend statins as the first-line therapy for those in high-risk groups (secondary prevention, patients with diabetes 40-75 years of age, and LDL-C ≥ 190 mg/dL) and in selected primary prevention patients. Statin assignment in the latter group occurs only in those with an estimated ≥7.5% 10-year atherosclerotic cardiovascular disease risk after shared decision making in a clinician–patient risk discussion. However, in numerous studies, statin nonadherence shows little or no benefit in reducing cardiovascular events or mortality compared to placebo, effectively negating the risk reduction expected from statin use and concomitantly increasing the total cost of health care. The causes and solutions for nonadherence are multifactorial and include patient, clinician, and health system factors. We believe that a clinician–patient partnership that facilitates patients’ understanding of the potential for optimal benefit with the least adverse effects is an important first step toward improving adherence. A transtheoretical model of stages of behavior change helps clinicians address many of the common factors limiting adherence to statins. We conclude with a teaching tool emphasizing a structured approach to statin therapy with patient-centered risk discussions.

Adherence to therapy and adverse drug reactions: is there a link?

INTRODUCTION

Advances in biomedical technology and access to effective medications have resulted in significant improvements in patient survival and quality of life. Patient adherence is crucial to quality healthcare outcomes; however, achievement of consistent adherence remains difficult. Patient non-adherence represents an important health problem, from a clinical/economic viewpoint, being associated with reduced treatment benefits and significant financial burden. Non-adherence potentially leads to adverse drug events (ADEs), which are generally responsible for poorer health outcomes and avoidable resource misuse. Further, adverse drug reactions (ADRs) exemplify one of the most significant barriers to patients' medication-taking behavior with further detrimental clinical/economic outcomes.

AREAS COVERED

The authors review adherence definitions and its measurement, emphasizing the consequences of the New European Pharmacovigilance Legislation on ADR definition. They analyzed the causes and the clinical/economic consequences of non-adherence and ADEs/ADRs in order to highlight a possible causal link.

EXPERT OPINION

Careful assessment of this harmful relationship is crucial in planning for the interventions needed to improve effectiveness of pharmacological care and to safeguard the sustainability of healthcare systems. Finally, through the 'deactivation' of this link, there will be more chance that advances in healthcare technologies will realize their potential to reduce the burden of chronic illness.

Impact of health literacy level on aspects of medication nonadherence reported by underserved patients with type 2 diabetes

BACKGROUND

Medication adherence can be affected by many factors, including health literacy. The purpose of this study is to determine (1) if a relationship exists between health literacy and self-reported or objectively measured medication adherence and (2) which aspect or aspects of medication nonadherence are most associated with health literacy.

SUBJECTS AND METHODS

This is a multicenter, cross-sectional survey study of adult patients with type 2 diabetes mellitus (T2DM), taking one or more antidiabetes medication for ≥6 months with a hemoglobin A1c (HbA1c) measure on record. Data collected included patient demographics (age, gender, race, language, highest level of education, injectable diabetes medication use, last HbA1c, and diabetes medication refill history) and two survey instruments (the Morisky eight-item Medication Adherence Scale [MMAS-8] and the short-form Test of Functional Health Literacy in Adults [s-TOFHLA]). Descriptive statistics and bivariate correlations were assessed, along with linear and logistic regression.

RESULTS

One hundred ninety-two patients with an average HbA1c level of 8.1% were included. Of these subjects, 32.8% had limited health literacy as measured by the s-TOFHLA, 58.9% had low adherence as measured by MMAS-8, and 65.1% were nonadherent based on cumulative medication gap (CMG) analysis. Age was associated with s-TOFHLA (-0.411; P<0.01) and MMAS-8 (0.157; P<0.05) scores. HbA1c was associated with MMAS-8 (-0.209; P<0.01) and CMG (0.152; P<0.05) scores. There was no significant association between s-TOFHLA and MMAS-8 or CMG. However, s-TOFHLA was positively related to MMAS-8 question 8, assessing difficulty remembering to take medications (P=0.017).

CONCLUSIONS

Health literacy level is not associated with self-reported or objectively measured medication adherence in underserved patients with T2DM. Lower health literacy scores are associated with a patient experiencing difficulty remembering to take medications.

A primary care, electronic health record-based strategy to promote safe drug use: study protocol for a randomized controlled trial

Background

The Northwestern University Center for Education and Research on Therapeutics (CERT), funded by the Agency for Healthcare Research and Quality, is one of seven such centers in the USA. The thematic focus of the Northwestern CERT is ‘Tools for Optimizing Medication Safety.’ Ensuring drug safety is essential, as many adults struggle to take medications, with estimates indicating that only half of adults take drugs as prescribed. This report describes the methods and rationale for one innovative project within the CERT: the ‘Primary Care, Electronic Health Record-Based Strategy to Promote Safe and Appropriate Drug Use’.

Methods/Design

The overall objective of this 5-year study is to evaluate a health literacy-informed, electronic health record-based strategy for promoting safe and effective prescription medication use in a primary care setting. A total of 600 English and Spanish-speaking patients with diabetes will be consecutively recruited to participate in the study. Patients will be randomized to receive either usual care or the intervention; those in the intervention arm will receive a set of print materials designed to support medication use and prompt provider counseling and medication reconciliation. Participants will be interviewed in person after their index clinic visit and again one month later. Process outcomes related to intervention delivery will be recorded. A medical chart review will be performed at 6 months. Patient outcome measures include medication understanding, adherence and clinical measures (hemoglobin A₁c, blood pressure, and cholesterol; exploratory outcomes only).

Discussion

Through this study, we will be able to examine the impact of a health literacy-informed, electronic health record-based strategy on medication understanding and adherence among diabetic primary care patients. The measurement of process outcomes will help inform how the strategy might ultimately be refined and disseminated to other sites. Strategies such as these are needed to address the multifaceted challenges related to medication self-management among patients with chronic conditions.

Trial registration

Clinicaltrials.gov NCT01669473.

Patient-provider communication, self-reported medication adherence, and race in a postmyocardial infarction population

OBJECTIVES

Our objectives were to: 1) describe patient-reported communication with their provider and explore differences in perceptions of racially diverse adherent versus nonadherent patients; and 2) examine whether the association between unanswered questions and patient-reported medication nonadherence varied as a function of patients' race.

METHODS

We conducted a cross-sectional analysis of baseline in-person survey data from a trial designed to improve postmyocardial infarction management of cardiovascular disease risk factors.

RESULTS

Overall, 298 patients (74%) reported never leaving their doctor's office with unanswered questions. Among those who were adherent and nonadherent with their medications, 183 (79%) and 115 (67%) patients, respectively, never left their doctor's office with unanswered questions. In multivariable logistic regression, although the simple effects of the interaction term were different for patients of nonminority race (odds ratio [OR]: 2.16; 95% confidence interval [CI]: 1.19-3.92) and those of minority race (OR: 1.19; 95% CI: 0.54-2.66), the overall interaction effect was not statistically significant (P=0.24).

CONCLUSION

The quality of patient-provider communication is critical for cardiovascular disease medication adherence. In this study, however, having unanswered questions did not impact medication adherence differently as a function of patients' race. Nevertheless, there were racial differences in medication adherence that may need to be addressed to ensure optimal adherence and health outcomes. Effort should be made to provide training opportunities for both patients and their providers to ensure strong communication skills and to address potential differences in medication adherence in patients of diverse backgrounds.

Medication Nonadherence Before Hospitalization for Acute Cardiac Events

Medication nonadherence increases the risk of hospitalization and poor outcomes, particularly among patients with cardiovascular disease. The purpose of this study was to examine characteristics associated with medication nonadherence among adults hospitalized for cardiovascular disease. Patients in the Vanderbilt Inpatient Cohort Study who were admitted for acute coronary syndrome or heart failure completed validated assessments of self-reported medication adherence (the Adherence to Refills and Medications Scale), demographic characteristics, health literacy, numeracy, social support, depressive symptoms, and health competence. We modeled the independent predictors of nonadherence before hospitalization, standardizing estimated effects by each predictor's interquartile range. Among 1,967 patients studied, 70.7% indicated at least some degree of medication nonadherence leading up to their hospitalization. Adherence was significantly lower among patients with lower health literacy (0.18-point change in adherence score per interquartile range change in health literacy), lower numeracy (0.28), lower health competence (0.30), and more depressive symptoms (0.52) and those of younger age, of non-White race, of male gender, or with less social support. Medication nonadherence in the period before hospitalization is more prevalent among patients with lower health literacy, numeracy, or other intervenable psychosocial factors. Addressing these factors in a coordinated care model may reduce hospitalization rates.

Racial/Ethnic differences in medication uptake and clinical outcomes among hospitalized cardiovascular patients with hypertension and diabetes

BACKGROUND

In the United States, hypertension and diabetes are more common among blacks and Hispanics than among others; the comorbidity is associated with worse clinical outcomes than each condition alone. Racial/ethnic differences in outcomes may be related to differential uptake of antihypertensive therapies, but data to evaluate this in real-world settings are limited. We aimed to determine the association between race/ethnicity and odds of rehospitalization or death, accounting for medication prescription, among a cohort of patients with hypertension and diabetes hospitalized for cardiovascular disease.

METHODS

This was a 1-year prospective study of individuals that participated in a National Heart, Lung, and Blood Institute clinical outcomes study. Clinical/medication data and outcomes (rehospitalization and death at 30 days and at 1 year) were documented by electronic medical record, National Death Index, and standardized mail survey. Logistic regression was used to evaluate associations between race/ethnicity and outcomes adjusted for type of antihypertensive medication, demographics, and comorbidity.

RESULTS

Participants (n = 1,126) were 14% black, 28% Hispanic, and 58% white/other. A total of 611 (54%) participants were rehospitalized at 1 year. Predictors of rehospitalization at 1 year included Hispanic ethnicity, diuretic prescription, lack of health insurance, peripheral vascular disease, and heart failure (P < 0.05). Race/ethnicity was not associated with rehospitalization at 30 days or death at 30 days or at 1 year. Increased odds of rehospitalization at 1 year among Hispanics remained significant after multivariable adjustment (odds ratio = 1.6; 95% confidence interval = 1.2-2.1).

CONCLUSIONS

In this study of hospitalized hypertension patients with diabetes, Hispanics had higher odds of rehospitalization than whites/others at 1 year but not at 30 days, and this was not explained by type of antihypertension medication prescribed.

Medication prescription and adherence disparities in non valvular atrial fibrillation patients: an Italian portrait from the ARAPACIS study

Non-valvular atrial fibrillation (NVAF) represents a major health-care problem, needing an extensive and strict thrombosis prevention for stroke and cardiovascular (CV) disease risks. NVAF management guidelines recommend adequate antithrombotic and anti-atherosclerotic therapies. Medication adherence has been recognized as a pivotal element in health quality promotion and in the achievement of better clinical outcomes. We conducted a post-hoc analysis of the "Atrial fibrillation Registry for Ankle-brachial index Prevalence Assessment-Collaborative Italian Study (ARAPACIS)" with the aim of discerning differences in pharmacological management and medication adherence among NVAF Italian patients. Furthermore, data were analysed according to Italian geographical macro-regions (North, Center, South) to evaluate whether socioeconomic conditions might also influence medication adherence. Thus, we selected 1,366 NVAF patients that fulfilled the Morisky Medication Adherence Scale-4 items. Regional disparities in drug prescriptions were observed. In particular, in high-risk patients (CHA2DS2-VASc ≥2) oral anticoagulants were more prescribed in Northern and Center patients (61 and 60 %, respectively) compared to 53 % of high-risk Southern patients. Also, medication adherence showed a progressive decrease from North to South (78 vs. 60 %, p < 0.001). This disparity was independent of the number of drugs consumed for any reason, since prevalence of poly-therapy among the three macro-regions was similar. Our results show regional differences in NVAF patients' antithrombotic management and medication adherence, potentially reflecting well-known disparities in socioeconomic status among Italian regions. Future interventions promoting campaigns to global health-care education may be desirable to improve clinical outcomes in NVAF patients.

An exploratory study of inactive health information seekers

PURPOSE

This study aims to identify people who do not actively seek out health information and the demographic characteristics of Inactive Seekers. The possible determinants of inactive seeking behaviors are also explored.

DESIGN AND MEASUREMENTS

A total of 14,420 survey respondents were drawn from the 2009 Annenberg National Health Communication Survey (ANHCS) data. K-means clustering was used to discriminate Inactive Seekers from Active Seekers. The inactive information seeker group was formed based on their experience with health information seeking. The potential determinants that were tested to predict inactive seeking included the following: health condition, health service use, health media exposure, and computer/Internet activities.

RESULTS

Within this national survey data, the respondents were more likely to be included in the Inactive Seekers (N=8312, 58.5%) compared to Active Seekers (N=5908, 41.5%). The demographic characteristics indicated that the Inactive Seekers were identified as younger, male, highly educated, White, and high household income people. The binary logistic regression results from the study model indicated that healthier people were less likely to seek out health information than their counterparts. In addition, those who were exposed to various media were almost 1.6 times more likely to seek out health information than those who were not exposed to such media. Within this study data, the statistically significant determinants identified were health condition and health media exposure while computer/Internet activities did not show strong indications in predicting inactive seeking behavior.

CONCLUSION

The development of more generalizable measures for health literacy or behavioral patterns will bolster advanced study on inactive seeking relating to knowledge of technology and health context. Further study should be directed at estimating the negative aspects of information seeking such as information ignorance or information avoidance.

Low literacy is associated with uncontrolled blood pressure in primary care patients with hypertension and heart disease

OBJECTIVES

To evaluate the association between low literacy and uncontrolled blood pressure (BP) and their associations with medication adherence.

METHODS

Cross-sectional study of 423 urban, primary care patients with hypertension and coronary disease. The relationship between low literacy (Rapid Estimate of Adult Literacy in Medicine ≤ 44) and uncontrolled BP (≥140/90 mmHg, ≥130/80 mmHg for patients with diabetes) was evaluated by crude and adjusted logistic regression. Relationships with self-reported adherence and refill adherence were explored using adjusted linear and logistic regression.

RESULTS

Overall, 192 (45%) subjects had low literacy and 227 (52.9%) had uncontrolled BP. Adjusting for age, gender, race, employment, education, mental status, and self-reported adherence, low literacy was associated with uncontrolled BP (OR 1.75, 95% CI 1.06-2.87). Lower self-reported adherence was associated with uncontrolled BP; the relationship between refill adherence and uncontrolled BP was not statistically significant.

CONCLUSION

Low literacy is independently associated with uncontrolled BP.

PRACTICE IMPLICATIONS

Awareness of the relationships among patient literacy, BP control, and medication adherence may guide healthcare providers as they communicate with patients.

Effects of health literacy and polypharmacy on medication adherence

OBJECTIVE

To determine if health literacy has an effect on medication adherence in patients taking fewer than five prescriptions (no polypharmacy), and those taking five or more prescriptions (polypharmacy).

DESIGN

Retrospective cohort.

SETTING

The Primary Care Residents' Clinic at Virginia Commonwealth University Health System (VCUHS).

PATIENTS

Those who received a Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R) assessment at the clinic between June 1, 2009, and June 30, 2010, and utilized the VCUHS outpatient pharmacies to fill their prescriptions. A total of 648 individuals were identified.

INTERVENTIONS

The degree of health literacy and level of medication adherence were analyzed per patient by accessing the clinic's electronic health records. The number of medications each patient filled was determined using VCUHS outpatient pharmacy databases.

MAIN OUTCOME MEASURE

To determine if there are any associations among the degree of health literacy, the level of medication adherence, and the amount of medications a patient is taking.

RESULTS

There was a significant association found between the level of medication adherence and the degree of polypharmacy. We found no association between the degree of health literacy and the level of adherence to a prescribed medication regimen. Additionally, there was no relationship between the degree of polypharmacy and health literacy. Those patients with more medications were also found to have lower levels of medication adherence and vice versa.

CONCLUSION

Our study does not show an association between health literacy and medication adherence nor between health literacy and polypharmacy. Thus, potential changes to improving health literacy may not have a significant effect on adherence.

Provider-patient communication about adherence to anti-retroviral regimens differs by patient race and ethnicity

Disparities in HIV care and outcomes negatively affect Black and Hispanic patients. Features of clinical communication may be a factor. This study is based on coding transcripts of 404 routine outpatient visits by people with HIV at four sites, using a validated system. In models adjusting for site and patient characteristics, with provider as a random effect, providers were more "verbally dominant" with Black patients than with others. There was more discussion about ARV adherence with both Black and Hispanic patients, but no more discussion about strategies to improve adherence. Providers made more directive utterances discussing ARV treatment with Hispanic patients. Possible interpretations of these findings are that providers are less confident in Black and Hispanic patients to be adherent; that they place too much confidence in their White, non-Hispanic patients; or that patients differentially want such discussion. The lack of specific problem solving and high provider directiveness suggests areas for improvement.

A health literacy pilot intervention to improve medication adherence using Meducation® technology

OBJECTIVE

To determine whether antihypertensive medication adherence could improve using a Meducation® technology health literacy intervention.

METHODS

We conducted a six-month feasibility study among patients with cardiovascular disease (CVD) risk factors receiving care from hospital-based primary care clinics. All patients received a personalized Meducation® calendar listing CVD-related medications. We evaluated changes in medication adherence and clinical outcomes at six months.

RESULTS

There was a 42% enrollment rate (n=23). Forty percent had low health literacy, defined as less than 9th grade reading level. At three months, self-reported medication adherence improved. At six months, medication possession ratio improved 3.2%. Also, at six months there were decreases in patients' average systolic blood pressure (0.5 mmHg), diastolic blood pressure (1.5 mmHg), and body weight (3.6 pounds) (p>0.05).

CONCLUSIONS

A health literacy intervention may be a feasible mechanism to improve cardiovascular-related medication adherence and outcomes.

PRACTICE IMPLICATIONS

Health literacy interventions may improve adherence while requiring relatively few resources to implement.

Association of health literacy with elevated blood pressure: a cohort study of hospitalized patients

BACKGROUND

The clinical consequences of low health literacy are not fully understood.

OBJECTIVES

We evaluated the relationship between low health literacy and elevated blood pressure (BP) at hospital presentation.

RESEARCH DESIGN AND SUBJECTS

We conducted a cross-sectional evaluation of adult patients hospitalized at a university hospital between November 1, 2010 and April 30, 2012.

MEASURES

Health literacy was assessed using the Brief Health Literacy Screen (BHLS). Low health literacy was defined as a BHLS score ≤9. BP was assessed using clinical measurements. The outcome was elevated BP (≥140/90 mm Hg; ≥130/80 mm Hg with diabetes or renal disease) or extremely elevated BP (>160/100 mm Hg) at hospital presentation. Multivariate logistic regression adjusted for age, sex, race, insurance, comorbidities, and antihypertensive medications; preplanned restricted analysis among patients with diagnosed hypertension was performed.

RESULTS

Of 46,263 hospitalizations, 23% had low health literacy, which occurred more often among patients who were older (61 vs. 54 y), less educated (28.4% vs. 11.2% had not completed high school), and more often admitted through the emergency department (54.3% vs. 48.1%) than those with BHLS>9. Elevated BP was more frequent among those with low health literacy [40.0% vs. 35.5%; adjusted odds ratio (aOR) 1.06; 95% confidence interval (CI), 1.01-1.12]. Low health literacy was associated with extremely elevated BP (aOR 1.08; 95% CI, 1.01-1.16) and elevated BP among those without diagnosed hypertension (aOR 1.09; 95% CI, 1.02-1.16).

CONCLUSIONS

More than ⅓ of patients had elevated BP at hospital presentation. Low health literacy was independently associated with elevated BP, particularly among patients without diagnosed hypertension.

A randomised controlled trial of providing personalised cardiovascular risk information to modify health behaviour

We conducted a feasibility study of a web-based intervention, which provided personalized cardiovascular disease (CVD) risk information, behavioural risk reduction strategies and educational resources. Participants were block-randomized to the 3-month intervention (n = 47) or to usual care (n = 49). Participants in the intervention group were presented with their CVD risk based on the Framingham risk score, and in three subsequent online encounters could select two behavioural/lifestyle modules, giving them an opportunity to complete six modules over the course of the study. Because it was self-guided, participants had differing levels of engagement with intervention materials. Most intervention group participants (77%, n = 36) completed all modules. After 3 months there were no significant differences between the intervention and usual care groups for systolic blood pressure, body-mass index, CVD risk, smoking cessation or medication non-adherence. The study suggests that modest clinical improvements can be achieved by interventions that are entirely web-administered. However, web-based interventions do not replace the need for human interaction to communicate CVD risk and assist with decision-making.

How can health literacy influence outcomes in heart failure patients? Mechanisms and interventions

Health literacy is discussed in papers from 25 countries where findings suggest that approximately a third up to one half of the people in developed countries have low health literacy. Specifically, health literacy is the mechanism by which individuals obtain and use health information to make health decisions about individual treatments in the home, access care in the community, promote provider-patient interactions, structure self-care, and navigate health care programs both locally and nationally. Further, health literacy is a key determinant of health and a critical dimension for assessing individuals' needs, and, importantly, their capacity for self-care. Poorer health knowledge/status, more medication errors, costs, and higher rates of morbidity, readmissions, emergency room visits, and mortality among patients with health illiteracy have been demonstrated. Individuals at high risk for low health literacy include the elderly, disabled, Blacks, those with a poverty-level income, some or less high school education, either no insurance or Medicare or Medicaid, and those for whom English is a second language. As a consequence, health literacy is a complex, multifaceted, and evolving construct including aspects of social, psychological, cultural and economic circumstances. The purpose of this paper is to describe the mechanisms and consequences of health illiteracy. Specifically, the prevalence, associated demographics, and models of health literacy are described. The mechanism of health illiteracy's influence on outcomes in heart failure is proposed. Tools for health literacy assessment are described and compared. Finally, the health outcomes and general interventions to enhance the health outcomes in heart failure are discussed.

Impact of health literacy on medication adherence: a systematic review and meta-analysis

OBJECTIVE

To systematically review the literature and estimate the effect size of the relationship between health literacy and medication adherence through meta-analysis.

DATA SOURCES

Databases searched included Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982-2013), International Pharmaceutical Abstracts (IPA; 1970-2013), MEDLINE OVID (1966-2013), PubMed (1966-2013), PsycInfo (1966-2013), and Web of Science (1966-2013).

STUDY SELECTION AND DATA EXTRACTION

Inclusion criteria were as follows: English language; published through May 1, 2013; medication adherence as the outcome variable; use of validated measures of health literacy and medication adherence; availability of a direct (not mediating) relationship between health literacy and medication adherence; and identifiable effect size and statistical significance of the relationship. Exclusion criteria were as follows: duplicated results, irrelevant results, conference abstracts, proceeding papers, books, dissertations, reviews, editorial letters, continuing education units, or book reviews. Data included author, publication year, disease area, sample size, sampling method, location, study design, effect size of the relationship between health literacy and medication adherence, and measures of health literacy and medication adherence.

DATA SYNTHESIS

There is a small statistically significant and positive association between health literacy and medication adherence. In the conservative results, the unweighted and weighted correlation coefficients were 0.081 and 0.056 with P values <0.001. In the less conservative results, the unweighted and weighted correlation coefficients were 0.088 and 0.072.

CONCLUSIONS

The relationship between health literacy and medication adherence is statistically significant but weak. It is plausible that health literacy has a mediator relationship with other adherence determinants. Future research should explore such relationships.

Cardiovascular health literacy and treatment adherence in persons with serious mental illness

Persons with serious mental illnesses have shorter life spans than the general population, and their earlier death is often related to cardiovascular disease. This study examined health literacy and cardiovascular medication adherence in a sample of 98 participants with serious mental illness. Sixty-two percent of the participants had adequate health literacy as measured by the Test of Functional Health Literacy in Adults. The association between health literacy and medication adherence was not significant after controlling for education. There was a significant association between health literacy and education level, health literacy and site, and health literacy and the sodium intake subscale of the Hill-Bone adherence scale.

Childhood socioeconomic position, young adult intelligence and fillings of prescribed medicine for prevention of cardiovascular disease in middle-aged men

OBJECTIVES

To explore the relationship between childhood socioeconomic position (SEP) and filling of medicine prescriptions for prevention of cardiovascular diseases (CVDs), with young adult intelligence (IQ) as a potential mediator.

DESIGN

Birth cohort study with logistic and Cox-proportional hazard regression analyses of associations between childhood SEP, retrieved from birth certificates, and prevalence, initiation of and refill persistency for CVD preventive medicine.

SETTING

Denmark.

PARTICIPANTS

8736 Danish men born in 1953, who had no CVD at the start of follow-up in 1995, were followed in the Danish National Prescription Register for initiation of and refill persistency for antihypertensives and statins, until the end of 2007 (age 54 years).

RESULTS

Low childhood SEP at age 18 was not associated with prescription fillings of antihypertensives, but was weakly associated with initiation of statins (HR = 1.19 (95% CI 1.00 to1.42)). This estimate was attenuated when IQ was entered into the model (HR=1.10 (95% CI 0.91 to 1.23)). Low childhood SEP was also associated with decreased refill persistency for statins (HR=2.23 (95% CI 1.13 to 4.40)). Thus, the HR for SEP only changed slightly (HR=2.24 (95% CI 1.11 to 4.52)) when IQ was entered into the model, but entering other covariates (education and body mass index in young adulthood and income in midlife) into the model attenuated the HR to 2.04 (95% CI 1.00 to 4.16).

CONCLUSIONS

Low childhood SEP was related to more frequent initiation of and poorer refill persistency for statins. IQ in young adulthood explained most of the association between childhood SEP and initiation of statins, but had no impact on refill persistency.

Psychosocial predictors of non-adherence to chronic medication: systematic review of longitudinal studies

OBJECTIVES

Several cross-sectional studies suggest that psychosocial factors are associated with non-adherence to chronic preventive maintenance medication (CPMM); however, results from longitudinal associations have not yet been systematically summarized. Therefore, the objective of this study was to systematically synthesize evidence of longitudinal associations between psychosocial predictors and CPMM non-adherence.

MATERIALS AND METHODS

PUBMED, EMBASE, CINAHL, and PsychINFO databases were searched for studies meeting our inclusion criteria. The reference lists and the ISI Web of Knowledge of the included studies were checked. Studies were included if they had an English abstract, involved adult populations using CPMM living in Western countries, and if they investigated associations between psychosocial predictors and medication non-adherence using longitudinal designs. Data were extracted according to a literature-based extraction form. Study quality was independently judged by two researchers using a framework comprising six bias domains. Studies were considered to be of high quality if ≥four domains were free of bias. Psychosocial predictors for non-adherence were categorized into five pre-defined categories: beliefs/cognitions; coping styles; social influences and social support; personality traits; and psychosocial well-being. A qualitative best evidence synthesis was performed to synthesize evidence of longitudinal associations between psychosocial predictors and CPMM non-adherence.

RESULTS

Of 4,732 initially-identified studies, 30 (low-quality) studies were included in the systematic review. The qualitative best evidence synthesis demonstrated limited evidence for absence of a longitudinal association between CPMM non-adherence and the psychosocial categories. The strength of evidence for the review's findings is limited by the low quality of included studies.

CONCLUSION

The results do not provide psychosocial targets for the development of new interventions in clinical practice. This review clearly demonstrates the need for high-quality, longitudinal research to identify psychosocial predictors of medication non-adherence.

Using quantile regression to assess disparities in medication adherence

OBJECTIVE

To examine racial/ethnic disparities in medication adherence between Asian and Pacific Islander Americans and Whites.

METHODS

This retrospective data analysis included diabetes patients enrolled in a health plan in Hawaii (N = 43,445). For anti-diabetic, lipid-lowering, and anti-hypertensive medications, quantile regression was estimated at 25(th), 50(th), and 75(th) quantiles to examine the association with race and ethnicity, controlling for other patient characteristics.

RESULTS

Consistently, Filipinos, Native Hawaiians, and other Pacific Islanders were significantly less adherent than Whites. The greatest disparities were found for other Pacific Islanders using lipid-lowering medications, with adjusted differences in medication adherence, with reductions relative to Whites of as much as 19% for lipid-lowering medications for the 25(th) quantile of adherence.

CONCLUSION

Whereas the large sample size undoubtedly contributed to the statistical significance, the large magnitude of the disparities, particularly for Filipinos, Native Hawaiians, and other Pacific Islanders, which suggests that these are meaningful differences that need to be addressed. The largest disparities were found at the lowest quantile suggests that they may be occurring among the most vulnerable populations with potentially poor access to care.

Single-item or two-item literacy screener to predict the S-TOFHLA among adult hemodialysis patients

OBJECTIVE

We compared single-item (SILS) and two-item (TILS) literacy screeners in predicting Short Test of Functional Health Literacy in Adults (S-TOFHLA) scores.

METHODS

Adult hemodialysis patients completed SILS, which determines need for assistance when reading written medical information; TILS (last grade completed and self-reported reading ability); and S-TOFHLA. Receiver operator characteristic curves (ROC) and stratum specific likelihoods were calculated.

RESULTS

Of 227 participants, median S-TOFHLA was 24 (IQR 15-34). 129 (55%) participants had adequate, 70 (30%) inadequate, and 37 (16%) marginal health literacy. SILS and TILS predicted S-TOFHLA scores equivalently. Test characteristics predicting inadequate health literacy were: SILS sensitivity for threshold >1, 54% (95%CI: 44, 64), for >2, 39% (29, 49) and specificity for >1, 73% (64, 80), for >2, 93% (87, 97), area under the ROC of 0.67 (0.60-0.74); TILS sensitivity for threshold >1, 72% (62, 80), for >2, 30% (21, 40) and specificity for >1, 54% (45, 63), for >2, 86% (79, 92), area under the ROC of 0.66 (0.59-0.73).

CONCLUSION

SILS and TILS had similar test characteristics in predicting S-TOFHLA.

PRACTICE IMPLICATIONS

While a positive result on either test increases the likelihood that a patient has low health literacy, the SILS is easier to administer and score.

A single-item self-report medication adherence question predicts hospitalisation and death in patients with heart failure

AIMS AND OBJECTIVES

To determine whether a single-item self-report medication adherence question predicts hospitalisation and death in patients with heart failure.

BACKGROUND

Poor medication adherence is associated with increased morbidity and mortality. Having a simple means of identifying suboptimal medication adherence could help identify at-risk patients for interventions.

DESIGN

We performed a prospective cohort study in 592 participants with heart failure within a four-site randomised trial.

METHODS

Self-report medication adherence was assessed at baseline using a single-item question: 'Over the past seven days, how many times did you miss a dose of any of your heart medication?' Participants who reported no missing doses were defined as fully adherent, and those missing more than one dose were considered less than fully adherent. The primary outcome was combined all-cause hospitalisation or death over one year and the secondary endpoint was heart failure hospitalisation. Outcomes were assessed with blinded chart reviews, and heart failure outcomes were determined by a blinded adjudication committee. We used negative binomial regression to examine the relationship between medication adherence and outcomes.

RESULTS

Fifty-two percent of participants were 52% male, mean age was 61 years, and 31% were of New York Heart Association class III/IV at enrolment; 72% of participants reported full adherence to their heart medicine at baseline. Participants with full medication adherence had a lower rate of all-cause hospitalisation and death (0·71 events/year) compared with those with any nonadherence (0·86 events/year): adjusted-for-site incidence rate ratio was 0·83, fully adjusted incidence rate ratio 0·68. Incidence rate ratios were similar for heart failure hospitalisations.

CONCLUSION

A single medication adherence question at baseline predicts hospitalisation and death over one year in heart failure patients.

RELEVANCE TO CLINICAL PRACTICE

Medication adherence is associated with all-cause and heart failure-related hospitalisation and death in heart failure. It is important for clinicians to assess patients' medication adherence on a regular basis at their clinical follow-ups.

Asthma outcomes are poor among older adults with low health literacy

OBJECTIVE

To examine the association of health literacy (HL) with asthma outcomes among older asthmatics.

METHODS

The study included adults ages ≥60 with moderate to severe asthma in New York City and Chicago. We assessed asthma control with the Asthma Control Questionnaire (ACQ) and the percent predicted forced expiratory volume at 1 s (FEV1) by spirometry, hospitalizations and emergency department (ED) visits in the past 6 months, and quality of life. HL was assessed with the Short Test of Functional Health Literacy in Adults (S-TOFHLA). Multivariate logistic regression models controlled for age, sex, race, income, general health and years with asthma.

RESULTS

Among 433 individuals, 36% had low HL, 55% were over age 65, 38% were Hispanic and 22% were black. Poor asthma control was reported by 40% and 32% had FEV1 <70% of predicted; 9% had a hospital stay, 23% had an ED and 38% had poor quality of life. In multivariable analysis, individuals with low HL were more likely to have FEV1 <70% predicted (odds ratio [OR] 2.34, 95% confidence interval [CI] 1.39-3.94, p = 0.001), hospitalizations (OR 2.53, 95% CI 1.17-5.49, p = 0.02) and ED visits for asthma (OR 1.81, 95% CI 1.05-3.10, p = 0.03). There were no differences in self-reported asthma control and quality of life.

CONCLUSIONS

Low HL is associated with poor asthma control by objective measure, and greater likelihood of ED visits and hospitalization. HL is a modifiable target for interventions to improve asthma outcomes in the elderly.

Association between perceived life chaos and medication adherence in a postmyocardial infarction population

BACKGROUND

The benefits of medication adherence to control cardiovascular disease (CVD) are well defined, yet multiple studies have identified poor adherence. The influence of life chaos on medication adherence is unknown. Because this is a novel application of an instrument, our preliminary objective was to understand patient factors associated with chaos. The main objective was to evaluate the extent to which an instrument designed to measure life chaos is associated with CVD-medication nonadherence.

METHODS AND RESULTS

Using baseline data from an ongoing randomized trial to improve postmyocardial infarction (MI) management, multivariable logistic regression identified the association between life chaos and CVD-medication nonadherence. Patients had hypertension and a myocardial infarction in the past 3 years (n=406). Nearly 43% reported CVD-medication nonadherence in the past month. In simple linear regression, the following were associated with higher life chaos: medication nonadherence (β=1.86; 95% confidence interval [CI], 0.96-2.76), female sex (β=1.22; 95% CI [0.22-2.24]), minority race (β=1.72; 95% CI [0.78-2.66]), having less than high school education (β=2.05; 95% CI [0.71-3.39]), low health literacy (β=2.06; 95% CI [0.86-3.26]), and inadequate financial status (β=1.93; 95% CI [0.87-3.00]). Being married (β=-2.09, 95% CI [-3.03 to -1.15]) was associated with lower life chaos. As chaos quartile increased, patients exhibited more nonadherence. In logistic regression, adjusting for sex, race, marital status, employment, education, health literacy, and financial status, a 1-unit life chaos increase was associated with a 7% increase (odds ratio, 1.07; 95% CI [1.02-1.12]) in odds of reporting medication nonadherence.

CONCLUSIONS

Our results suggest that life chaos may be an important determinant of medication adherence. Life chaos screenings could identify those at risk for nonadherence.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT000901277.

Computer-Based Programmed Instruction Did Not Improve the Knowledge Retention of Medication Instructions of Individuals With Type 2 Diabetes Mellitus

Purpose

The purpose of this study was to investigate whether computer-based programmed instruction (CPI) with a dynamic avatar (DA) improves retention of medication information better than text (controls) or better than CPI with text (T-CPI), CPI with voice (V-CPI), or CPI with static avatar with text (SA-CPI).

Methods

Participants with type 2 diabetes mellitus were enrolled in a randomized controlled trial comparing TDS with CPI in 4 conditions (T-CPI, V-CPI, SA-CPI, and DA-CPI). CPI sequentially delivers segmented information in text or voice followed by a multiple-choice question. Immediately after the user selects an option, CPI delivers elaborated feedback. Satisfaction was measured immediately after the interventions, and medication knowledge was measured at 2 weeks.

Results

One-hundred fifty individuals (30 per group) with a mean age 62 years (standard deviation [SD] 7.99 years) participated. There were no baseline differences in race, body mass index, education, and health literacy. Medication knowledge retention at 2 weeks was not significantly different between the groups, df(4), F = 0.17, P = .95 (TDS, mean = 25.43, SD = 5.11; T-CPI, mean = 25.07, SD = 4.98; V-CPI, mean = 25.77, SD = 4.89; SA-CPI, mean = 25.83, SD = 5.31; and DA-CPI, mean = 24.93, SD = 6.25). Satisfaction scores were significantly lower for TDS, df(4), F = 3.11, P = .01.

Conclusions

CPI did not improve medication knowledge retention at 2 weeks. CPI led to higher patient satisfaction compared with controls.