Does an educational leaflet improve self-reported adherence to therapy in osteoporosis? The OPTIMA study

Evaluation of medication adherence of glaucoma patients during the COVID-19 pandemic

PURPOSE

To evaluate changes in the medication adherence of glaucoma patients during the COVID-19 pandemic and the factors influencing medication adherence.

MATERIALS AND METHODS

This cross-sectional study included a total of 197 glaucoma patients who were followed for at least six months in the Glaucoma Unit of the Ophthalmology Department of Inonu University, Faculty of Medicine. Patients were given a 28-item questionnaire, including the eight-item Morisky Medication Adherence Questionnaire, to evaluate medication adherence. Demographic and clinical data were recorded. P<0.05 was considered statistically significant.

RESULTS

Interruption of glaucoma clinic visits during the pandemic was reported by 82 (41.6%) patients. Nonadherence was reported by 56 patients (28.4%) (95% confidence interval: 22.1-34.7). For these patients, the most common reasons for nonadherence were forgetfulness (50%), the inability to receive a prescription for the drug (10.7%) and being busy (10.7%). Factors influencing nonadherence were determined to be younger age, female gender, interruption of glaucoma clinic visits and high-income levels (P˂0.05).

CONCLUSION

Interruption of glaucoma clinic visits during the COVID-19 pandemic and the resulting inability to have medications prescribed resulted in patient nonadherence with medication use.

Scope of Outcomes in Trials and Observational Studies of Interventions Targeting Medication Adherence in Rheumatic Conditions: A Systematic Review

OBJECTIVE

Nonadherence to medications is common in rheumatic conditions and associated with increased morbidity. Heterogeneous outcome reporting by researchers compromises the synthesis of evidence of interventions targeting adherence. We aimed to assess the scope of outcomes in interventional studies of medication adherence.

METHODS

We searched electronic databases to February 2019 for published randomized controlled trials and observational studies of interventions with the primary outcome of medication adherence including adults with any rheumatic condition, written in English. We extracted and analyzed all outcome domains and adherence measures with prespecified extraction and analysis protocols.

RESULTS

Overall, 53 studies reported 71 outcome domains classified into adherence (1 domain), health outcomes (38 domains), and adherence-related factors (e.g., medication knowledge; 32 domains). We subdivided adherence into 3 phases: initiation (n = 13 studies, 25%), implementation (n = 32, 60%), persistence (n = 27, 51%), and phase unclear (n = 20, 38%). Thirty-seven different instruments reported adherence in 115 unique ways (this includes different adherence definitions and calculations, metric, and method of aggregation). Forty-one studies (77%) reported health outcomes. The most frequently reported were medication adverse events (n = 24, 45%), disease activity (n = 11, 21%), bone turnover markers/physical function/quality of life (each n = 10, 19%). Thirty-three studies (62%) reported adherence-related factors. The most frequently reported were medication beliefs (n = 8, 15%), illness perception/medication satisfaction/satisfaction with medication information (each n = 5, 9%), condition knowledge/medication knowledge/trust in doctor (each n = 3, 6%).

CONCLUSION

The outcome domains and adherence measures in interventional studies targeting adherence are heterogeneous. Consensus on relevant outcomes will improve the comparison of different strategies to support medication adherence in rheumatology.

The association between medication non-adherence and adverse health outcomes in ageing populations: A systematic review and meta-analysis

AIMS

The aim of this systematic review and meta-analysis was to synthesise the evidence relating to medication non-adherence and its association with health outcomes in people aged ≥50 years.

METHODS

Seven databases were searched up to February 2019 for observational studies that measured medication (non-)adherence as a predictor of the following health outcomes in adults aged ≥50 years: healthcare utilisation (hospitalisation, emergency department visits, outpatient visits and general practitioner visits), mortality, adverse clinical events and quality of life. Screening and quality assessment using validated criteria were completed by 2 reviewers independently. Random effects models were used to generate pooled estimates of association using adjusted study results. The full methodological approach was published on PROSPERO (ID: CRD42017077264).

RESULTS

Sixty-six studies were identified for qualitative synthesis, with 11 of these studies eligible for meta-analyses. A meta-analysis including 3 studies measuring medication non-adherence in adults aged ≥55 years showed a significant association with all-cause hospitalisation (adjusted odds ratio 1.17, 95% confidence interval [CI] 1.12, 1.21). A meta-analysis including 2 studies showed that medication non-adherence was not significantly associated with an emergency department visit (adjusted odds ratio 1.05, 95% CI 0.90, 1.22). Good adherence was associated with a 21% reduction in long-term mortality risk in comparison to medication non-adherence (adjusted hazard ratio 0.79, 95% CI 0.63, 0.98).

CONCLUSION

Medication non-adherence may be significantly associated with all-cause hospitalisation and mortality in older people. Medication adherence should be monitored and addressed in this cohort to minimise hospitalisation, improve clinical outcomes and reduce healthcare costs.

Osteoporosis Knowledge Among Spine Surgery Patients

Background

The purpose of this study is to evaluate the knowledge and attitudes on osteoporosis among first-time spine surgery patients.

Methods

An electronic survey consisting of demographics, prior experience with osteoporosis, and the Facts on Osteoporosis Quiz (FOOQ) was sent via email to first-time spine surgery patients. Patients were then randomized into 2 groups: 1 received a brief osteoporosis information packet prior to beginning the FOOQ, and 1 proceeded directly to the survey.

Results

A total of 63 patients who participated in this study, 29 in the information packet group and 34 in the non-information packet group, completed the survey. The mean FOOQ scores for the information packet patients was 16.37 (± 2.35) and for the non-information packet patients was 15.62 (± 2.87), with a P value of .12. There were no statistically significant differences between the 2 groups in terms of patient demographics or prior experience with osteoporosis. The information packet group trended to higher interest with a P value of .068.

Conclusions

Our study demonstrates high FOOQ scores among all first-time spine patients as compared to historical scores in general at-risk populations. No statistical differences between FOOQ scores were noted between the group that received the information packet and the control group. This study demonstrates that patients new to spine care have a good understanding of osteoporosis and are thus willing to participate in osteoporosis treatment as part of their spine care.

The Impact of Educational Interventions on Osteoporosis Knowledge among Korean Osteoporosis Patients

Background

The purpose of this study was to determine the impact of an educational intervention that includes information sharing about absolute fracture risk on the knowledge of osteoporosis and modifiable risk factors among Korean patients with osteoporosis.

Methods

Adults aged >50 years who visited the outpatient clinic for osteoporosis were recruited. Subjects with trauma-related fractures or pathological fractures were excluded. The anthropometric data and clinical risk factors for fracture were collected at baseline. The participants completed the survey questionnaire that measured their knowledge regarding osteoporosis at baseline and then received information about the risk of fracture and individual education. Fracture risk was classified into five groups according to degree. The post-survey was conducted 3 months later. The pretest results were compared with the posttest results.

Results

In this study, 179 subjects (15 men and 164 women) were enrolled. After the educational intervention, the mean osteoporosis knowledge score significantly increased from 10.6±5.7 at pre-education (baseline) to 11.7±6.3 at post-education (P<0.001). When comparing the pre- and post-education Korean fracture risk scores, a negligible difference was found between the "very low risk" and "low risk" groups. However, the scores in the "very high risk" and "high risk" groups decreased from 77.6% to 76.0%. We found a difference over time only in physical activity.

Conclusions

Simple educational intervention is effective in increasing osteoporosis knowledge among Korean patients with osteoporosis. It may confer some benefit by providing information about osteoporotic fracture risks to improve knowledge and awareness regarding osteoporosis.

[Evaluation of the FD-66 Scale as a tool for predicting treatment adherence in patients with chronic non-communicable diseasesAvaliação da escala EFD-66 como instrumento para predizer a adesão ao tratamento em pacientes com doenças crônicas não transmissíveis]

Objective

The objectives of this study are to validate the construct of the stages of grief scale (FD-66) as an instrument for measuring the stages of grief and to evaluate its usefulness in discriminating among patients with chronic non-communicable diseases in terms of adherence to the pharmacological treatment prescribed.

Methods

A cross-sectional study was conducted from April to October 2015 to determine the association between the stages of grief and treatment adherence. Data were collected using a prolective design. Three instruments were applied: a sociodemographic document, the FD-66 scale, and the Morisky-Green questionnaire. Patients with a history of CNCDs were recruited from the Gustavo A. Madero Family Medicine Clinic in Mexico City. The data were analyzed using the appropriate statistical tests.

Results

A total of 165 patients were included. It was observed that high scores on the subscales of denial (odds ratio [OR]: 1.124; confidence interval of 95% [CI95%]: 1.066-1.186; P < 0,001); anger (OR: 1.157; CI95%: 1.080-1.240; P < 0.001), and depression (OR: 1.071; CI95%: 1.029-1.116; P = 0.001) are associated with poor treatment adherence; however, a high score on the acceptance subscale (OR: 0.913; CI95%: 0.880-0.948; P < 0.001) is associated with good treatment adherence. The greatest sensitivity among the subscales was observed in the denial and anger stages (area under the [ABC] curve: 0.597 in both).

Conclusions

The FD-66 is an instrument with good construct validity as a tool for measuring the stages of grief and makes it possible to identify patients with CNCD that will adhere to treatment. We therefore recommend its use in outpatient medical consultations. Furthermore, our findings indicate that grief is a risk factor that increases poor treatment adherence.

Clinical guidelines for the prevention and treatment of osteoporosis: summary statements and recommendations from the Italian Society for Orthopaedics and Traumatology

BACKGROUND

The Italian Society for Orthopaedics and Traumatology conceived this guidance-which is primarily addressed to Italian orthopedic surgeons, but should also prove useful to other bone specialists and to general practitioners-in order to improve the diagnosis, prevention, and treatment of osteoporosis and its consequences.

MATERIALS AND METHODS

Literature reviews by a multidisciplinary team.

RESULTS

The following topics are covered: the role of instrumental, metabolic, and genetic evaluations in the diagnosis of osteoporosis; appraisal of the risk of fracture and thresholds for intervention; general strategies for the prevention and treatment of osteoporosis (primary and secondary prevention); the pharmacologic treatment of osteoporosis; the setting and implementation of fracture liaison services for tertiary prevention. Grade A, B, and C recommendations are provided based on the main levels of evidence (1-3). Toolboxes for everyday clinical practice are provided.

CONCLUSIONS

The first up-to-date Italian guidelines for the primary, secondary, and tertiary prevention of osteoporosis and osteoporotic fractures are presented.

Patient education in osteoporosis prevention: a systematic review focusing on methodological quality of randomised controlled trials

This review summarizes evidence regarding the effects of patient education in osteoporosis prevention and treatment. The included studies reveal mixed results on a variety of endpoints. Methodological improvem ent of future RCTs (e.g. with regard to randomization and duration of follow-up) might yield more conclusive evidence on the effects of patient education in osteoporosis INTRODUCTION: This review aims to evaluate the effects of patient education on osteoporosis prevention and treatment results.

METHODS

Multiple databases including PubMed and Embase were searched until February 2016. Randomised controlled trials (RCTs) were eligible if they included adults diagnosed with or at risk of osteoporosis and assessed patient education interventions (group- or individual-based). Outcomes regarding osteoporosis management including initiation of and adherence to pharmacological therapy, physical activity, calcium and vitamin D intake, changes in smoking behaviour, fractures, quality of life (QoL) and osteoporosis knowledge were evaluated. The Cochrane collaboration's tool for assessing the risk of bias was used to assess the internal validity of included trials.

RESULTS

Fifteen articles (13 different studies) published between 2001 and 2013 were included (group-based education = 7, individual-based education = 5, both = 1). The general risk of bias was considered as moderate to high. The effects on 'bone mineral density (BMD) testing and/or pharmacological therapy' (composite endpoint), 'calcium intake' and 'vitamin D intake' as well as 'osteoporosis knowledge' were statistically significant in favour of the intervention in ≥50% of the studies analysing these outcomes. Differences between the intervention and the control group regarding 'pharmacological therapy', 'medication adherence', 'physical activity', 'fractures' and 'QoL' were found to be statistically significant in <50% of the trials.

CONCLUSIONS

This review indicates that it is still unclear whether patient education is beneficial and whether it has a significant and clinically relevant impact on osteoporosis management results. Educational programmes for osteoporosis require further investigation within the context of well-conducted RCTs.

Influence of patient training on persistence, compliance, and tolerability of different dosing frequency regimens of bisphosphonate therapy: An observational study in Turkish patients with postmenopausal osteoporosis

Objective

In our study, we aimed to evaluate the influence of training on compliance and persistence with bisphosphonate treatment given on a weekly vs. monthly basis in postmenopausal osteoporosis patients.

Methods

A total of 979 patients with postmenopausal osteoporosis (mean age: 63.2 ± 7.2 years) were included in this national, multicenter, prospective non-interventional observational cohort registry study. Patients were randomized into training (n = 492, 50.3%, mean age: 63.4 ± 7.2 years) and control (n = 487, 49.7%, mean age: 63.0 ± 7.1 years) groups. Patients in each intervention group were given weekly (44.9% and 44.6% for training and control subjects, respectively) or monthly (55.1% and 55.4%, respectively) bisphosphonate regimens. After the initial visit, patients were followed up at three-month intervals throughout 12 months of treatment for evaluation of persistence, compliance and adverse events.

Results

On average, 79.4% of the patients were persistent with the treatment with a mean of 350.4 days of duration during the 12-month follow-up period. The mean compliance in the compliant and fully compliant group remained at an average of 86.6%. No significant difference was detected between the training and control groups in terms of compliance and persistence. Significantly longer persistence (360.0 ± 89.0 vs. 345.0 ± 108.0 days; p = 0.035), higher percentage of persistent patients (83.4% vs. 74.2%; p = 0.012) and higher compliance rates (88.8% vs. 83.3%; p = 0.002) were noted in monthly regimen patients in comparison to those given weekly regimen.

Conclusion

Our findings revealed remarkably high rates for persistence and compliance with bisphosphonate treatment in postmenopausal osteoporosis, with no impact of training on compliance and persistence rates. Longer persistence and better compliance rates were achieved with the monthly bisphosphonate regimen when compared to the weekly regimen.

Bone care nurses and the evolution of the nurse's educational function: the Guardian Angel(®) research project

Osteoporosis mostly affects females over 50 years old, worldwide. The main osteoporosis complication is fragility fractures that reduce quality of life and cause morbidity and mortality. Most patients who have fragility fractures are treated for the fracture. However, patients' adherence to follow-up treatment plans is poor. Therefore, tailored educational interventions are needed to improve medication adherence and healthy lifestyles. In this context, the role of bone care nurses is important, as they can act at different levels of osteoporosis prevention and fracture liaison services, which are secondary fracture prevention programmes implemented by health care systems to treat osteoporotic patients. In Italy, a research project called Guardian Angel(®) was developed to provide tailored education to osteoporotic women in order to improve their disease management and reduce related complications.

The Most Common Barriers to Glaucoma Medication Adherence: A Cross-Sectional Survey

PURPOSE

To evaluate the frequency of 11 commonly cited barriers to optimal glaucoma medication adherence among glaucoma patients and to identify barriers contributing to poor adherence.

DESIGN

Prospective, cross-sectional survey.

PARTICIPANTS

One hundred ninety adults with glaucoma taking 1 or more glaucoma medication who received care in glaucoma clinics in Ann Arbor, Michigan, and Baltimore, Maryland.

METHODS

Participants completed a survey on demographic and disease characteristics, barriers to optimal glaucoma medication adherence, interest in an eye drop aid, and self-reported adherence (measured by the Morisky Adherence Scale). Descriptive statistics and logistic regression analyses were performed.

MAIN OUTCOME MEASURES

Frequency and number of barriers to adherence among both adherent and nonadherent patients. Odds ratios (ORs) with 95% confidence intervals (CIs) identifying barriers associated with poor adherence.

RESULTS

Twenty-seven percent of the sample reported poor adherence. Sixty-one percent of all participants cited multiple barriers and 10% cited a single barrier as impediments to optimal adherence. Twenty-nine percent of subjects cited no barriers, although only 13% of patients who cited no barriers were nonadherent. Among nonadherent patients, 31% or more cited each of the 11 barriers as important. Logistic regression analysis, adjusted for age, revealed that the following barriers were associated with higher odds of nonadherence: decreased self-efficacy (OR, 4.7; 95% CI, 2.2-9.7; P ≤ 0.0001), difficulty instilling drops (OR, 2.3; 95% CI, 1.1-4.9; P = 0.03), forgetfulness (OR, 5.6; 95% CI, 2.6-12.1; P ≤ 0.0001), and difficulties with the medication schedule (OR, 2.9; 95% CI, 1.4-6.0; P = 0.006). For each additional barrier cited as important, there was a 10% increased odds of being nonadherent (OR, 1.1; 95% CI, 1.0-1.2; P = 0.01).

CONCLUSIONS

Each of the 11 barriers was important to at least 30% of surveyed patients with poor adherence, with most identifying multiple barriers to adherence. Low self-efficacy, forgetfulness, and difficulty with drop administration and the medication schedule were barriers associated with poor adherence. Interventions to improve medication adherence must address each patient's unique set of barriers.

Helping our patients take HIV pre-exposure prophylaxis (PrEP): a systematic review of adherence interventions

OBJECTIVES

Adherence is critical for maximizing the effectiveness of pre-exposure prophylaxis (PrEP) in preventing HIV infection. Strategies for promoting adherence to HIV treatment, and their potential application to PrEP adherence, have received considerable attention. However, adherence promotion strategies for prevention medications have not been well characterized and may be more applicable to PrEP. We aimed to identify adherence support interventions that have been effective in other prevention fields and could be applied in the HIV prevention context to support pill taking among PrEP users.

METHODS

To identify adherence support interventions that could be evaluated and applied in the PrEP context, we conducted a systematic review across the following prevention fields: hypertension, latent tuberculosis infection, hyperlipidaemia, oral contraceptives, osteoporosis, malaria prophylaxis, and post-exposure prophylaxis for HIV infection. We included randomized controlled trials that evaluated the efficacy of interventions to improve adherence to daily oral medications prescribed for primary prevention in healthy individuals or for secondary prevention in asymptomatic individuals.

RESULTS

Our searches identified 585 studies, of which 48 studies met the eligibility criteria and were included in the review; nine evaluated multiple strategies, yielding 64 separately tested interventions. Interventions with the strongest evidence for improving adherence included complex, resource-intensive interventions, which combined multiple adherence support approaches, and low-cost, low-intensity interventions that provided education or telephone calls for adherence support.

CONCLUSIONS

Our review identified adherence interventions with strong evidence of efficacy across prevention fields and provides recommendations for evaluating these interventions in upcoming PrEP studies.

Interventions to improve osteoporosis medication adherence and persistence: a systematic review and literature appraisal by the ISPOR Medication Adherence & Persistence Special Interest Group

This study aims to systematically review, critically appraise and identify from the published literature, the most effective interventions to improve medication adherence in osteoporosis. A literature search using Medline, EMBASE, Cochrane library, and Cumulative Index to Nursing and Allied Health Literature was undertaken to identify prospective studies published between January 1, 1999 and June 30, 2012. We included studies on adult users of osteoporosis medications that tested a patient adherence intervention (e.g., patient education, intensified patient care, different dosing regimens) and reported quantitative results of adherence. The Delphi list was modified to assess the quality of studies. Of 113 articles identified, 20 studies fulfilled the inclusion criteria. The most frequent intervention was education (n = 11) followed by monitoring/supervision (n = 4), drug regimens (n = 2), drug regimens and patient support (n = 1), pharmacist intervention (n = 1), and electronic prescription (n = 1). Although patient education improved medication adherence in four studies, two large-scale randomized studies reported no benefits. Simplification of dosing regimens (with and without patient support program) was found to have a significant clinical impact on medication adherence and persistence. Monitoring/supervision showed no impact on medication persistence while electronic prescription and pharmacist intervention increased medication adherence or persistence. In conclusion, this review found that simplification of dosing regimens, decision aids, electronic prescription, or patient education may help to improve adherence or persistence to osteoporosis medications. We identified wide variation of quality of studies in the osteoporosis area. The efficacy of patient education was variable across studies, while monitoring/supervision does not seem an effective way to enhance medication adherence or persistence.

Impact of the training on the compliance and persistence of weekly bisphosphonate treatment in postmenopausal osteoporosis: a randomized controlled study

Long-term patient adherence to osteoporosis treatment is poor despite proven efficacy. In this study, we aimed to assess the impact of active patient training on treatment compliance and persistence in patients with postmenopausal osteoporosis. In the present national, multicenter, randomized controlled study, postmenopausal osteoporosis patients (45-75 years) who were on weekly bisphosphonate treatment were randomized to active training (AT) and passive training (PT) groups and followed-up by 4 visits after the initial visit at 3 months interval during 12 months of the treatment. Both groups received a bisphosphonate usage guide and osteoporosis training booklets. Additionally, AT group received four phone calls (at 2(nd), 5(th), 8(th), and 11(th) months) and participated to four interactive social/training meetings held in groups of 10 patients (at 3(rd), 6(th), 9(th), and 12(th) months). The primary evaluation criteria were self-reported persistence and compliance to the treatment and the secondary evaluation criteria was quality life of the patients assessed by 41-item Quality of Life European Foundation for Osteoporosis (QUALEFFO-41) questionnaire. Of 448 patients (mean age 62.4±7.7 years), 226 were randomized to AT group and 222 were randomized to PT group. Among the study visits, the most common reason for not receiving treatment regularly was forgetfulness (54.9% for visit 2, 44.3% for visit 3, 51.6% for visit 4, and 43.8% for visit 5), the majority of the patients always used their drugs regularly on recommended days and dosages (63.8% for visit 2, 60.9% for visit 3, 72.1% for visit 4, and 70.8% for visit 5), and most of the patients were highly satisfied with the treatment (63.4% for visit 2, 68.9% for visit 3, 72.4% for visit 4, and 65.2% for visit 5) and wanted to continue to the treatment (96.5% for visit 2, 96.5% for visit 3, 96.9% for visit 4, and 94.4% for visit 5). QUALEFFO scores of the patients in visit 1 significantly improved in visit 5 (37.7±25.4 vs. 34.0±14.6, p<0.001); however, the difference was not significant between AT and PT groups both in visit 1 and visit 5. In conclusion, in addition to active training, passive training provided at the 1(st) visit did not improve the persistence and compliance of the patients for bisphosphonate treatment.

Awareness of osteoporosis, risk and protective factors and own diagnostic status: a cross-sectional study

We conducted a cross-sectional study of the understanding on osteoporosis amongst community-dwelling geriatric patients. Patient understanding on the pathology, risk factors and its complications was suboptimal, but better amongst women and persons with diagnosed osteoporosis. Improving patient osteoporosis education may lead to improved compliance with preventive and therapeutic measures.

PURPOSE

Osteoporosis is often preventable and treatable. Establishing levels of understanding in an Irish population will help inform future public and patient education.

METHODS

We conducted a cross-sectional survey of 126 randomly selected geriatric day hospital patients, interviewing next of kin where abbreviated mental test score was <6. Questions assessed awareness of (1) basic pathology, (2) predisposing and protective factors, (3) complications and (4) personal osteoporosis status and treatment.

RESULTS

Participants included 103 patients and 23 carers; 78.6 % were female; patients' mean age was 81.6 years. Of the patients surveyed, 87.3 % had heard of osteoporosis; 56.1 % knew affected bone; and 30.2 % were cognisant of architectural change. About 65.9 % reported that a doctor had never discussed the condition; 92.9 % correctly identified whether diagnosed with osteoporosis, and >96 % correctly identified their treatment status. Rates of risk factor identification were as follows: 88.9 % for ageing, 83.8 % female gender, 65.1 % smoking, 62.4 % low BMI and 51.6 % alcohol excess; <10 % identified other risk factors. Awareness of complications ranged from 91.3 % for fractures to 44.4 % for height loss. Awareness of protective factors (calcium/vitamin D-rich food, medication and exercise) was >85 % for each. More women had heard of osteoporosis (p = 0.02), knew affected bone (p = 0.005) and recognised gender as a risk factor (p = 0.015) and pain (p = 0.05) or kyphosis (p = 0.014) as complications. Osteoporotic patients (N = 38) were more likely to know it as affected bone (p = 0.006). Amongst patients surveyed [abbreviated mental test score (AMTS) 6-10], AMTS score did not predict understanding. Age did not predict understanding, nor were next of kin more likely to understand osteoporosis than patients.

CONCLUSION

There is scope for enhancing patient osteoporosis education, which may improve compliance with preventive and therapeutic measures.

Adherence to bisphosphonate therapy in postmenopausal osteoporotic women

INTRODUCTION

Osteoporosis is a metabolic bone disease caused by a decrease in the bone mineral density. It is a major public health threat as it weakens bones, especially those in the wrist, spine, or hip, and causes them to break easily.

AIM

The study aimed to find how strictly postmenopausal women with osteoporosis adhere to a long-term therapy with bisphosphonates.

PATIENTS AND METHODS

The study was conducted over a 24-month period. It included a total of 341 randomized patients with postmenopausal osteoporosis; the diagnosis was made on the basis of clinical and radiological evidence and a DXA T-score of the axial skeleton and the left hip less than -2.5 SD. Therapy included per os administration of alendonate 70 mg once a week or 50 mg of ibandronate once a month.

RESULTS

The patient medication persistence at the end of month 12 was 86.80%, and at the end of month 24 month - 58.94%. The medication possession ratio (MPR) in the bisphosphonate therapy at 6, 12, 18, and 24 months varied from 0.93 to 1.00. This suggests that there was a very good patient medication adherence of the study subjects to the 24-month treatment with bisphosphonates. The patient medication persistence dropped significantly at the end of month 12.

CONCLUSION

Compliance of patients with antiresorptive therapy depends on the specific socio-economic conditions and the attending physician's behaviour. Very rarely, treatment is discontinued because of adverse effects exerted by the drugs or because patients may not be convinced that they have osteoporosis.

Malic enzyme gene polymorphism is associated with responsiveness in circulating parathyroid hormone after long-term calcium supplementation

OBJECTIVE

To identify genetic variations associated with parathyroid hormone (PTH) suppression after long-term calcium supplementation.

DESIGN AND PARTICIPANTS

For high throughput SNP screening, subjects consisted of 171 postmenopausal women without osteoporosis at the lumbar spine. A separate group of 19 premenpausal women were recruited for calcium absorption study. Postmenopausal women in the screening group were given 500 mg/day calcium supplementation.

SETTING

Bangkok, Thailand.

MEASUREMENTS

Parathyroid hormone (PTH) and bone mineral density (BMD) were measured at baseline and 2 years after calcium supplementation. High throughput single-nucleotide polymorphism (SNP) screening was performed by comparing estimated allele frequencies derived from hybridization signal intensities of pooled DNA samples on Affymetrix's 10K SNP genotyping microarrays based responsiveness in PTH after calcium supplementation. Genotyping of SNP rs1112482 in malic enzyme gene (ME1) gene, a SNP among those with highest odds ratio of being related to PTH suppression after calcium, was performed in all postmenopausal subjects in the screening group and premenopausal women in the calcium absorption study group in which fractional calcium absorption was assessed by stable isotope dilution. Data were expressed as mean +/- SEM.

RESULTS

PTH significantly decreased after 2 years of calcium supplementation (4.7 ± 1.9 vs. 4.4 ± 1.6 pmol/L, P < 0.01). There was a significant increase in lumbar spine BMD (1.03 ± 0.01 vs. 1.01 ± 0.01 g/cm2, P < 0.001) but not femoral neck BMD. In 108 subjects whose PTH levels decreased after calcium, the suppression of PTH was higher in those with at least one C allele in rs1112482 of ME1 gene (-26.3 ± 2.1 vs. -16.9 ± 1.4%, P < 0.001). Fractional calcium absorption also tends to the higher in subjects in the calcium absorption study group with at least one C allele (n = 6) compared to those without the C allele (n = 13) (58.0 ± 4.9 vs. 49.3 ± 2.8%, P = 0.054).

CONCLUSION

Cytosolic malic enzyme 1 gene polymorphism is associated with the degree of suppression of parathyroid hormone after long-term calcium supplementation. The effect is probably mediated through an increase in intestinal calcium absorption.

GRAND: the German retrospective cohort analysis on compliance and persistence and the associated risk of fractures in osteoporotic women treated with oral bisphosphonates

This database analysis of over 4,000 German women prescribed oral bisphosphonates between December 2004 and November 2007 showed that compliance and persistence with oral bisphosphonates in German women with osteoporosis were inadequate.

INTRODUCTION

GRAND is a database analysis designed to investigate persistence and compliance with oral bisphosphonate regimens, and their association with fracture incidence, in women with osteoporosis.

METHODS

Diagnostic, treatment and fracture data were obtained from the IMS Disease Analyzer patient database in Germany. Women with osteoporosis prescribed one of six specified oral bisphosphonates between December 2004 and November 2007 with no similar prescription for at least 1 year beforehand were eligible for analysis. Those treated with intravenous bisphosphonates were excluded. Persistence (prescription refill gap of ≤ 30 days or change of treatment frequency) and compliance (medication possession ratio) were measured for 2 years from therapy start.

RESULTS

Data from 4,147 women were evaluable, with a median oral bisphosphonate treatment duration of 145.5 days. Persistence rates after 1 and 2 years were 27.9% and 12.9%, respectively, and 66.3% of women were compliant. As expected, persistence rates were higher when the refill gap was increased to 60 or 90 days. No significant differences in 1-year persistence between patients on weekly or monthly treatment regimens were observed (28.6% and 29.4%, respectively), although 1-year persistence with daily treatment was only 7.2%. After 24 months of therapy, compliant women had fewer fractures than non-compliant women (88.1% and 85.0% fracture-free, respectively; p = 0.0147). In multivariate Cox regression analysis, treatment compliance was the only factor that significantly decreased fracture risk (p = 0.0034).

CONCLUSIONS

Compliance and persistence with oral bisphosphonates in German women with osteoporosis were inadequate. Better compliance and persistence can prevent fractures in these women.

What Do Israeli Osteoporotic Men Know and Do about Their Disease?

Aims. The aims of the current study were to evaluate the level of knowledge about osteoporosis among osteoporotic men and to assess the correlations with their health behaviors. Method. A convenience sample of 100 osteoporotic men (mean age 63) attending the bone and mineral clinic at a major medical center in Israel was recruited in 2004. Participants were interviewed by phone using an adapted version of the Facts on Osteoporosis Quiz (FOOQ). Participants were also asked to report on their daily calcium intake and participation in physical activities. Results. The overall level of knowledge about the disease demonstrated by the participants was moderate. Higher education, older age, and fewer fractures were correlated with a higher level of knowledge. In addition, higher levels of education and knowledge were correlated with higher calcium intake. Lastly, a higher knowledge level, older age, and fewer fractures were correlated with higher participation in physical activities. Conclusions. Given the correlations between health behaviors and the level of knowledge among osteoporotic men, intervention programs should be used to evaluate and improve knowledge about osteoporosis, especially among less educated patients.

Overcoming problems with adherence to osteoporosis medication

Nonadherence to pharmacological treatment in osteoporosis is a well-recognized problem. As in other chronic diseases, adherence to osteoporosis treatment is poor, resulting in enormous burden on patients and healthcare resources. Most importantly, low adherence rates consistently result in increased rates of fractures. However, it seems that efforts to evaluate and improve rates of both compliance and persistence are increasing. The extension of dosing intervals may be an element, among others, allowing improvements in therapeutic adherence. Improved patient education, enhancing healthcare provider-patients interaction, taking into account patient's preferences and involving them in treatment decisions may improve adherence.

Improving adherence in osteoporosis: a new management algorithm for the patient with osteoporosis

INTRODUCTION

Bisphosphonates are the first-choice treatment for osteoporosis. They effectively increase bone mineral density, reduce markers of bone resorption, and lower the incidence of new fractures in patients with osteoporosis-related fracture. However, the efficacy observed in clinical trials may not be realized in a real-life setting, partly due to poor adherence to therapy, with a significant worsening of clinical outcomes. Several issues contribute to poor adherence to osteoporosis medication, including inconvenient dosing regimens and concerns about possible adverse events. Although strategies to improve adherence have been investigated, new approaches are required.

AREAS COVERED

We review available data and propose a new approach to improve adherence to osteoporosis therapy in clinical practice. We present the current evidence and personal experience from a group of Italian osteoporosis experts.

EXPERT OPINION

To improve adherence, we propose a multifaceted approach, which includes the Triad Model suggested by the World Health Organization, direct observed therapy and the use of drugs with longer administration intervals, e.g., zoledronic acid. The integration of these strategies may provide the basis for a marked increase in adherence to osteoporosis therapy, and improved clinical outcomes in a real-life scenario.

A systematic review assessing the effectiveness of interventions to improve persistence with anti-resorptive therapy in women at high risk of clinical fracture

BACKGROUND

despite availability of effective treatments for osteoporosis, impact on fracture rates may be suboptimal because of failure to adhere to recommended anti-resorptive therapy.

OBJECTIVE

to identify randomized controlled trials (RCTs) evaluating interventions intended to improve persistence with anti-resorptive therapy for treating women with osteoporosis or osteopenia. The design of the study is a systematic review and meta-analysis of RCTs.

METHODS

included trials were those reporting interventions to improve persistence with or adherence to anti-resorptive treatment compared to a control medication or usual care. A search of MEDLINE, EMBASE, CINAHL and the Cochrane Library was supplemented by review of cited literature. Reports were reviewed and data pooled where appropriate. The primary outcome was duration of persistence with medication.

RESULTS

six trials met inclusion criteria, including four reporting persistence as an outcome measure indicating a relative reduction in non-persistence of 22% (pooled relative risk: 0.78, 95% confidence interval 0.65-0.95) for active compared to control interventions. Heterogeneity between the trial effects was present but not significant (I(2) = 47%, P = 0.11). Interventions were varied in design, and some measurements of adherence were subject to self-report bias. Two trials included the majority of participants (3386/3497), accounting for >90% of the weight in the pooled estimate.

CONCLUSIONS

trials to date suggest potential for improving persistence with medication taking thus improving treatment outcomes and reducing fracture risk. More precise measurement of medication taking and promoting fidelity to a precisely defined intervention protocol may lead to better assessment of impact on clinically important outcomes.

Patient education in groups increases knowledge of osteoporosis and adherence to treatment: a two-year randomized controlled trial

OBJECTIVE

Non-adherence to pharmacological treatment in osteoporosis is a well-recognized problem. We hypothesized that a group-based educational programme would increase patients' knowledge and level of adherence with medical treatment.

METHODS

A total of 300 patients (32 men aged 65 ± 9 years and 268 women aged 63 ± 8 years), recently diagnosed with osteoporosis, were randomised to either an osteoporosis school programme (four classes of 8-12 participants over four weeks) or a control group. Teaching was multidisciplinary, based on patients' experiences and background and designed to encourage empowerment. Patients' knowledge about osteoporosis and adherence to treatment was assessed with self-completed questionnaires at baseline and after 3, 12, and 24 months.

RESULTS

There were no significant differences at baseline between the two groups with respect to knowledge score or level of adherence. At two years' follow-up, the improvement in knowledge score was 2 [0-4] points (median [25-75 percentiles]) in the school group and 0 [-2 to 2] in controls (p<0.001) and self-reported adherence to pharmacological therapy was significantly higher in the school group (92%) compared to the control group (80%), p<0.001.

CONCLUSION

The programme increased knowledge about osteoporosis and increased self-reported adherence to pharmacological treatment over a period of two years.

Effects of pharmaceutical care on adherence and persistence to bisphosphonates in postmenopausal osteoporotic women

WHAT IS KNOWN AND OBJECTIVE

Studies have shown that comprehensive interventions by pharmacists can improve adherence and persistence to osteoporosis therapy, but the association between adherence and bone turnover markers (BTMs) has never been studied. Therefore, the aim of this study was to evaluate the effects of pharmaceutical care on medication adherence (and its effects on BTMs), as well as persistence of postmenopausal osteoporotic women to prescribed bisphosphonates.

METHODS

A randomized controlled trial was conducted from 2005 to 2009 in the University Malaya Medical Centre, Malaysia.

INCLUSION CRITERIA

postmenopausal osteoporotic women diagnosed with osteoporosis with a T-score ≤ -2·5 or who had a low-trauma fracture and prescribed weekly alendronate/risedronate. Intervention participants received counselling on osteoporosis, risk factors, lifestyle modifications, goals of therapy, side effects and the importance of adherence. Adherence was assessed at months 3, 6 and 12, and persistence at month 12. Feedback on BTMs was provided at months 4 and 7. The control group received no counselling. Two BTMs were used: serum C-terminal cross-linking telopeptide of type I collagen (CTX-I) and serum osteocalcin (OC).

MAIN OUTCOMES MEASURED

medication adherence, BTMs and persistence.

RESULTS AND DISCUSSION

Intervention participants who received pharmaceutical care reported significantly higher medication adherence at 6 (P = 0·015) and 12 months (P = 0·047) compared with the control group; but this effect was not shown by the BTMs. This is probably due to the long effect of bisphosphonates in bone. A significant difference was found between serum CTX-I and OC in identifying non-responders to anti-resorptive therapy (P < 0·001), indicating the usefulness of BTMs as an objective marker. However, pharmaceutical care did not affect persistence to osteoporosis therapy within a 1-year period [log rank (Mantel-Cox) χ² = 0·496, P = 0·481]. The proportion of participants who were persistent with bisphosphonate therapy after 12 months was 89·8% and 87·0% in the control and intervention group respectively.

WHAT IS NEW AND CONCLUSION

The provision of pharmaceutical care improved medication adherence but not persistence. BTMs were not appropriate objective measures for assessing adherence to weekly bisphosphonates but were useful for identifying non-responders to treatment within 3-6 months, much earlier than using bone mineral density. The study indicates that pharmacists have a role in improving medication adherence, but its long-term effect on persistence warrants further studies with longer duration.

A systematic review of interventions by healthcare professionals on community-dwelling postmenopausal women with osteoporosis

A systematic review was conducted to evaluate evidence concerning the effect of non-drug interventions by healthcare professionals on community-dwelling postmenopausal osteoporotic women. Evidence available indicates that such interventions are effective in improving the quality of life, medication compliance, and calcium intake, but effect on other outcomes is less conclusive.

INTRODUCTION

The purpose of this study is to conduct a systematic review to evaluate evidence concerning the effect of non-drug interventions by healthcare professionals on community-dwelling postmenopausal osteoporotic women.

METHODS

Randomized controlled trials (RCTs) published in English between year 1990 and 2009 were identified. Types of patient outcome used as assessment included quality of life (QOL), bone mineral density (BMD), medication compliance and persistence, knowledge level, and lifestyle modification.

RESULTS

Twenty four RCTs met the inclusion criteria. Seven studies assessed interventions by physiotherapists, six by physicians, seven by nurses, three by multi-disciplinary teams and one by dietitians. Variability in the types and intensity of interventions made comparison between each study difficult. Collectively, these studies provided some evidence to show that interventions by healthcare professionals improved the QOL medication compliance and calcium intake of patients but its effects on BMD, medication persistence, knowledge, and other lifestyle modifications were less conclusive.

CONCLUSIONS

From this review, it was found that some outcome measures of such non-drug interventions still required further studies. Future studies should use validated instruments to assess the outcomes, with focus on common definitions of interventions and outcome measures, more intensive one-to-one interventions, appropriate control groups, adequate randomization procedures, and also provide information on effect size.

Correlation between adherence rates measured by MEMS and self-reported questionnaires: a meta-analysis

Purpose

It is vital to understand the associations between the medication event monitoring systems (MEMS) and self-reported questionnaires (SRQs) because both are often used to measure medication adherence and can produce different results. In addition, the economic implication of using alternative measures is important as the cost of electronic monitoring devices is not covered by insurance, while self-reports are the most practical and cost-effective method in the clinical settings. This meta-analysis examined the correlations of two measurements of medication adherence: MEMS and SRQs.

Methods

The literature search (1980-2009) used PubMed, OVID MEDLINE, PsycINFO (EBSCO), CINAHL (EBSCO), OVID HealthStar, EMBASE (Elsevier), and Cochrane Databases. Studies were included if the correlation coefficients [Pearson (r_p) or Spearman (r_s)] between adherences measured by both MEMS and SRQs were available or could be calculated from other statistics in the articles. Data were independently abstracted in duplicate with standardized protocol and abstraction form including 1) first author's name; 2) year of publication; 3) disease status of participants; 4) sample size; 5) mean age (year); 6) duration of trials (month); 7) SRQ names if available; 8) adherence (%) measured by MEMS; 9) adherence (%) measured by SRQ; 10) correlation coefficient and relative information, including p-value, 95% confidence interval (CI). A meta-analysis was conducted to pool the correlation coefficients using random-effect model.

Results

Eleven studies (N = 1,684 patients) met the inclusion criteria. The mean of adherence measured by MEMS was 74.9% (range 53.4%-92.9%), versus 84.0% by SRQ (range 68.35%-95%). The correlation between adherence measured by MEMS and SRQs ranged from 0.24 to 0.87. The pooled correlation coefficient for 11 studies was 0.45 (p = 0.001, 95% confidence interval [95% CI]: 0.34-0.56). The subgroup meta-analysis on the seven studies reporting r_p and four studies reporting r_s reported the pooled correlation coefficient: 0.46 (p = 0.011, 95% CI: 0.33-0.59) and 0.43 (p = 0.0038, 95% CI: 0.23-0.64), respectively. No differences were found for other subgroup analyses.

Conclusion

Medication adherence measured by MEMS and SRQs tends to be at least moderately correlated, suggesting that SRQs give a good estimate of medication adherence.

Quality of life in glaucoma and three other chronic diseases: a systematic literature review

Chronic diseases have a long-term negative impact on quality of life (QOL). Decreased QOL is associated with increased financial burden on healthcare systems and society. However, few publications have investigated the impact of glaucoma on patients' QOL in comparison with other chronic diseases observed in patients with similar demographic characteristics. To this end, a systematic literature search to assess QOL in glaucoma and three other chronic diseases (osteoporosis, type 2 diabetes mellitus and dementia) was performed. A total of 146 publications were identified that reported QOL using six commonly used generic QOL instruments: 36-, 12- and 20-item Short-Form Health Surveys (SF-36, -12 and -20), EuroQoL (EQ-5D), Sickness Impact Profile (SIP) and the Health Utilities Index-Mark III (HUI-III). The publication breakdown was as follows: glaucoma (10%), osteoporosis (26%), diabetes (52%) and dementia (12%); one publication assessed QOL in glaucoma, diabetes and dementia. QOL was affected to a similar or slightly lesser degree by glaucoma than by osteoporosis, diabetes or dementia. Among the publications reporting SF-36, -12 and -20 evaluations, physical component scores were generally lower than mental component scores across all diseases. QOL was affected more in patients with glaucoma than in demographically matched non-glaucomatous controls according to SF-20 assessment. EQ-5D and SIP results showed that QOL decreased as the severity of glaucoma increased. Patients with glaucoma had the lowest scores on the SIP instrument, indicating better QOL than patients with osteoporosis or diabetes (no data were available on dementia). The HUI-III instrument identified poorer QOL in patients with dementia than other diseases, probably due to cognitive deficits. However, for some of the instruments, data were scarce, and interpretation of the results should be conservative. Although there are limited published QOL studies in glaucoma, its impact on QOL appears to be broadly similar to that of other serious chronic diseases. Development of a QOL instrument that measures vision-specific and general health aspects would better document the impact of glaucoma on QOL and would facilitate comparisons with other chronic disease states.

Concordance of adherence measurement using self-reported adherence questionnaires and medication monitoring devices

The primary objective of this review was to identify and examine the literature on the association between medication adherence self-reported questionnaires (SRQs) and medication monitoring devices. The primary literature search was performed for 1980-2009 using PubMed, PubMed In Process and Non-Indexed, Ovid MEDLINE, Ovid MEDLINE In-Process, PsycINFO (EBSCO), CINAHL (EBSCO), Ovid HealthStar, EMBASE (Elsevier) and Cochrane Databases and using the following search terms: 'patient compliance', 'medication adherence', 'treatment compliance', 'drug monitoring', 'drug therapy', 'electronic', 'digital', 'computer', 'monitor', 'monitoring', 'drug', 'drugs', 'pharmaceutical preparations', 'compliance' and 'medications'. We identified studies that included SRQs and electronic monitoring devices to measure adherence and focused on the SRQs that were found to be moderately to highly correlated with the monitoring devices. Of the 1679 citations found via the primary search, 41 full-text articles were reviewed for correlation between monitoring devices and SRQs. A majority (68%) of articles reported high (27%), moderate (29%) or significant (12%) correlation between monitoring devices (37 using Medication Event Monitoring System [MEMS®] and four using other devices) and SRQs (11 identified and numerous other unnamed SRQs). The most commonly used SRQs were the Adult/Pediatric AIDS Clinical Trial Group (AACTG/PACTG; 24.4%, 10/41) followed by the 4-item Morisky (9.8%, 4/41), Brief Medication Questionnaire (9.8%, 4/41) and visual analogue scale (VAS; 7.3%, 3/41). Although study designs differed across the articles, SRQs appeared to report a higher rate of medication adherence (+14.9%) than monitoring devices. In conclusion, several medication adherence SRQs were validated using electronic monitoring devices. A majority of them showed high or moderate correlation with medication adherence measured using monitoring devices, and could be considered for measuring patient-reported adherence prospectively.

A blinded randomized controlled trial of motivational interviewing to improve adherence with osteoporosis medications: design of the OPTIMA trial

We have designed an innovative randomized controlled trial for improving adherence with osteoporosis medications. Recruitment and randomization have been successful. Also, the counseling intervention has been well accepted by subjects randomized to this treatment arm.

INTRODUCTION

While many effective treatments exist for osteoporosis, most people do not adhere to such treatments long term. No proven interventions exist to improve osteoporosis medication adherence. We report here on the design and initial enrollment in an innovative randomized controlled trial aimed at improving adherence to osteoporosis treatments.

METHODS

The trial represents a collaboration between academic researchers and a state-run pharmacy benefits program for low-income older adults. Beneficiaries beginning treatment with a medication for osteoporosis are targeted for recruitment. We randomize consenting individuals to receive 12 months of mailed education (control arm) or an intervention consisting of one-on-one telephone-based counseling and the mailed education. Motivational interviewing forms the basis for the counseling program which is delivered by seven trained and supervised health counselors over ten telephone calls. The counseling sessions include scripted dialog and open-ended questions about medication adherence and its barriers, as well as structured questions. The primary end point of the trial is medication adherence measured over the 12-month intervention period. Secondary end points include fractures, nursing home admissions, health care resource utilization, and mortality.

RESULTS

During the first 7 months of recruitment, we have screened 3,638 potentially eligible subjects. After an initial mailing, 1,115 (30.6%) opted out of telephone recruitment and 1,019 (28.0%) could not be successfully contacted. Of the remaining, 879 (24.2%) consented to participate and were randomized. Women comprise over 90% of all groups; mean ages range from 77 to 80 years old, and the majority in all groups was white. The distribution of osteoporosis medications was comparable across groups and the median number of different prescription drugs used in the prior year was eight to ten.

CONCLUSIONS

We have developed a novel intervention for improving osteoporosis medication adherence. The intervention is currently being tested in a large-scale randomized controlled trial. If successful, the intervention may represent a useful model for improving adherence to other chronic treatments.

Knowledge and compliance from patients with postmenopausal osteoporosis treatment

OBJECTIVE

The aim of this study was to evaluate the knowledge, attitudes and expectations of patients receiving treatment for postmenopausal osteoporosis, analysing the factors related to good compliance with treatment.

METHODS

A national, epidemiological, cross-sectional study collected information on personal medical history, family history, bone densitometry, and treatment and compliance of patients over 45 years who were receiving treatment for osteoporosis and provided their informed consent. The patients anonymously completed a questionnaire about their knowledge of osteoporosis and the Morisky and Green treatment compliance evaluation test.

RESULTS

Three hundred and fifteen specialists in gynaecology participated, recruiting 1179 patients with postmenopausal osteoporosis. The mean age was 59.9 years (standard deviation [SD] = 7.5). Only 22.6% of the patients showed an acceptable knowledge of osteoporosis (the criterion established was correct response to 80% of the questions). Treatment compliance was evaluated using a combination of Morisky-Green and Haynes-Sackett criteria. Of the patients 39.2% were classified as compliant, 74.6% of the patients were very or quite concerned about their condition and 53.3%; described their health status as excellent or good. However, 63.6% of the patients indicated that they needed more information about osteoporosis. The factors related to good compliance were the existence of one or no concomitant disease (odds ratio [OR] = 1.38, P = 0.025) and the type of knowledge about their disease (acceptable knowledge: OR = 1.33, P = 0.043).

CONCLUSIONS

Correct knowledge about osteoporosis would increase the possibility of appropriate compliance with the prescribed treatment, thus reducing the risk of osteoporotic fractures.

Interventions to improve adherence and persistence with osteoporosis medications: a systematic literature review

SUMMARY

Adherence and persistence with osteoporosis medications are poor. We conducted a systematic literature review of interventions to improve adherence and persistence with osteoporosis medications. Seven studies met eligibility requirements and were included in the review. Few interventions were efficacious, and no clear trends regarding successful intervention techniques were identified. However, periodic follow-up interaction between patients and health professionals appeared to be beneficial.

INTRODUCTION

Adherence and persistence with pharmacologic therapy for osteoporosis are suboptimal. Our goal was to examine the design and efficacy of published interventions to improve adherence and persistence.

METHODS

We searched medical literature databases for English-language papers published between January 1990 and July 2008. We selected papers that described interventions and provided results for control and intervention subjects. We assessed the design and methods of each study, including randomization, blinding, and reporting of drop-outs. We summarized the results and calculated effect sizes for each trial.

RESULTS

Seven studies met eligibility requirements and were included in the review. Five of the seven studies provided adherence data. Of those five studies, three showed a statistically significant (p < or = 0.05) improvement in adherence by the intervention group, with effect sizes from 0.17 to 0.58. Five of the seven studies provided persistence data. Of those five, one reported statistically significant improvement in persistence by the intervention group, with an effect size of 0.36.

CONCLUSIONS

Few interventions were efficacious, and no clear trends regarding successful intervention techniques were identified in this small sample of studies. However, periodic follow-up interaction between patients and health professionals appeared to be beneficial.

Adherence to osteoporosis treatments: room for improvement

PURPOSE OF REVIEW

Osteoporosis is a growing problem worldwide, with the greatest burden resulting from fractures. Currently available are several treatment options that are effective in reducing fracture risk. Patient adherence to these medications is required for benefit to be seen. Yet, similar to other chronic asymptomatic diseases, adherence to osteoporosis therapies is poor. The reasons for suboptimal adherence are multiple but include fear of possible side effects, dosing requirements, and an unwillingness to take a medication for a 'silent' disease. Poor adherence leads to reduced effectiveness, increased morbidity, and increased medical costs.

RECENT FINDINGS

Efforts to improve adherence to osteoporosis treatments are ongoing. The first obstacle in improving adherence to osteoporosis treatments is determining causes of poor adherence. Despite several identifiable causes, improving adherence is difficult. Passive patient education with printed information alone does not appear very effective. Physician-patient interaction, including discussion of bone mineral density results, discussion of osteoporosis medication benefits, and feedback of treatment effects, may be more effective.

SUMMARY

Improved patient education, better tolerated and less frequently dosed medications, and more healthcare provider-patient interaction may improve adherence and lead to greater fracture reduction.

Non-compliance: the Achilles' heel of anti-fracture efficacy

About 50% of patients fail to comply or persist with anti-osteoporosis treatment regimens within 1 year. Poor compliance is associated with higher fracture rates. Causes of poor compliance are unknown. As it is not possible to predict poor compliance, close monitoring of compliance is needed. Despite evidence supporting the anti-fracture efficacy of several pharmacological agents, approximately 50% of patients do not follow their prescribed treatment regimen and/or discontinue treatment within 1 year. Poor compliance is associated with higher fracture rates and increased morbidity, mortality and cost. However, as poor compliance, even to placebo, is associated with adverse outcomes, the higher morbidity appears to be only partly the result of lack of treatment: as yet, undefined characteristics place poor compliers at higher risk of morbidity and mortality. Only a small proportion (e.g., 6%) of the variability in compliance is explained by putative causal factors such as older age, co-morbidity or greater number of medications. Regimens with longer dosing intervals, such as weekly dosing, improve compliance, persistence and outcomes, but only modestly. As it is not possible to predict poor compliance, close monitoring of compliance should be an obligatory duty in clinical care. How this is best achieved has yet to be established, but poor persistence occurs as early as 3 months of starting treatment, indicating the need for early monitoring.